VIROLOGY INTRODUCTION SAMPLE LABELLING & COMPLETION OF REQUEST FORMS GENERAL GUIDELINES FOR VIRUS ISOLATION

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1 VIROLOGY INTRODUCTION Virological tests are usually costly and labour-intensive, therefore they should be undertaken only when good clinical indications for doing so exist, and after thoughtful consideration of the types of tests to request for. Virological tests fall into three categories: Culture of virus from infected body fluids or tissues Antibody detection in blood and, where appropriate, CSF Demonstration of the presence of viral antigen or viral nucleic acid in infected tissues or body fluids. SAMPLE LABELLING & COMPLETION OF REQUEST FORMS All samples must be clearly labelled with the patient s name and unique identification number, e.g. NRIC number, as well as the nature, source and date of collection of the sample. Each sample must be accompanied by a request form that is completed legibly with the patient s name, unique identification number, location, relevant history, findings and clinical diagnosis, the test(s) required, the nature, source and date of collection of the sample, and the name and for urgent requests, the contact number of the requesting doctor. The form must be signed by the requestor. It should be ensured that these requirements are met to avoid rejection of the sample by the laboratory or a delay in reporting. GENERAL GUIDELINES FOR VIRUS ISOLATION 1. For most viral infections, the causative agents can only be isolated during the first 3 4 days of the acute illness. 2. Most viruses are slow growing and results may become available only after 1 3 weeks _PathoH_SL.indd 209 4/3/08 1:03:19 PM

2 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS 3. Viruses are usually very labile, so samples should reach the laboratory within one hour of collection. If this is not possible, the sample must be refrigerated at 4 C (for a maximum period of 48 hours) until transport. Do not freeze samples as many viruses are inactivated at 20 C. Within SGH, the telelift should not be used for culture samples, as this will result in considerable delay in their reaching the laboratory. For samples collected after office hours, refrigerate at 4 C until transport to the laboratory. Do not freeze. 4. Transport the sample with an ice pack or in a bag of ice cubes. First seal the sample in a plastic bag, then place this bag inside an outer plastic bag containing the ice pack or ice cubes. On no account should the ice cubes come into direct contact with the sample bottle as contamination will occur. Place the accompanying request form into another plastic bag to keep the form dry. 5. All swabs and tissue samples for virus isolation must be transported in virus transport medium (VTM). Dry swabs will not be accepted by the laboratory because the virus would probably have died. Blood, CSF, stools and effusions may be sent without VTM. For urine, see special instructions given below. 6. Swabs used for sampling should be made of cotton, dacron or rayon, not of calcium alginate, and the shaft of the swab stick should preferably be made of plastic. COLLECTION METHODS FOR VIRUS ISOLATION BY SAMPLE TYPE THROAT SWABS 1. Swab the pharynx and both tonsils vigorously. 2. If the patient has an associated rhinitis, collect a nasal swab at the same time, using a separate swab. Place both swabs in the same bottle of VTM. NASOPHARYNGEAL ASPIRATES Nasopharyngeal aspirates are superior to throat swabs for the recovery of viruses. Further, immunofluorescence microscopy can be carried out on exfoliated cells in the aspirate for rapid diagnosis. 1. Attach a disposable polythene catheter (French catheter 8 for infants) to a mucus trap and a suction pump. 2. Insert the catheter through the nose for a distance equal to that from the tip of the nose to the angle of the jaw. 3. Using the suction pump, aspirate mucus into the trap. If secretions are thick and trapped in the catheter, dislodge the mucus by sucking up 1 3 ml of VTM. 4. Disconnect the trap when collection is complete and empty contents into a bottle of VTM. (It may be necessary to pour the VTM into the mucus trap, swirl the contents, then pour it back into the VTM bottle). 5. If a suction pump is not available, attach the catheter to a 20 ml syringe, aspirate secretions, then expel secretions into VTM. SALIVA For mumps isolation, swab the buccal mucosa opposite the upper molars where Stensen s ducts open, then swab the floor of the mouth at the openings of the _PathoH_SL.indd 210 4/3/08 1:03:20 PM

