SPECIMEN SUBMISSION GUIDELINES

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1 Walter Reed Army Institute of Research DEPARTMENT OF LABORATORY DIAGNOSTICS AND MONITORING SPECIMEN SUBMISSION GUIDELINES Version: June 2017 Page 1 of 38

2 TABLE OF CONTENTS 1.0 GENERAL INFORMATION LABORATORY SERVICES TEST MENU LABORATORY HOURS AND ADDRESS POINTS OF CONTACT SPECIMEN COLLECTION, PROCESSING AND HANDLING PATIENT PREPARATION ORDER OF DRAW REQUIREMENTS (IF NOT SPECIFIED IN INDIVIDUAL TEST) LABELING OF SPECIMENS SPECIMEN TEST REQUEST FORMS SPECIMEN REJECTIONS PACKAGING AND SHIPMENT OF SPECIMEN SPECIMEN STORAGE REPORTING OF RESULTS FOLLOW-UP PROCEDURES FOR POSITIVE RESULTS SUPPORTING DOCUMENTS June 2017 SUMMARY OF CHANGES o New HDRL web page is: o Changed HIV Algorithm and the HDRL Test Menu to replace Multispot HIV 1/ 2 assay with Geenius HIV 1/ 2 Supplemental Assay because the vendor of Multispot kits stopped production of the kits. o o Effective 12/1/2016, Geenius HIV 1/ 2 Supplemental Assay replaced Bio-Rad Multispot HIV 1/ 2 assay in the new US Army HIV Algorithm at the HIV Diagnostics and Reference Laboratory (HDRL). Sites will not see any change in the ordering process. On the Result Report, the Multispot HIV 1/ 2 result was replaced with the Geenius HIV 1/ 2 results. Effective 6/22/2017, SOP revised and reformatted. Significant changes included in the revision are: updated mission, inclusion of order of specimen draw instruction, addition of Test Specifications, reformatting and addition of Test Request forms to the SOP, molecular testing was broken out into three Test Request Forms based upon qualitative, quantitative and send out testing procedures, and addition of HIV test algorithms to the SOP. Reference a complete list of the Summary of Changes on the HDRL website at: Page 2 of 38

3 HDRL Mission: The (HDRL), as part of the Department of Laboratory Diagnostics and Monitoring (DLDM), is dedicated to defining and executing stateof-art infectious pathogen diagnostics and monitoring in support of the Department of Defense and Department of Army personnel and their beneficiaries. HDRL assures the highest quality test results within the shortest feasible turnaround time. 1.0 GENERAL INFORMATION 1.1 LABORATORY SERVICES The (HDRL), Department of Laboratory Diagnostics and Monitoring (DLDM), U.S. Military HIV Research Program (USMHRP), at the Walter Reed Army Institute of Research (WRAIR), is a Department of Defense Clinical Laboratory Improvement Program (DOD-CLIP) and College of American Pathologists (CAP) accredited Reference Laboratory that offers testing to Department of Defense (DoD) Laboratories. HDRL began its mission in 1986 as the HIV Diagnostics Laboratory, when Congress authorized creation of the USMHRP to protect U.S. troops and serve the global community by reducing the risk of HIV-1 infection. HDRL conducts standard retroviral serology and HIV clinical (viral load) monitoring testing for both clinical care and in support of the USMHRP research protocols. HDRL provides HIV screening of all U.S. Military Entrance Processing Command (USMEPCOM) applicants, confirmatory HIV testing for the Air Force and Navy and additional confirmatory Hepatitis B testing for Navy recruits. The Laboratory also provides HIV-1 resistance genotyping services to all DoD HIV infected force members. HDRL is responsible for technical oversight for all Army retroviral diagnostics performed by independent government contractors. NOTE: Only the U.S. Army European Command (USAREUR) and U.S. Army Central Command (CENTCOM) are authorized to use WRAIR/HDRL to meet HIV Surveillance (Force Screen) requirements. Non-USAREUR facilities must use Service-directed test facilities (contract laboratory); special requests for assistance must be coordinated with HDRL. 1.2 TEST MENU Type Tests Available Test Specs Serology o HIV Combo Ag/Ab EIA o HIV-1 Western Blot (WB) Supplemental o Geenius HIV 1/2 Supplemental o Hepatitis B Surface Antigen (HBsAg) Confirmatory Assay Molecular o HIV-1 Viral Load (COBAS AmpliPrep/ COBAS TaqMan) o HCV Viral Load (COBAS AmpliPrep/ COBAS TaqMan) o HIV-1 RNA Qualitative Assay (APTIMA) o HCV RNA Qualitative Assay (APTIMA) o HIV-1 Resistance Genotype o HIV-1 Integrase Genotype o HIV-1 Phenotype (sent out to Monogram Biosciences) o HIV-1 Trofile (sent out to Monogram Biosciences) o HIV-1 DNA PCR, HIV-2 DNA PCR Appendix A1 Appendix A2 Appendix A3 Appendix A4 Appendix A5 Appendix A6 Appendix A7 Appendix A8 Appendix A9 Appendix A10 Appendix A11 Appendix A12 Appendix A13 Page 3 of 38

