Area Laboratory Service

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1 THIS IS A CONTROLLED DOCUMENT. DO NOT COPY Organisational Unit: Title: Ref No: Version No: Date Issued: Author: Authorised by: Review date: Area Laboratory Service Microbiology Scottish Toxoplasma Reference Laboratory user manual MQ Jun-2017 Roger Evans Roger Evans 11-Jun-2018 Location of this Copy : Microbiology Serology The master copy of this document is held and controlled on ipassport QMS. Document review history is recorded on ipassport.

2 SCOTTISH TOXOPLASMA REFERENCE LABORATORY USER MANUAL Page 1 of 14

3 Contents Section Page 1 Introduction 3 2 Contact details and key personnel 3 3 Opening hours 3 4 Service provided Samples and Reference Laboratory Tests Clinical information 5 5 Specimen and request form labelling 6 6 Specimen transportation 7 7 Charges 7 8 Results and turn around times 9 9 References 9 10 Toxoplasma request form Attached pdf 11 Algorithm for referral of serum samples to STRL 10 Page 2 of 14

4 1.0 Introduction The Scottish Toxoplasma Reference Laboratory (STRL) is located within the Microbiology Department, Raigmore Hospital, Inverness and is funded by National Services Scotland (NSS), Scottish Government Health Directorates. The department is accredited by Clinical Pathology Accreditation (UK) Ltd. The laboratory provides specialist diagnostic testing service, advice on the management of infection and clinical management of individual patients. It also supplies epidemiological information for health protection purposes. The STRL is unique in the UK in its use of toxoplasma tachyzoites grown in cell culture for its in-house dye test. 2.0 Contact details and key personnel 2.1 Address: Postal address: Scottish Toxoplasma Reference Laboratory Microbiology Department Zone 3, Raigmore Hospital Old Perth Road Inverness IV2 3UJ 2.2 Telephone/ Fax/ General enquiries (09:00-17:00 Monday to Friday) 2.3 Key personnel: DX address DX IV / (direct) nhshighland.microbiology@nhs.net The staff may be contacted at any time for advice and support. Complaints should be directed to Director/Clinical Lead. Designation Name Telephone Director Dr Roger Evans Clinical Lead Dr Chin Lim Clinical Scientist Dr Sally Mavin Microbiology Service Manager Dr David Ashburn Opening hours 3.1 Core Hours are Monday Friday 9.00am to 5.00pm. 3.2 The STRL does not operate an out-of-hours service. Page 3 of 14

5 4.0 Service provided 4.1 Samples and Reference Laboratory Tests Serology: Clotted blood (10ml)/ serum (500µl). Results from plasma samples may be unreliable. : - Whole blood (EDTA) (1ml). Serum/plasma is not suitable. - CSF and amniotic fluid (>200µl). Samples should not be centrifuged prior to referral. - Aqueous/vitreous fluid (200µl) - Tissue - samples must be accompanied by a serum sample for serology. Patient group Required sample Laboratory test Immunocompetent: Current Infection Serum (500µl) Dye test, EIA IgG/M, IgG avidity, IgG Avidity Western blot Chronic infection Pregnancy Congenital Serum (500µl) Whole blood (EDTA)(1ml) Serum (500µl) Amniotic fluid (>200µl) Baby blood Maternal blood (taken at same time as baby s sample) (500µl) Dye test, EIA IgG/M, IgG avidity, IgG avidity Western blot Dye test, EIA IgG/M IgG avidity, IgG Avidity Western blot Dye test, EIA IgG/M, ISAGA IgM, IgG Western blot Dye test, EIA IgG/M, IgG Western blot Ocular Immunocompromise Placenta Foetal tissues Serum (500µl) Aqueous/vitreous fluid Serum (500µl) Dye test, EIA IgG/M, ISAGA IgM Dye test, EIA IgG/M, ISAGA IgM Whole blood (EDTA)(1ml) CSF (if CNS involvement) (>200µl) Difficult cases Discuss with laboratory prior to sending samples As appropriate Page 4 of 14