3 VIROLOGY submandibular gland ducts. For cytomegalovirus (CMV) isolation, swab the buccal mucosa or aspirate saliva into a mucous trap and send in VTM. VESICULAR LESIONS Sample fresh skin vesicles during the first three days following the appearance of the eruption. Crusted lesions have a lower chance of yielding viable virus. Macules or papules should not be sampled. 1. Gently clean the surface of the vesicle with sterile saline. Do not use alcohol. 2. If the vesicle is intact, use a sterile needle to lift off the roof of the vesicle. 3. Using a sterile swab, soak up all the fluid from the vesicle, then swab the base of the lesion vigorously to dislodge cells on the base (which contain the virus) onto the swab. 4. Using the same swab, repeat the procedure with a number of vesicles, if present, in order to increase the yield of virus. 5. Insert the swab into a bottle of VTM, break off the stick and screw-cap the bottle tightly. OPEN LESIONS Clean open lesions on the skin and genitalia with sterile saline to remove any pus, then swab firmly to sample the basal cells. For oral lesions, swab the base of the lesions. Insert the swab into a bottle of VTM, break off the stick and screw-cap the bottle tightly. For keratoconjunctivitis, scrapings from lesions must be sent for virus isolation and/ or immunofluorescence. CONJUNCTIVAL SWABS Using a swab moistened with sterile saline, pull down the lower lid and swab the conjunctiva firmly, then evert the upper lid and swab similarly. Insert the swab into a bottle of VTM, break off the stick and screw-cap the bottle tightly. For keratoconjunctivitis, scrapings from lesions must be sent for virus isolation and/ or immunofluorescence. CERVICAL SWABS 1. Use a speculum during collection. 2. Use one swab to clean the cervix of mucus and discard. 3. Insert a second swab about 1 cm into the cervical canal. 4. Rotate and leave for a few seconds to absorb the secretions. 5. If vesicles or open lesions are present, sample as described above in Collection s for Virus Isolation by Sample Type (Virology Section, Vesicular Lesions and Open Lesions). 6. Transport in VTM. BIOPSY AND AUTOPSY SAMPLES Fresh samples have to be sent for virus isolation. Formalinised or fixed tissues cannot be used, as the virus would have been destroyed. Place a piece of the sample about 1 cm in size (or smaller if necessary) directly into the bottle of VTM, and send immediately to the laboratory on ice _PathoH_SL.indd 211 4/3/08 1:03:20 PM

4 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS URINE For adults, instruct the patient to clean the urethral/vulval and perineal areas with soap and water, then to collect a mid-stream sample in a sterile bottle. For infants and young children, clean the perineum and genitalia and collect the sample in a sterile bottle. Transfer the urine into the urine culture bottle up to the mark indicated (about 10 ml). This bottle, which contains antibiotics, can be obtained from the Client Services Section of the Department of Pathology. STOOLS Stools should be sent for the diagnosis of enteroviral infections. In enteroviral infections, virus is excreted in the faeces for several weeks, so stools can be collected after the first week of illness if a diagnosis is required at that stage. Most of the gastroenteritis-causing viruses such as rotavirus, the enteric adenoviruses and the caliciviruses cannot be cultured in tissue cultures at present, and virus isolation is usually non-productive for viral gastroenteritis. With CMV enteritis, stool cultures are usually negative and an intestinal biopsy sample is required for virus isolation or antigen detection. Stools in amount equivalent to the tip of the little finger should be collected in a sterile bottle without VTM. RECTAL SWABS Collect from cases with suspected enteroviral infections only when stools are difficult to collect, as rectal swabs are inferior to stools. Insert a sterile swab into the anal orifice, (at least 3 cm deep in an adult) and rotate to ensure collection of faeces. Place swab in a bottle of VTM, break off swab stick and screw-cap firmly. BLOOD Viruses may be isolated from leucocytes and/or plasma so unclotted blood must be sent. 1. Collect 6 ml blood into EDTA tubes. (EDTA is to be preferred to heparin as an anticoagulant because some viruses may be inactivated by heparin). 2. Mix the sample gently to prevent clotting and lysis of cells. 3. Do not freeze the sample during transport as this will cause cell lysis. CSF 1 2 ml CSF should be collected in a sterile bottle without VTM. EFFUSIONS Collect 3 4 ml of fluid in a sterile bottle without VTM _PathoH_SL.indd 212 4/3/08 1:03:20 PM