4 1.3 LABORATORY HOURS AND ADDRESS Open Monday through Saturday from 0800 to 1830 EST for testing. Client Services available Monday through Friday from 0700 to 1600 EST at the number listed below. Closed Sundays and holidays. Web Site SPECIMEN SUBMISSION SHIPPING ADDRESS LABORATORY MAILING ADDRESS: Department of Laboratory Diagnostics and Monitoring US HIV Military Research Program, Walter Reed Army Institute of Research Phone: (301) Fax: (301) US Military HIV Research Program Reference the HDRL web page: for the latest Specimen Submission Guidelines, Test Descriptions, Testing Algorithms, Test Request and Point of Contact (POC) forms, and Accreditation Certificates (CAP and Clinical Laboratory Improvement Program [CLIP]). 1.4 POINTS OF CONTACT Director, US Military HIV Research Program COL Nelson Michael, MD, PhD Chief, Department of Laboratory Diagnostics and Monitoring Laboratory Director, Sheila A. Peel, MSPH, PhD, Commercial (301) Assistant Chief, Department of Laboratory Diagnostics and Monitoring CDR Jennifer Malia, MS, DrPH, Commercial (301) Laboratory Manager, LTC John Nuckols, Commercial (301) Assistant Laboratory Manager, CPT Malinda Davis, Commercial (301) Serology Technical Supervisor, Jason Ouellette, Commercial (301) Molecular Technical Supervisor, Joanna Freeman, Commercial (301) Page 4 of 38

5 2.0 SPECIMEN COLLECTION, PROCESSING AND HANDLING 2.1 PATIENT PREPARATION Verify patient identification and tests requested before blood draw and follow local approved standard operating procedures. 2.2 ORDER OF DRAW When multiple specimens are required, follow the proper order of draw (CLSI H3-A6, Section 8.10). Order Tube(Type Tube(Stopper(Color( Mix(by(Inverting 1 Blood&Culture,SPS Yellow&& 8,10&Times 2 ACD* Yellow 8,10&Times 3 Citrate Light&Blue 3,4&Times 4 BD(Vacutainer (SSTTM(Gel(Separator(* Orange&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&or&Red/Black 5&Times 5 Serum((Plastic(Only)* Red 5&Times 6 Heparin Green 8,10&Times 7 BD Vacutainer PST Gel Separator with Heparin Light&Green&&&&&&&&&&&&&&&&&&&&&&or&Light&Green/Black 8,10&Times 8 EDTA*(and(PPT* Lavender&&&&&&&&&&&&&&&&&&&&&&&&&&&White 8,10&Times 9 Flouride&(Glucose) Grey 8,10&Times * Signifies collection tubes used for tests identified in this manual 2.3 REQUIREMENTS NOTE: REFERENCE APPENDIX A: SPECIMEN SUBMISSION GUIDELINES FOR TEST SPECIFICATIONS AND INDIVIDUAL TEST DESCRIPTIONS. SUBMISSION OF THE APPROPRIATE VOLUME AND TYPE OF SPECIMEN IS REQUIRED OR TEST(S) MAY BE REJECTED. WHOLE BLOOD Collect whole blood according to instructions provided for the individual test referenced in Appendix A. Thoroughly mix blood tubes containing additives by gently inverting the tube as noted in order of draw above, and by referencing specific test specifications. Maintain the specimen at room temperature before shipping to HDRL unless instructed otherwise by Test Specification requirements. Never freeze whole blood unless instructed to do so in accordance with a test s specimen collection and handling requirements (Appendix A). Do not place whole blood specimens in direct contact with ice/cool packs. PLASMA Plasma contains fibrinogen and other clotting factors when separated from the red blood cells. Evacuated tubes used to collect plasma specimens contain anticoagulants and, frequently, a preservative. The additive in each tube is specified on the label and tube stoppers are color-coded according to the additive present. Page 5 of 38