6 4.2 Clinical Information Toxoplasmosis is caused by the protozoan parasite Toxoplasma gondii and can present in different patient groups with a range of clinical symptoms. Clinical information and date of onset allows interpretation of serological results thereby helping us to provide a better reference service. Please do not hesitate to contact the laboratory to discuss any queries or unusual cases. Primary acquired The STRL provides confirmatory testing and determination of timing of infection. In immunocompetent adults the symptoms and signs of toxoplasma-like illness are fever, lymphadenopathy, malaise, myalgia, flu-like symptoms, hepatitis and other organ involvement. It must be remembered many infected people are asymptomatic. Pregnancy In pregnancy the STRL provides further testing for women who have a screen positive test at any stage in pregnancy, a history of exposure or foetal abnormalities detected at ultra sound. Initially a current specimen of serum and, if available, sera from earlier in the pregnancy or prenatal bloods are required. If appropriate, amniotic fluid can be tested by. Testing at delivery will be directed by the STRL as required. Congenital The STRL will test any babies that present with symptoms or signs of toxoplasma infection e.g. fever, lymphadenopathy, hepatitis, retinochoroiditis, hydrocephalus, encephalitis, intracranial calcifications. If there is a suspicion of congenital infection, a serum sample from both mother and baby at the time of birth should be sent for parallel testing by IgG Western blot. Unique bands or a greater intensity of bands in the neonatal sample compared to the maternal sample is indicative of congenital toxoplasmosis. Tissues from a stillbirth can be tested by. A maternal clotted blood sample is useful in these cases. Late presentation: diagnosis is difficult in infants older than 1 year. A range of tests is used to determine whether infection is due to infection after birth or congenital infection. Page 5 of 14

7 Ocular Ocular toxoplasmosis presents usually as retinochoroiditis and less commonly as panuveitis, papillitis producing optic atrophy and conjunctivitis. The majority of ocular cases are thought to be reactivation of a congenital infection. A sensitive and specific test (e.g., dye test) is important as a negative result (<2iu/ml) can exclude disease. As >80% of the normal population do not have antibody, any positive dye test result supports the clinical diagnosis. All suspected ocular cases should be referred as many screening tests do not detect the low levels of antibody that can occur with congenital infection. Ocular disease may also result from primary acquired infection. can be performed on aqueous/vitreous fluid for both congenital and acquired disease. Immunocompromise Reactivation Immunocompromised patients (HIV, malignancy, bone marrow transplants, patients on corticosteroids, anti-cancer therapy and treatment for connective tissue disease) can be at risk of reactivated toxoplasma infection. Symptoms are similar to primary acquired infection plus encephalitis, pneumonia, chorioretinitis or multi-organ failure. o o o o With disease progression, patients may lose antibody. Therefore, on diagnosis of HIV or prior to commencing immunosuppressive regime, patients should be tested for specific antibody so that reactivated infection can be recognised. If symptomatic, sera should be assessed for rising dye test result, toxoplasma specific IgM and IgG avidity. CSF for may be useful for CNS involvement (in addition to a serum sample). Whole blood for may be useful. Primary Patients in this group may be susceptible to a primary acquired infection. However, those most at risk from acquiring primary infection are seronegative transplant recipients receiving an organ from a seropositive donor, particularly heart or liver, usually within 1-2 months of transplantation. Symptoms are similar to primary acquired infection plus encephalitis, pneumonia, chorioretinitis or multi-organ failure. Serum for toxoplasma antibody in organ transplant donors is required so that mismatches may be avoided. If symptomatic, serum should be assessed by the dye test or for the presence of toxoplasma specific IgM and low IgG avidity. Page 6 of 14