5 VIROLOGY GENERAL GUIDELINES FOR VIRUS SEROLOGY 1. Collect 3 5 ml of plain blood for serology (6 8 ml if a panel of tests is being ordered). Introduce into a screw-capped container, without anticoagulants, and send the sample to the laboratory inside a sealed plastic bag. If any delay is anticipated, the sample must be refrigerated at 4 C until transport. Do not freeze as this will cause lysis of the cells, resulting in possible interference with some serological tests. 2. To demonstrate a significant rise in antibody levels, the acute sample should be collected as soon as possible after the onset and the second sample 10 days to two weeks later, and not earlier than seven days. When sending the second sample, label the sample as second. The two samples will then be tested in parallel in the same test run. 3. Tests must be requested by name as well as methodology, if more than one type of test is offered (e.g. rubella EIA* or rubella HI ). If in doubt about what to ask for, consult the laboratory. 4. Where an urgent result is required, the first serum can be tested for IgM antibody. However, even IgM antibody may be absent in a sample collected within 1 3 days of the onset, and a second sample taken seven days later will be required to test for IgM. False negative IgM results can also occur, especially in infants with congenital infections (e.g. CMV, HIV). Conversely, false positive IgM antibody results can occur in patients with rheumatoid factor, collagen diseases or, sometimes, with other viral infections. 5. Great care must be taken not to send a traumatised, blood-stained CSF sample, as interpretation will be difficult. The antibody detected may merely represent that present in the blood. When sending CSF, always collect a blood sample at the same time, as this will be useful for determining the significance of any antibody detected in the CSF. 6. For immunity screening, a single sample will suffice. Results are given as antibody Present or Absent, or in the case of hepatitis B and rubella antibody, in international units. The complement fixation test (CFT) should not be requested for immunity screening because complement fixing antibody is not long lasting. 7. Serology for enteroviral infections is not available from this laboratory. For diagnosis, isolation must be carried out (see under Enterovirus Isolation). 8. For Rubella Serology on female patients suspected of having acute rubella or who are contacts of rubella cases, an additional form giving clinical details and LMP (last menstrual period) dates must be filled in. * EIA: Enzyme Immunoassay HI: Haemagglutination-inhibition _PathoH_SL.indd 213 4/3/08 1:03:20 PM

6 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS GENERAL GUIDELINES FOR VIRAL ANTIGEN DETECTION 1. The direct detection of viral antigen in secretions and tissues is very useful for the rapid diagnosis of viral infections, as direct antigen detection may give results within one and a half to two hours. However, a negative result by antigen detection may still be followed by a positive result by culture. It is therefore useful to send samples in viral transport medium, so that both antigen detection and isolation can be carried out at the same time. 2. Where both culture and antigen detection are required, samples must be sent in VTM. If only antigen detection is required, the sample can be sent in a clean bottle with 1 2 ml of sterile saline added. Place the container in a sealed plastic bag for despatch to the laboratory. If delay is anticipated, refrigerate at 4 C but do not freeze as this will cause cell lysis, making antigen detection impossible. 3. The types of samples that can be sent for antigen detection include: (a) respiratory secretions such as nasopharyngeal aspirates, bronchoalveolar lavage and sputum (throat swabs are unsuitable because of the sparsity of respiratory epithelial cells in such samples) (b) fluids from skin vesicles, pericardial and pleural fluid (c) scrapings from the base of vesicle or open skin lesions or the conjunctivae (d) body fluids such as urine and CSF (e) white cells in blood (for CMV) (f) biopsy or autopsy tissue samples A SUMMARY OF TESTS AND SAMPLES TO COLLECT FOR VIRAL INFECTIONS Presentation Respiratory infection Possible pathogens Influenza, RSV, rhinovirus, adenovirus, parainfluenza, CMV, VZV, HSV, enteroviruses, SARS-CoV Samples for isolation TS, NPA or BAL, lung biopsy, ETTA in VTM. Pleural fluid without VTM Samples for serology Paired sera for CFT (all except rhinoviruses, enteroviruses, SARS-CoV). Serum for SARS- CoV total antibody EIA, and IgM and IgG Samples for antigen detection NPA or BAL (all except rhinovirus, enterovirus, SARS-CoV) Neurological diseases (meningitis, encephalitis, paralysis) Enteroviruses, mumps, measles, HSV, VZV, JE, HIV CSF, stool, NPA, brain biopsy. (VTM for NPA and biopsy sample) Paired sera and CSF for CFT, (excluding HIV & enteroviruses), acute serum for IgM (except JE, entero), one serum for HIV EIA NPA for measles, mumps; Vesicle swab for HSV,VZV; Brain biopsy for HSV, VZV, measles, mumps Conjunctivitis, keratoconjunctivitis Adenovirus, coxsackie A24, enterovirus 70, HSV, VZV Conjunctival swab or scraping in VTM Single serum for VZV IgM; paired sera for VZV, HSV and Adeno CFT Conjunctival scraping for HSV, VZV, adenovirus _PathoH_SL.indd 214 4/3/08 1:03:20 PM