6 Consult the Test Specification requirements to determine the correct additive/tube to use. If specimen is transferred to a secondary tube, indicate the specimen type (plasma) on the plastic screw-cap vial for transport and on the corresponding test request form. SERUM HDRL recommends the use of serum separator collection tubes (SSTs) for most serological analyses. When using a serum separator tube, invert the tube gently five times. Further inversion may cause alterations in specimen integrity. DO NOT centrifuge immediately after drawing blood. Allow the blood to clot in an upright position for at least 30 minutes, but not longer than 2 hours before centrifugation. If specimen is transferred to a secondary tube, indicate that the specimen is serum on the plastic screw-cap vial for transport and on the corresponding test request form. CENTRIFUGATION Instructions for centrifugation of specimen collection tubes: 1) Draw 5 ml of whole blood for each 2 ml of serum or plasma required in an appropriate collection tube in appropriate order (section 2.2 Order of Draw). 2) If serum is required, allow the specimen to clot for at least 30 minutes, but no longer than 2 hours, in an upright position prior to centrifugation. 3) For serum, centrifuge within 2 hours of collection per manufacturer guidelines unless otherwise specified for the individual test.* 4) For plasma, centrifuge within 4 hours of collection per manufacturer guidelines unless otherwise specified for the individual test.* 5) Pipette the serum or plasma into a clean plastic screw-cap vial and attach the label. Do not transfer red cells to the vial. *All non-gel blood collection tubes (including those that contain heparin, EDTA and non-gel serum tubes) can be centrifuged at 1300 RCF for 10 minutes. The BD Vacutainer SST and PST gel tubes should be spun at room temperature at a speed of 1000 to 1300 RCF for 10 minutes in a swing bucket centrifuge and 15 minutes in a fixed-angle centrifuge. Information for conversions of RCF to RPM follows: g Force (RCF) = (rpm) r RPM = [RCF/(r 1.118)] LABELING OF SPECIMENS Verify identification once again post draw and before labeling the tubes. Each submitted specimen must be labeled legibly with the following information to prevent test delay: o o o o o o Patient name Unique DOD number Social Security number (SSN) and family member prefix (FMP) (Required for inquiry of patient results/status in legacy LIMS) Date of birth and/or barcode written exactly as it appears on the test request form Date of collection/draw date Specimen type (e.g., serum, plasma, whole blood, etc.) Failure to include required information on the specimen label may result in rejection of the specimen (section 2.6 Specimen Rejections). Page 6 of 38

