North Carolina State Laboratory of Public Health Dee Pettit, Assistant Director [email protected] 919-807-8940
Communication and Partnerships Disease Control and Prevention Reference and Specialized Testing Emergency Response Training and Education Environmental Health and Protection Food Safety Public Health-Related Research Laboratory Improvement and Regulation Policy Development Integrated Data Management
Provide medical and environmental laboratory services to promote, protect, and assure the health of citizens
Mission: To maintain an integrated national and international network of laboratories that can respond quickly to acts of chemical or biological terrorism, emerging infectious diseases and other public heath threats and emergencies.
Treat agents B. anthracis Influenza viruses Francisella tularensis MERS-CoV Brucella spp. Ebola Burkholderia spp. Zika virus Yersina pestis Smallpox
National – CDC, USAMRIID, NMRC Reference – State PHLs
Limited Standard Advanced
Sentinel Clinical/Hospital Local PHLs Military Veterinary Agricultural Food Environmental
RULE OUT possibility of Brucella spp. or REFER to a reference LRN laboratory (State PHL)
Brucellosis is the most commonly reported laboratory-associated bacterial infection.
LAIs Inhalation
▪ Sniffing plates
▪ Aerosol generating procedures
Percutaneous exposure
Brucella spp. 96hrs growth
Laboratory leadership ▪ Laboratory Directors
▪ DPH
Medical Consultation Unit
Clinicians, Epidemiologist,
& Public Health Nurses
Development of Guidelines
Laboratory improvement consultants
Physician
Travel history
Consumption of unpasteurized dairy
products
Occupation
Appropriate handling of
potential Brucella specimens
Notification of an Exposure
Event
Post exposure risk assessment
(classification of high and low
risk exposures)
All specimens collected from sterile sites or suspect sites should be worked in Class II, certified, BSC
BSL 3 work practices How to safely conduct tests to r/o Brucella Tape plates of suspected cases
http://www.cdc.gov/brucellosis/laboratories/risk-level.html
http://www.cdc.gov/brucellosis/laboratories/risk-level.html
Daily Monitor Log Worried well
Refuse PEP
Monitor temperature once/day for 28 days
Fever (100.4) or symptoms listed report to your medical provider
**Malaise is described as: general feeling of being unwell, tired, fatigued, low appetite, &/or lack of energy. †Loss of appetite
Internal and Local
EXPOSURE RISK
PROCEDURE
POTENTIAL HAZARD LIKELIHOOD CONSEQUENCE RISK RATING
CONTROL/ PROTECTION
ADDITIONAL INFORMATION
Package receipt and transfer of packages to testing area
Leaking package
Unlikely
Infection, Illness,
Disease, Death
Low
Assess Packaging labels. Place leaking package in plastic bag and transfer to a BSC while using appropriate PPE including nitrile/latex gloves, lab coat, and safety glasses.
Contact RO/ARO/Safety Officer immediately.
Disinfect exterior of sealed plastic bag prior to transfer to testing area.
Unexpected delivery
Moderate
Infection, Illness,
Disease, Death
Low to Moderate
Immediately transfer to BSC and contact RO/ARO/Safety Officer of unexpected delivery.
Notify key staff of expected package delivery.
Deliver specimen in original Category A packaging to testing area.
All Category A packages opened in a Class II BSC with safety blades. Outreach follow-up for all mislabeled packages.
EXPOSURE RISK
PROCEDURE POTENTIAL
HAZARD LIKELIHOOD CONSEQUENCE RISK RATING
CONTROL/ PROTECTION
ADDITIONAL INFORMATION
Decon Following Testing
Contamination of BSC surfaces
Moderate
Infection, Illness,
Disease, Death
Medium
Use plastic- backed bleach soaked surface pads when manipulating sample
Remove PPE following the
Ebola Zaire Virus-Specific
Operational Plan and discard.
Decontaminate BSC with Dispatch, contact time of 10 minutes, followed by 70% Ethanol.
Waste Autoclaving
External contamination
of waste containers
Moderate
Infection, Illness,
Disease, Death
Medium
Disinfect outside of waste containers before removal from BSC and BSL-3, using Dispatch with a contact time of 10 minutes, followed by 70% Ethanol.
Autoclave waste in isolation room. Once biological indicator demonstrates inactivation take materials to pass-through
BSL 3 or Access to the laboratory is restricted to trained personnel when samples are being processed in BSC
Workers trained in use of BSL3 work practices Adequate PPE: gloves, face shield, N-95 respirator, and back-
closing gowns An autoclave is available to successfully inactive pathogens in
laboratory waste. Laboratorians follow ASM Interim Guidance documents to
prepare THIN blood smears for malaria testing. Handle all specimens within a Class II Type A BSC in an isolated
room Remove the stopper from EDTA blood tube with bleach-soaked
gauze Wipe to prevent aerosol formation, and fixing the blood film
with methanol (30 min) and 95°C dry heat (1 hr) to inactivate all pathogens.