7 VIROLOGY Presentation Possible pathogens Samples for isolation Viral STD HSV, HIV Penile, vaginal or cervical swab in VTM for HSV Maculopapular rashes Vesicular skin lesions Cardiovascular: myo- or pericarditis, pleurodynia Hepatitis Gastroenteritis Measles, rubella, dengue, HIV, enteroviruses, parvovirus B19 HSV, VZV, enteroviruses Enteroviruses, influenza HAV, HBV, HCV, HDV, HEV, CMV, EBV Rotavirus, norovirus, adenovirus, CMV, enterovirus (infants) and others Enteroviruses: throat swab in VTM and stools. Dengue: Blood Measles: NPA, TS, sputum in VTM, urine Swab and fluid from lesion in VTM Throat swabs and NPA in VTM, stools (enteroviruses only), periocardial fluid CMV: as below Intestinal biopsy for CMV in VTM. Stool for enteroviruses, adenoviruses Samples for serology Paired sera for CFT for HSV. Single serum for HIV EIA Measles and rubella: Acute serum for IgM and paired sera for HI or CFT. Dengue: see under Dengue heading below. HIV: EIA or PA Parvo. B19: single serum for IgG and IgM EIA Paired sera for CFT (HSV and VZV only) For influenza: paired sera for CFT CMV: as below. EBV: one serum for IgM. Rest: one serum for EIA Paired sera for CFT (CMV and adenovirus) Parotitis Mumps virus Saliva, urine Single serum for IgM. Paired sera for CFT CMV Infection CMV Saliva, NPA, BAL, biopsy in VTM, blood, urine Dengue Dengue types Blood 1 4 Paired sera for CFT, acute serum for IgM Serum for IgM EIA Samples for antigen detection Swab or scraping from lesion in saline for HSV Measles: NPA for antigen detection Swab or scraping from lesion for HSV and VZV For influenza: NPA for antigen CMV: as below Stool for rotavirus and norovirus antigen NPA, urine or saliva for mumps antigen Blood, BAL, biopsy tissue, or urine Blood Note: Bold type indicates preferred samples and test _PathoH_SL.indd 215 4/3/08 1:03:20 PM

8 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS BAL : broncho-alveolar lavage CFT : complement fixation test CMV : cytomegalovirus EBV : Epstein-Barr virus EIA : enzyme immunoassay ETTA : endotracheal tube aspirate HAV : hepatitis A virus HBV : hepatitis B virus HCV : hepatitis C virus HDV : hepatitis D (or delta) virus HEV : hepatitis E virus HI : haemagglutination-inhibition HIV : human immunodeficiency virus HSV : herpes simplex virus IF : immunofluorescence JE : Japanese encephalitis virus LCM : lymphocytic choriomeningitis virus NPA : nasopharyngeal aspirate RSV : respiratory syncytial virus SARS-CoV : severe acute respiratory syndrome coronavirus STD : sexually transmitted diseases TS : Throat swab VTM : viral transport medium VZV : varicella-zoster virus _PathoH_SL.indd 216 4/3/08 1:03:21 PM