7 2.5 SPECIMEN TEST REQUEST FORMS Complete the appropriate HDRL Test Request Form (Appendix B) for each specimen: Serology Clinical Test Request Form - Suspicion of acute HIV infection: order the Acute HIV Algorithm on the Serology Clinical Test Request Form. A 4 th generation HIV Ag/Ab Combo test (with a shorter diagnostic window period) will be performed along with an HIV RNA Qualitative Test to assist with diagnosis of acute or primary HIV infection. HIV Verification Algorithm Test Request Forms (NOTE: CONUS and OCONUS forms are different) Molecular Aptima/Qualitative Test Request Form - Aptima HCV RNA Qualitative Assay is offered on the Molecular Test menu as a confirmatory test for the repeat reactive HCV EIA result. A quantitative HCV RNA test is available, if required, to assist with diagnosis and management of HCV infection. Molecular Viral Load (Quantitative)/Drug Resistance Test Request Form Molecular Send Out Test Request Form Vaccine Induced Sero-Reactivity Test Form - For Vaccine Induced Sero-Reactivity (VISR) individuals in whom Sero-Reactivity is suspected due to participation in a HIV vaccine trial, a complete HIV algorithm will be performed inclusive of DNA PCR (Additional testing may be performed if needed). Hepatitis B Surface Antigen Test Request Form All forms can be found on the HDRL website at: NOTE: Enclose the appropriate Test Request Form(s) with patient specimen (s) in the shipment. Multiple tests may be requested, but each requested test requires a dedicated specimen. Ensure that the specimens are shipped using federal, state, and international regulations as appropriate. See Section 5.0 or HDRL website VERBAL TEST REQUESTS WILL ONLY BE ACCEPTED WHEN AN ADDITIONAL REQUEST IS ADDED POST-SUBMISSION ONLY IF FOLLOWED BY THE APPROPRIATE TEST REQUEST FORM WITHIN FIVE (5) BUSINESS DAYS. NOTE: Do not send s containing PHI to HDRL accounts that do no end When sending an that is inclusive of PHI, ensure that is transmitted encrypted. NOTE: HDRL follows test algorithms (Section 5.0). We may modify your request in order to run an initial screening test and then reflex, if needed, for the test you requested. 2.6 SPECIMEN REJECTIONS HDRL reserves the right to reject and discard specimens that: (1) Do not meet the specimen collection and storage requirements specified on the appropriate Test Request Form(s) (2) Contain the following errors: Page 7 of 38

8 A. Test Request Form errors include, but are not limited to: o Illegible information o Missing draw date o Missing family member prefix (FMP) o Missing/incomplete Social Security Number (SSN) o Missing/incomplete date of birth o Missing name of requesting physician and/or site B. Specimen errors include, but are not limited to: o Provided specimen quantity not sufficient (QNS) o Duplicate specimen (same assay requested for same person within one 7-day period), unless authorized by the Laboratory Director o Illegible label o Incomplete information on label (at least two identifiers required per regulation) o Leaking/Cracked specimen tube o Incorrect specimen type o Specimens collected in expired collection tubes o Hemolyzed, contaminated, lipemic, or coagulated specimen o Package not in compliance with applicable federal and state shipping standards (such shipments will be rejected) o Specimens not shipped at specified shipping temperature C. Mismatch errors between Test Request Form and specimen to include, but not limited to: o Discrepancy between specimen label and Test Request Form o Incorrect type of specimen for test requested o Missing specimen or Test Request Form The submitting laboratory will be notified of any rejected specimen either by or telephone call. 2.7 PACKAGING AND SHIPMENT OF SPECIMEN DO NOT SEND SPECIMENS TO HDRL DURING COURIER OBSERVED HOLIDAYS, FOR ARRIVAL ON SUNDAYS OR FOR ARRIVAL ON FEDERAL HOLIDAYS. Sites submitting specimens must comply with all applicable federal and state regulations concerning shipment for diagnostic specimens. The minimum requirements for packaging and shipping are: A. Wrap all vials individually to avoid contact B. Surround individually wrapped specimens with enough absorbent material to contain spillage C. Package specimen in a watertight primary and secondary container. Additional information can be found on the HDRL website at: D. Place request forms within the container but separate from the tubes E. Label container and ship specimens according to applicable guidelines for diagnostic specimens F. Mail to shipping address listed in section 1.3 Laboratory Hours and Address G. Fax/ a FedEx/UPS tracking and/or invoice number to ensure all shipments sent to HDRL are received, IAW CAP GEN (REQUIRED OF SUBMITTING LABORATORY). Page 8 of 38