8 CSF for may be useful for CNS involvement (in addition to a serum sample). Whole blood for may also be useful. 5.0 Specimen and request form labelling 5.1 For the safety of patients and staff, the NHS Highland Area Laboratory Service operates a strict specimen acceptance policy (full copy is available on request). 5.2 Specimens may be submitted either using a referring laboratory s own request form or with a letter. However both the request form (or letter) and sample must be labelled with a minimum of three pieces of information to allow unequivocal identification of the patient: MINIMUM DATA SET Request form Sample Patient s surname (1) Patient s surname (1) Patient s forename(s) Patient s forename(s) CHI number (2) CHI number (2) Date of birth (not age) Date of birth (not age) Senders laboratory sample number (if applicable) Senders laboratory sample number (if applicable) (1) Or accepted coded identifier (e.g. soundex code) (2) Where the CHI number is not available a third point of identification (e.g. address) must be provided. In addition please ensure the request form includes: Name and location of sender (or details of where the final report should be sent if different) Specimen type Date and time of collection Associated clinical and epidemiological information. For pregnant women it is very useful to have the stage of pregnancy stated which can be entered in the additional comments box on the request form. 5.3 Specimens that do not conform to the minimum data set will NOT be processed by the laboratory. 5.4 The department will reject specimens that present a Health & Safety hazard to staff (e.g. leaking specimens, contamination of specimen containers external surfaces), inappropriate and insufficient specimens. 6.0 Specimen transportation 6.1 Samples must be appropriately packaged and transported in accordance with current regulations. 6.2 If unsure of the current regulations please contact STRL for advice. Page 7 of 14

9 6.3 Please ensure that packages contain sufficient absorbent material to contain all liquid. 6.4 Please ensure request forms are placed between the plastic container and cardboard outer and not with the sample inside the plastic container. 6.5 Samples should be sent to the laboratory via Royal Mail or DX courier to the address shown in section NHS Highland users should use appropriate transport within NHS Highland and should refer to the NHS Highland transport policy on the intranet regarding specifications for delivery. 7.0 Charges STRL is funded by National Services Scotland (NSS) and testing is carried out free of charge for Scottish NHS laboratories. Samples received from other laboratories and private companies will be subject to charge; prices are reviewed annually and are available on request. 8.0 Results and turn around times Serology Urgent requests Within 7 working days Within 7 working days Please contact the laboratory Results are returned by Royal Mail to the address on the request form. Significant results or those that are required urgently will be reported by telephone. 9.0 References Health Protection Scotland: NHS Highland intranet (available to NHS Highland only): ies/raigmore/microbiology/pages/default.aspx 10.0 Toxoplasma request form See separate pdf file 11.0 Algorithm for referral of serum samples to STRL Overleaf Page 8 of 14

10 Algorithm for referral of serum samples to STRL. * Laboratories that screen may not refer seronegative samples on Immunocompromise/Immunity patients but if they do so they should be aware of the level of sensitivity of their screening test. Immunocompetent Pregnancy Congenital Ocular Immunocompromise* Current infection? Immunity? Current infection? Local Test No local test Local Test No local test Local Test No local test Congenital infection? Local Test No local test Reactivation/ current infection? Immunity/ current infection? Repeat if <4/52 onset Susceptible Repeat if <4/52 onset No evidence congenital infection Refer serum to Scottish Toxoplasma Page 9 of 14 Reference Laboratory

11 Appendix: Document Scottish Toxoplasma Reference Laboratory user manual Appendix Links Please note: links are only correct at time of printing next if type == Linked to Controlled Document - Document: MF024: Toxoplasma request form v1.0 (Authorised) Document Revision History Document Correction on 22-Nov :37 by Roger Evans Minor changes were made to MQ028 by Roger Evans on :37:20 UTC, Procedure was changed to STRL_user_manual_2017.doc. Chnage telephone numbers as may be a source for patients to contact lab staff directly.. Superseded on 09-Jun :17 by Roger Evans Version 3.0 superseded by version 3.1 Authorised on 09-Jun :17 by Roger Evans Authorised version Authorised 9/6/17 RE. The following users will be notified when a review is due for this document: Roger Evans Draft Created on 06-Jun :09 by Roger Evans Reason: USer manual due for review. Changes to be made. Superseded on 06-Jun :24 by Sally Mavin Version 2.1 superseded by version 3.0 Authorised on 06-Jun :24 by Sally Mavin Authorised version The following users will be notified when a review is due for this document: Roger Evans Page 10 of 14