9 VIROLOGY ALPHABETICAL TEST LISTING VIRUS ISOLATION ADENOVIRUS ISOLATION Specimen required Turnaround time Day(s) test set up : Urine in cases of cystitis Nasopharyngeal aspirate, brochoalveolar lavage, sputum, endotracheal tube aspirate, throat swab in respiratory disease Conjunctival swab or scraping in conjunctivitis or keratoconjunctivitis (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) : Tissue culture : Reported as positive/negative : Positive report with typing results : 2 6 weeks Negative report : 21 days : Monday Saturday CYTOMEGALOVIRUS ISOLATION Specimen required : 6 ml unclotted blood in EDTA bottle for all clinical presentations, except congenital infections and gastroenteritis Urine for all clinical presentations Saliva, sputum, nasopharyngeal aspirate or bronchoalveolar lavage for pneumonia Saliva and urine for congenital infections Intestinal biopsy for gastroenteritis Other biopsy samples (e.g. lymph node, liver) Uterine curetting (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 2 days 3 weeks Negative report : 21 days DENGUE VIRUS ISOLATION Specimen required : 3 5 ml plain blood or 6 ml unclotted blood in EDTA bottle within 1 week of illness Where clinically indicated, 1 2 ml CSF in sterile bottle (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) _PathoH_SL.indd 217 4/11/08 1:24:18 PM

10 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS 218 : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 8 days Negative report : 7 days ENTEROVIRUS ISOLATION Specimen required : 1 2 ml CSF in sterile bottle for neurological diseases Stool for all clinical presentations. Two stool samples within 48 hours of each other must be sent from all patients aged 15 years and below with a diagnosis of AFP (acute flaccid paralysis) for poliomyelitis surveillance. Throat swab/nasopharyngeal aspirate within the first 3 4 days of onset for all clinical presentations Throat swab, nasopharyngeal aspirate or bronchoalveolar lavage for respiratory infections Pericardial fluid for pericarditis Vesicular fluid for vesicular eruptions (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation By Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive preliminary report : 2 days 3 weeks Final report with enterovirus typing results : 2 8 weeks Negative report : 3 weeks HERPES SIMPLEX VIRUS ISOLATION Specimen required : Swabs or scrapings from vesicles on skin, mouth or genitalia CSF (1 2 ml) in sterile bottle for neurological diseases Conjunctival swab or scraping for eye infections Brain biopsy for encephalitis (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 1 7 days Negative report : 7 days _PathoH_SL.indd 218 4/3/08 1:03:21 PM

11 VIROLOGY INFLUENZA VIRUS ISOLATION Specimen required : Throat swab, sputum, endotracheal tube aspirate but preferably nasopharyngeal aspirate or bronchoalveolar lavage Biopsy/autopsy lung tissue (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 5 21 days Negative report : 21 days MEASLES VIRUS ISOLATION Specimen required : Nasopharyngeal aspirate/wash, throat/nasopharyngeal swabs, sputum Urine in urine culture tube : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 2 14 days Negative report : 14 days Day(s) test set up : Monday-Saturday MUMPS VIRUS ISOLATION Specimen required : Saliva in virus transport medium Urine in urine culture bottle CSF (in cases of meningitis) in sterile bottle (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 7 21 days Negative report : 21 days NEUROTROPIC VIRUS PANEL ISOLATION Viruses to be expected : Herpes simplex, measles, mumps and enterovirus encephalitis viruses. Varicella-zoster virus, although not included in the panel, can also be requested. Specimen required : CSF (1 2 ml) in sterile bottle : Tissue culture : Reported as positive/negative _PathoH_SL.indd 219 4/3/08 1:03:21 PM