9 NOTE: All personnel handling specimens for transport MUST be trained in safe handling practices and in decontamination procedures in case of spillage. NOTE: If you would like your shipping boxes returned to your site, enclose a pre-paid FedEx/UPS shipping label or address slip with FedEx/UPS billing information and material to cover hazardous warning markings. 2.8 SPECIMEN STORAGE Immediate Shipping: To avoid hemolysis, separate serum from cells within 2 hours of draw and separate plasma within 4 hours of draw for EDTA or 2 hours of draw for PPT (refer to section 2.3 Requirements). Ship specimen to HDRL in an appropriate specimen shipping container adhering to specimen temperature requirements listed on the Test Request Form(s) (Appendix A). Delayed Shipping: Separate serum or plasma from cells within specified time (2 hour for serum, 4 hours for EDTA plasma, 2 hours for PPT plasma) and freeze. Ship specimen frozen on dry ice in an insulated shipping container to HDRL. Use 2+ lbs. of dry ice per day of transport for frozen specimens. Specimens must arrive frozen. Plan/coordinate for the additional dry ice for any delays that may occur during shipment. NOTE: HDRL recommends using an additional 6 lbs. of dry ice in the event the package is delayed in transit to HDRL. 3.0 REPORTING OF RESULTS HDRL will test all specimens submitted that adhere to specified Specimen Submission Guideline Test Specifications in an expeditious manner and in accordance with specified turnaround times. HDRL generates hardcopy or electronic reports and transmits them via secured fax or encrypted to a designated Point of Contact (POC) for each submitting facility. On a limited basis, HDRL enters results directly in CHCS for specimens received through LIO. Result reports are also sent via secure file transfer to the Service-directed test facilities for the Army and Navy and directly to USMEPCOM. Due to the sensitive nature of our reports, only the designated POC (or alternate) can receive reports from HDRL. The facility POC is the sole manager of distribution of HDRL reports within that institution. To designate a POC for results reporting, complete a Point of Contact Form Results Reporting (Appendix C). To designate a healthcare provider POC for notification and follow-up of positive patient test results, complete a Point of Contact Form Notification and Follow-up (Appendix C). Fax these forms to HDRL at New sites MUST submit these forms before shipping specimens to HDRL for the first time. Use the same forms for updates/changes to these POCs. HDRL cannot/will not change or create POCs without these forms. 4.0 FOLLOW-UP PROCEDURES FOR POSITIVE RESULTS Complete follow-up procedures are outlined in HDRL Standard Operating Procedure GEN 002. HDRL/WRAIR complies with AR Army HIV Surveillance Program closely adhering to the following key points: Initial (first-time) HIV positive result for Active Duty Service members require the submission of a second specimen for independent verification of infection status. HDRL will coordinate with the site POC for shipment of a collection kit to the site as described below: CONUS Active Duty Service members: Page 9 of 38

10 o o An HIV Verification Request Kit and Form (CONUS sites only) will be shipped to your site The site must complete the accompanying Test Request Form and return the kit with specimens to HDRL according to the instructions provided All other Active Duty Service members (OCONUS) and other Service Components: o Complete the HIV Verification Algorithm Test Request Form (Sites other than CONUS) found on the HDRL website o Ship the specimen to the address provided on the form If the original specimen and verification specimen are discordant, a third independent verification specimen will be required. Per AR , each site is required to have an appointed HIV Program Manager. This individual will serve as the POC for follow-up test coordination with HDRL. The identified Primary or Secondary POC will be notified by the HDRL or Army Public Health Command in accordance with HDRL SOP GEN SUPPORTING DOCUMENTS Appendix A: Specimen Submission Guidelines (tests description and specification) Appendix B: Test Request Forms Appendix C: Point of Contact Forms Appendix D: HIV Testing Algorithm Appendix E: HIV Acute Infection Algorithm NOTE: All documents (including CAP and DOD-CLIP certificates and Historical Changes to HDRL testing operations) are available online at: Page 10 of 38