Federal and Local Partners
Mosquito-borne emerging arbovirus
Flavivirus - closely related to
dengue, yellow fever, Japanese encephalitis and West Nile viruses
Since 2015: Endemic transmission in Central & South America
Nontraditional transmission Intrauterine Perinatal Sexual
~1 in 5 people infected with Zika virus become ill Symptom onset: 3–12 days after exposure Symptoms resolution: 2–7 days after onset
Symptoms include:
Rash (mostly maculopapular) Non-purulent conjunctivitis Mild fever Headaches Arthralgia Myalgia
Presentation is similar to dengue and chikungunya infection
Severe disease requiring hospitalization and
fatalities are rare
Shinohara, K, Kutsuna, S, Takasaki T, et al. Zika fever imported from Thailand to Japan, and diagnosed by PCR in urine. Journal of Travel Medicine 2016, 1-3
ECDC Rapid Risk Assessment. Microcephaly in Brazil potentially linked to the Zika virus epidemic. 24 November 2015
Brazil 2015: Reports of microcephaly and other poor outcomes in babies of mothers who were infected with Zika virus while pregnant
Brazil current Zika case estimate 440,000 – 1,300,000
Mapped travelers departing from regions with sustained transmission in 2014 2.8 M to US
60% of US population conducive for autochothonous transmission
Brazil home to the 2016 Summer Olympics
Ongoing transmission of multiple arboviruses Isaac Bogoch et. al Lancet. 387: 335-336
1) Arch Gesamte Virusforsch 1973;43(4): 315-9. 2) Simpson DI. Zika virus infection in man. Trans R Soc Trop Med Hyg 1964;58:335-8.
Laboratory Hazards 14 LAIs Percutaneous exposure Bites from experimentally infected mosquito
Risk Reduction BSL 2 facilities and work practices Lab coat and gloves Aerosol generating procedures in a BSC Use of needles, syringes, and other sharp objects should
be strictly limited Open wounds, cuts, scratches, and grazes should be
covered with waterproof dressings. http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/index-eng.php
Laboratory Hazards 42 LAIs Inhalation of CHIKV containing aerosols from blood Percutaneous exposure
Risk Reduction BSL 3 facilities and work practices Solid-front gowns with tight fitting wrists, gloves,
booties, and respiratory protection. Use of needles, syringes, and other sharp objects
should be strictly limited Open wounds, cuts, scratches, and grazes should be
covered with waterproof dressings.
http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/chikungunya-eng.php
Specimen Test Performed Specimen
Volume Shipment
Serum & CSF
Chikungunya RT-PCR & IgM (NCSLPH); Zika and Dengue RT-PCR and virus-specific IgM; Flavivirus PRNT
2 – 5 mL
Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice. Urine, Saliva, &
Semen
Zika RT-PCR 1 – 3 ml
Amniotic Fluid*
Zika RT-PCR 0.5 – 3 ml Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice.
Cord Blood Zika RT-PCR & IgM Flavivirus PRNT
0.5 – 3 ml Refrigerated (4°C), placed on cold packs
Placental Tissue Zika RT-PCR Viral Culture
2 – 5 grams Freeze at -70°C & ship on dry ice.
Placental Tissue
and Umbilical Cord
Immunohistochemical Staining and Zika virus RT-PCR
2 – 5 grams of tissue and/or
paraffin blocks
Tissue should be formalin-fixed or paraffin-embedded. Ship specimens at room temperature. Note: Request consultation with NCSLPH for specific instructions.
*Patient and healthcare provider must weigh risks and benefits of testing prior to collection of amniotic fluid
Technology used to conduct testing is based on when the specimen is collected after symptom onset
Specimen Type Days Post-onset Testing Technology
Serum
< 4 RT-PCR
4 -7* RT-PCR, IgM, Flavivirus PRNT
> 7 IgM, Flavivirus PRNT
Urine, Saliva, Semen, & CSF
Currently being evaluated RT-PCR Zika only
* IgM negative specimens collected < 7 days should be repeated > 21 days post-onset
BSL 3 facility with BSL3 work practices due to co-localization of CHIKV
Restriction of pregnant workers
IgM analysis Heat inactivation in BSL3 Specimen testing in BSL2
RT- PCR Nucleic acid extraction BSL 3 Assay set-up BSL 2
Facilities and Equipment
Safety equipment ▪ BSC and thimble duct
▪ Aerosol-barrier rotors
Laboratory facilities ▪ Annual verification of
systems
▪ Autoclave
Mechanical monitoring
Cycle time
Temperature
Pressure
Chemical indicators – autoclave tape
Biological indicators
“Based on our testing and inspections we have verified that the third floor BSL3 laboratory meets or exceeds the requirements and guidelines in the BMBL 5th edition for BSL3 laboratories.”
Executive Summary
100 ͦ
Autoclave operation Bio Bag Cycle 1: 121 ͦͦ C/15 psig for 60
minutes Data logger wrapped in clean PPE (smocks,
shoe covers, gloves) and the bag was tightly tied
Run Data Autoclave tape recorded 122 ͦͦ C for 60
minutes 15 psig for 60 minutes Temperature increased from 30 ͦͦ C to 96 ͦͦ C Biological Indicator – Failed
120 ͦ
120 ͦ
120 ͦ
Chris Goforth John Bunting