12 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS Turnaround time Day(s) test set up : Positive report : 2 21 days Negative report : 7 days for herpes simplex virus, 14 days for measles virus, 21 days for mumps and enterovirus : Monday Saturday RESPIRATORY VIRUS ISOLATION Viruses to be expected : Influenza A and B, respiratory syncytial virus (especially in infants and young children), parainfluenza viruses, rhinovirus, adenovirus, SARS coronavirus, cytomegalovirus, enteroviruses, varicella-zoster virus Specimen required : Throat swab, sputum, endotracheal tube aspirate but preferably nasopharyngeal aspirate or bronchoalveolar lavage Biopsy/autopsy lung tissue (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 5 21 days For enterovirus final report with enterovirus typing results : 2 8 weeks Negative report : 21 days SARS CORONAVIRUS ISOLATION Specimen required : Nasopharyngeal aspirate, endotracheal aspirate or bronchoalveolar lavage prefereable. Sputum, throat swab Biopsy/autopsy lung, brain, heart tissue (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 7 21 days Negative report : 21 days VARICELLA ZOSTER VIRUS ISOLATION Specimen required : Swabs or scrapings from vesicles on skin CSF (1 2 ml) in sterile bottle for neurological presentation Conjunctival swab or scraping for ophthalmic zoster _PathoH_SL.indd 220 4/3/08 1:03:21 PM

13 VIROLOGY Nasopharyngeal aspirate, sputum or bronchoalveolar lavage or pneumonia (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 2 14 days Negative report : 14 days VIRUS ISOLATION IN CARDIAC DISEASES Viruses to be expected : Enteroviruses, influenza viruses Sample Required : Stool for enteroviruses Throat swab, nasopharyngeal aspirate during the first 3 4 days of onset Pericardial fluid for pericarditis (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive report Influenza : 1 2 weeks Enteroviruses : 2 days 3 weeks (preliminary) 2 8 weeks for final report with enterovirus typing results Negative report : 3 weeks VIRUS ISOLATION IN NEUROLOGICAL INFECTIONS Viruses to be expected : Enteroviruses, mumps, herpes simplex, varicella-zoster and influenza viruses Specimen required : Throat swab, nasopharyngeal aspirate during the first 3 4 days of the illness Stools CSF Swabs or scrapings of vesicles if present Saliva (instead of throat swab or nasopharyngeal aspirate) and urine if mumps suspected Brain biopsy for herpes encephalitis _PathoH_SL.indd 221 4/3/08 1:03:21 PM

14 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS (See also Virology Sections, General Guidelines for Virus Isolation & Collection s for Virus Isolation by Sample Type.) Refrigerate samples until transport to laboratory. Do not freeze. : Tissue culture : Reported as positive/negative Turnaround time : Positive report : 1 21 days For enteroviruses final report with enterovirus typing results : 2 8 weeks Negative report : 21 days _PathoH_SL.indd 222 4/3/08 1:03:21 PM

15 VIROLOGY ALPHABETICAL TEST LISTING VIRUS SEROLOGY CHLAMYDIA GROUP TOTAL ANTIBODY Specimen required : 3 5 ml plain blood. Do not freeze. Send paired sera taken two weeks apart for rising titre. : Complement Fixation Test (CFT) : Significant result: 4 fold rise by CFT in paired sera Turnaround time : 1 6 days after acute or convalescent serum is received Day(s) test set up : Tuesday and Thursday COXIELLA BURNETII TOTAL ANTIBODY Specimen required : 3 5 ml plain blood. Do not freeze. Send paired sera taken two weeks apart for rising titre. : Complement Fixation Test (CFT) : Significant result: 4 fold rise by CFT in paired sera Turnaround time : 1 6 days after acute or convalescent serum is received Day(s) test set up : Tuesday and Thursday CYTOMEGALOVIRUS (CMV) ANTIBODY Cytomegalovirus IgM Antibody (anti-cmv IgM) Cytomegalovirus IgG Antibody (anti-cmv IgG) Cytomegalovirus CF Total Antibody (anti-cmv total) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute infection, send acute sample for CMV IgM Antibody and second serum taken 14 days later for CMV CF Total Antibody on the pair. (b) To diagnose previous infection, send single sample for CMV IgG Antibody. : Anti-CMV IgM : Enzyme Immunoassay & Immunofluorescence Anti-CMV IgG : Microparticle Enzyme Immunoassay Anti-CMV total : Complement Fixation Test (CFT) : Acute infection : IgM Ab positive and/or paired sera showing 4 fold rise of CF Ab titres Single sample having CF Ab titre 128 is suggestive of an acute infection. Confirm by virus isolation. Previous (latent) infection : CMV IgG present. Turnaround time : 1 8 days Day(s) test set up : Anti-CMV IgM : Monday Anti-CMV IgG : Tuesday and Friday Anti-CMV total : Tuesday and Thursday _PathoH_SL.indd 223 4/3/08 1:03:22 PM