11 Appendix A: Specimen Submission Guidelines (Tests description and specification) Page 11 of 38

12 Appendix A1 Page 12 of 38

13 Appendix A2 Page 13 of 38

14 Appendix A3 Page 14 of 38

15 Appendix A4 Page 15 of 38

16 Appendix A5 Page 16 of 38

17 Appendix A6 Page 17 of 38

18 Appendix A7 Page 18 of 38

19 Appendix A8 Page 19 of 38

20 Appendix A9 Page 20 of 38

21 Appendix A10 Page 21 of 38

22 Appendix A11 Page 22 of 38

23 Appendix A12 Page 23 of 38

24 Appendix A13 Page 24 of 38

25 Appendix B: Test Request Forms Page 25 of 38

26 Appendix B1 Page 26 of 38

27 Appendix B2 Page 27 of 38

28 Appendix B3 CONUS! HIV DIAGNOSTICS AND REFERENCE LABORATORY 13 Taft Ct. Suite 100 Rockville, MD HIV Verification Algorithm Test Request Form TESTS SPECIMEN REQUIREMENT DRAW TUBE HIV Algorithm 4 ml plasma (Cold Pack) PPT SHIP FROZEN PLASMA IF SAMPLE WILL NOT BE RECEIVED AT HDRL WITHIN 72 HOURS. PATIENT IDENTIFICATION Patient Stamp must include: Full Name*, FMP*/SSN*, DOB* Specimen Draw Date / Time*: Ship Date: Sample Storage (circle): Frozen / Refrig / Ambient Sample Shipping (circle): Dry Ice / Cold Pack CONTACT INFORMATION POC* Physician Name* Clinic / Center* Center Address* Telephone Number Fax Number (Commercial # only; please include area/country code) Alternate POC Name Alternate POC Phone *Required PROCESSING LAB (For internal use only) BARCODE DATE RECEIVED QUANTITY & TYPE RECEIVED/INITIALS TUBES DRAWN SPECIMEN REQUIREMENT INSTRUCTIONS 4 PPT s 2 CPTs Aliquot!PPL!into!NINE!(9)!cryovials! 8 2, 1.0 ml each 8 2, 0.5 ml each 8 1, 2mL 8 2, 1.20 ml each 8 1, 2 ml 8 2, remaining volume Collect!Cell!Pellets!and!store!into!SEVEN!(7)!cryovials! 8 2, 5 million cells each 8 5, 1 million cells each Freeze!at!880 C!or!lower! Forward!one!vial!of!plasma!at!1! ml!to!hdrl!for!confirmatory! testing Freeze!at!880 C!or!lower! Form # TR VA Version May 2014 Page 28 of 38

29 Appendix B4 Page 29 of 38

30 Appendix B5 Page 30 of 38

31 Appendix B6 Page 31 of 38

32 Appendix B7 Page 32 of 38

33 Appendix B8 Page 33 of 38

34 Appendix C: Point of Contact Forms Page 34 of 38

35 Appendix C1 Page 35 of 38

36 Appendix C2 Page 36 of 38

37 Appendix D: HIV Testing Algorithm Page 37 of 38

38 Appendix E: HIV Acute Infection Algorithm Page 38 of 38

APHL/CDC HIV Demonstration Project Demonstration Project for HIV Nucleic Acid Testing (NAT) Referral Updated: January 2018

APHL/CDC HIV Demonstration Project Demonstration Project for HIV Nucleic Acid Testing (NAT) Referral Updated: January 2018 Shipping and Submission Instructions Thank you for participating as a submitting