North Carolina State Laboratory of Public Health Dee Pettit, Assistant Director

Transcription

1 North Carolina State Laboratory of Public Health Dee Pettit, Assistant Director

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

3 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

4 National CDC, USAMRIID, NMRC Reference State PHLs Limited Standard Advanced Sentinel Clinical/Hospital Local PHLs Military Veterinary Agricultural Food Environmental

5 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. Brucella spp. 96hrs growth LAIs Inhalation Sniffing plates Aerosol generating procedures Percutaneous exposure

6 Laboratory leadership Laboratory Directors DPH Medical Consultation Unit Clinicians, Epidemiologist, & Public Health Nurses Development of Guidelines Laboratory improvement consultants

7 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)

8 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

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14 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

15 Internal and Local

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18 PROCEDURE Package receipt and transfer of packages to testing area EXPOSURE RISK POTENTIAL HAZARD LIKELIHOOD CONSEQUENCE RISK RATING Leaking package Unexpected delivery Unlikely Moderate Infection, Illness, Disease, Death Infection, Illness, Disease, Death Low Low to Moderate CONTROL/ PROTECTION 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. Immediately transfer to BSC and contact RO/ARO/Safety Officer of unexpected delivery. Deliver specimen in original Category A packaging to testing area. ADDITIONAL INFORMATION Contact RO/ARO/Safety Officer immediately. Disinfect exterior of sealed plastic bag prior to transfer to testing area. Notify key staff of expected package delivery. All Category A packages opened in a Class II BSC with safety blades. Outreach followup for all mislabeled packages.

19 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 plasticbacked bleach soaked surface pads when manipulating sample Decontaminate BSC with Dispatch, contact time of 10 minutes, followed by 70% Ethanol. Remove PPE following the Ebola Zaire Virus- Specific Operational Plan and discard. 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 passthrough

20 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 backclosing 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.

21 Federal and Local Partners

22 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

23 ~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

24 Brazil 2015: Reports of microcephaly and other poor outcomes in babies of mothers who were infected with Zika virus while pregnant ECDC Rapid Risk Assessment. Microcephaly in Brazil potentially linked to the Zika virus epidemic. 24 November 2015

25 Brazil current Zika case estimate 440,000 1,300,000 Mapped travelers departing from regions with sustained transmission in 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:

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

27 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.

28 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.

29 Specimen Serum & CSF Urine, Saliva, & Semen Amniotic Fluid* Cord Blood Placental Tissue Placental Tissue and Umbilical Cord Test Performed Chikungunya RT-PCR & IgM (NCSLPH); Zika and Dengue RT-PCR and virus-specific IgM; Flavivirus PRNT Zika RT-PCR Specimen Volume Shipment 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 1 3 ml at -70 C & ship on dry ice. Zika RT-PCR 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. Zika RT-PCR & IgM Flavivirus PRNT Zika RT-PCR Viral Culture Immunohistochemical Staining and Zika virus RT- PCR ml Refrigerated (4 C), placed on cold packs 2 5 grams Freeze at -70 C & ship on dry ice. 2 5 grams of tissue and/or paraffin blocks Tissue should be formalin-fixed or paraffinembedded. 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

30 Technology used to conduct testing is based on when the specimen is collected after symptom onset Specimen Type Days Post-onset Testing Technology < 4 RT-PCR Serum 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

31 BSL 3 facility with BSL3 work practices due to colocalization 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

32 Facilities and Equipment

33 Safety equipment BSC and thimble duct Aerosol-barrier rotors Laboratory facilities Annual verification of systems Autoclave

34 Mechanical monitoring Cycle time Temperature Pressure Chemical indicators autoclave tape Biological indicators

35 Executive Summary 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.

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37 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

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43 Chris Goforth John Bunting

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