16 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS DENGUE VIRUS ANTIBODY Dengue IgM antibody (anti-dengue IgM) Dengue Total HI antibody (anti-dengue total) Specimen required : 3 5 ml plain blood. Do not freeze. To diagnose acute infection, send acute sample for dengue IgM antibody and a second sample taken 7 10 days later for dengue IgM and dengue HI antibody on the pair. : Anti-Dengue IgM : Enzyme immunoassay Anti-Dengue total : Haemagglutination inhibition : Acute infection : IgM antibody positive on acute serum or paired sera showing seroconversion Paired sera showing significant rise of HI antibody titers Turnaround time : Anti-dengue IgM : 2 5 days Anti-dengue total : 2 8 days Day(s) test set up : Anti-Dengue IgM : Monday, Wednesday and Friday Anti-Dengue total : Once a week EPSTEIN-BARR VIRUS (EBV) ANTIBODY Epstein-Barr virus VCA IgM Antibody (anti-vca IgM) Epstein-Barr virus VCA IgG Antibody (anti-vca IgG) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute infection, send single sample for EBV VCA IgM Antibody and second serum taken days later if indicated. (b) To diagnose previous infection, send single sample for EBV VCA IgG Antibody. : Immunofluorescence : Acute infection : EBV VCA IgM positive or paired sera showing seroconversion Previous (latent) infection : EBV VCA IgG positive Turnaround time : Anti-VCA IgM/IgG : 1 4 days Day(s) test set up : Tuesday and Friday HANTAVIRUS TOTAL ANTIBODY Specimen required : 3 5 ml plain blood. Do not freeze. To diagnose acute infection, send paired sera taken two weeks apart for Hantavirus total Ab. : Immunofluorescence : Acute infection : Paired sera showing 4 fold rise of total Ab titres Turnaround time : 1 4 days Day(s) test set up : Tuesday and Friday _PathoH_SL.indd 224 4/3/08 1:03:22 PM

17 VIROLOGY HEPATITIS A VIRUS (HAV) ANTIBODY Hepatitis A IgM Antibody (anti-hav IgM) Hepatitis A Total Antibody (anti-hav total) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute infection, send one sample for anti- HAV IgM. (b) To diagnose previous infection and immunity, send one sample for anti-hav total Ab. : Microparticle Enzyme Immunoassay (for anti-hav total Ab) Chemiluminescent Microparticle Immunoassay (for anti-hav IgM) : Acute infection : IgM positive Past infection : Total Ab positive, IgM negative Turnaround time : Anti-HAV IgM : 1 2 days Anti-HAV Total : 1 3 days Day(s) test set up : Anti-HAV IgM : Monday Saturday Anti-HAV Total : Monday Friday HEPATITIS B VIRUS SEROLOGY Hepatitis B Surface Antigen (HBsAg) Antibody to Surface Antigen (anti-hbs) IgM Antibody to Core Antigen (anti-hbc IgM) Antibody to Core Antigen (anti-hbc total) Hepatitis B e Antigen (HBeAg) Antibody to e Antigen (anti-hbe) Confirmatory Test for HBsAg Specimen required : 3 ml plain blood for single marker 6 8 ml plain blood for panel of markers Do not freeze. (a) To diagnose acute hepatitis B infection or the carrier state, send blood for HBsAg and anti-hbc IgM. (b) To determine immune status following past infection or vaccination, send blood for anti-hbs. (c) In a carrier, send blood for HBeAg and anti-hbe. : Chemiluminescent Microparticle Immunoassay (for all above) HBsAg Anti-HBs Anti-HBc IgM Anti-HBc total HBeAg Interpretation + or <10 miu/ml or Acute Hepatitis B + <10 or or Hep B carrier miu/ml 10 miu/ml + Past Infection* 10 miu/ml Vaccination* * An anti-hbs antibody level >10 miu/ml is considered to be protective _PathoH_SL.indd 225 4/3/08 1:03:22 PM