12 Appendix: Document Scottish Toxoplasma Reference Laboratory user manual Review Task Completed on 02-Jun :47 by Roger Evans Roger Evans completed task, "User manaul revised and sent to Sally Mavin for authorisation. Tasked Linda Brady to upload on to the NHSH intranet. " Peer Review Requested on 20-Jan :34 by Roger Evans Peer Review tasks were assigned to the following users: Roger Evans. This review is to be completed by 31-Mar-2016 Draft Created on 21-Dec :07 by Roger Evans Reason: User manual to be reviewed: staff changes and procedural changes to be made Superseded on 30-Sep :21 by Roger Evans Version 2.0 superseded by version 2.1 Authorised on 30-Sep :21 by Roger Evans Authorised version The following users will be notified when a review is due for this document: Roger Evans Review Task Verified on 30-Sep :03 by Roger Evans Roger Evans verified review task: "" Notes: Change Request Approved on 30-Sep :55 by Roger Evans Roger Evans approved change request: "section 2.3 Complaints should be directed to Dr Evans (not Chatterton) " Review Task Completed on 30-Sep :37 by Neil Spence Neil Spence completed task, "Changes made to section 2.3 as discussed." Change Requested on 30-Sep :32 by David Ashburn David Ashburn requested a change: "section 2.3 Complaints should be directed to Dr Evans (not Chatterton) " Page 11 of 14

13 Appendix: Document Scottish Toxoplasma Reference Laboratory user manual Peer Review Requested on 30-Sep :12 by Roger Evans Peer Review tasks were assigned to the following users: David Ashburn, Neil Spence. This review is to be completed by 03-Oct-2014 Draft Created on 30-Sep :23 by Roger Evans Reason: Review Superseded on 28-Jun :06 by David Ashburn Version 1.0 superseded by version 2.0 Authorised on 28-Jun :06 by David Ashburn Authorised version The following users will be notified when a review is due for this document: David Ashburn Review Task Verified on 28-Jun :06 by David Ashburn David Ashburn verified review task: "" Notes: Review Task Verified on 28-Jun :06 by David Ashburn David Ashburn verified review task: "" Notes: Change Request Approved on 28-Jun :06 by David Ashburn David Ashburn approved change request: "1. I have a cell culture picture that could go on the front page with the Giemsa stained tachyzoites 2. Index. PAge numbers do not marry with the ipassport document. This may change when other alterations are done so suggest that this is the last aspect to be checked before issuing document. 3. General comment - it would be helpful to have similar information on the same page whenever possible eg David s name is on page 5 and it would be better as part of the whole table on page Page 5 Section 4.1 Delete for in sentence beginning : CSF Page 5, Table. Congenital section. Move (x2) down one line to line up with samples. 6. Page 7. Move 6.6 Ocular and 6.7 Immunocompromiose sections on p8 to clinical section. Need to lose the numbering system for these sections. 7. Page 8, section 6.5. Insert section 2.1 rather than section Page 9, Immunocompromise. I would put Whole blood for may be useful as a bullet point. 9. Page 10, Acquired. This heading is not needed and I would insert bullet points as for the Immunocompromise section. " Page 12 of 14

14 Appendix: Document Scottish Toxoplasma Reference Laboratory user manual Change Request Approved on 28-Jun :06 by David Ashburn David Ashburn approved change request: "Track changes on - new upload required? Going out with ipassport front page - if so, pagination is one page out. 2.2 Telephone availability given as 09:00-17:30 but phones currently not answered in office after 17:15.? whether still the same with new staff. 2.2 / 3.1 Core hours given as Mon-Fri, but Saturday also included in phone info These sections are all Clinical-? should these be included under clinical section as sub-numbers. Titles and text could be expanded to clarify e.g. Infection in pregnancy, Infection in immonocompromised patients. It would be worth discussing this. 9.0 Congenital section (last paragraph) needs clarification. Can we currently process tissue? 11.0 Immunocompromised: Reactivation - include whole blood with other samples (? bullet points should be used or sub-numbers) Table - some aligment changes " Review Task Completed on 21-Jun :24 by Neil Spence Neil Spence completed task, "reviewed and discussed with JC." Review Task Completed on 20-Jun :10 by Emma Watson Emma Watson completed task, "" Change Requested on 20-Jun :41 by Roger Evans Roger Evans requested a change: "1. I have a cell culture picture that could go on the front page with the Giemsa stained tachyzoites 2. Index. PAge numbers do not marry with the ipassport document. This may change when other alterations are done so suggest that this is the last aspect to be checked before issuing document. 3. General comment - it would be helpful to have similar information on the same page whenever possible eg David s name is on page 5 and it would be better as part of the whole table on page Page 5 Section 4.1 Delete for in sentence beginning : CSF Page 5, Table. Congenital section. Move (x2) down one line to line up with samples. 6. Page 7. Move 6.6 Ocular and 6.7 Immunocompromiose sections on p8 to clinical section. Need to lose the numbering system for these sections. 7. Page 8, section 6.5. Insert section 2.1 rather than section Page 9, Immunocompromise. I would put Whole blood for may be useful as a bullet point. 9. Page 10, Acquired. This heading is not needed and I would insert bullet points as for the Immunocompromise section. " Review Task Completed on 18-Jun :33 by David Ashburn David Ashburn completed task, "Changes incorporated as discussed with JC" Minor Change on 18-Jun :33 by David Ashburn Minor changes were made to MQ028 by David Ashburn on Tue Jun 18 11:33: , Name was changed from Scottish Toxoplasma Reference Laboratory users guide to Scottish Toxoplasma Reference Laboratory user manual, the reason to make a change was: inconsistency between ipassport title and document title. Page 13 of 14

15 Appendix: Document Scottish Toxoplasma Reference Laboratory user manual Change Requested on 13-Jun :24 by Susan McDonagh Susan McDonagh requested a change: "Track changes on - new upload required? Going out with ipassport front page - if so, pagination is one page out. 2.2 Telephone availability given as 09:00-17:30 but phones currently not answered in office after 17:15.? whether still the same with new staff. 2.2 / 3.1 Core hours given as Mon-Fri, but Saturday also included in phone info These sections are all Clinical-? should these be included under clinical section as sub-numbers. Titles and text could be expanded to clarify e.g. Infection in pregnancy, Infection in immonocompromised patients. It would be worth discussing this. 9.0 Congenital section (last paragraph) needs clarification. Can we currently process tissue? 11.0 Immunocompromised: Reactivation - include whole blood with other samples (? bullet points should be used or sub-numbers) Table - some aligment changes " Peer Review Requested on 07-Jun :06 by David Ashburn Peer Review tasks were assigned to the following users: David Ashburn, Jean Chatterton, Roger Evans, Susan McDonagh, Neil Spence, Emma Watson. This review is to be completed by 14-Jun-2013 Draft Created on 07-Jun :51 by David Ashburn Reason: Review following CPA non-conformance Authorised on 16-May :53 by David Ashburn Authorised version The following users will be notified when a review is due for this document: Roger Evans Creation on 15-May :12 by David Ashburn New Document created Authorisation This document was securely signed and authorised by Roger Evans on 09-Jun-2017 Page 14 of 14