18 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS Turnaround time : HBsAg or anti-hbs : 1 2 days Anti-HBc IgM or Anti-HBc total : 1 3 days HBeAg or anti-hbe : 1 3 days Confirmatory HBsAg : 1 7 days Hepatitis B panels : 1 3 days Day(s) test set up : HBsAg and anti-hbs : Monday Saturday Anti-HBc IgM and Anti-HBc total : Monday, Wednesday and Friday HBeAg and anti-hbe : Monday Friday Confirmatory HBsAg : Once a week HEPATITIS C VIRUS (HCV) SEROLOGY Hepatitis C Virus Antibody (anti-hcv IgG) Anti-HCV Supplemental Assay (anti-hcv RIBA) Specimen required : 5 ml plain blood. Do not freeze. (a) The Supplemental Assay is only carried out to determine whether the screening test is a true positive or not. Do not order Supplemental Assay if anti-hcv IgG is nonreactive. (b) If the first sample is negative for hepatitis A, B and C markers, send a second sample 3 6 months later for anti-hcv IgG to exclude acute HCV infection. : Anti-HCV IgG : Chemiluminescent Microparticle Immunoassay Anti-HCV RIBA : Strip Immunoassay : See Laboratory report for result interpretation. Turnaround time : Anti-HCV IgG : 1 2 days Anti-HCV RIBA : 2 15 days Day(s) test set up : Anti-HCV IgG : Monday Saturday Anti-HCV RIBA : Every other Tuesday HEPATITIS DELTA VIRUS ANTIBODY (ANTI-HDV TOTAL AB) Specimen required : 3 5 ml plain blood. Do not freeze. : Enzyme Immunoassay : A positive test result must be interpreted in conjunction with the clinical features of the patient and the test results for HBV markers. Turnaround time : 1 8 days Day(s) test set up : Wednesday HEPATITIS E VIRUS (HEV) ANTIBODY Hepatitis E IgM Antibody (anti-hev IgM) Hepatitis E IgG Antibody (anti-hev IgG) In acute HEV infection, both IgM and IgG tests are recommended Specimen required : 3 5 ml plain (clotted) blood. Do not freeze _PathoH_SL.indd 226 4/3/08 1:03:22 PM

19 VIROLOGY Turnaround time Day(s) test set up : Enzyme Immunoassay for both above : Acute infection : IgM positive Past infection : IgG positive, IgM negative : Negative report : 1 14 days Positive report : days : Every other Wednesday HEPATITIS, VIRAL PANEL TESTS Hepatitis, Acute Viral Screen Specimen required : 6 8 ml plain blood. Do not freeze. To diagnose acute hepatitis A and B infections, send blood for anti-hav IgM, HBsAg and anti-hbc IgM. : Chemiluminescent Microparticle Immunoassay Anti-HAV IgM HBsAg Anti-HBc IgM Interpretation + Acute type A hepatitis + + or + Acute type B hepatitis + + Acute type A hepatitis in a hepatitis B carrier Non-A, Non-B hepatitis Turnaround time : 1 2 days Day(s) test set up : See serological tests for hepatitis A and B. Hepatitis B Screen (HBsAg + anti-hbs or anti-hbc IgM) Specimen required : 6 8 ml plain blood. Do not freeze. Hepatitis B screen: To test for present or past hepatitis B infection. The serum will first be tested for HBsAg. If HBsAg is negative, serum will be quantitatively tested for anti-hbs. If HBsAg is positive, it will be tested for anti-hbc IgM instead. : Chemiluminescent Microparticle Immunoassay HBsAg Anti-HBs Anti-HBc IgM Interpretation <10 miu/ml Not tested Non-immune to hepatitis B 10 miu/ml Not tested Antibody present: immune if level >10 miu/ml + Not tested + Acute type B hepatitis + Not tested Possible hepatitis B carrier Turnaround time : 1 3 days Day(s) test set up : See Serological tests for hepatitis B _PathoH_SL.indd 227 4/3/08 1:03:22 PM

20 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS 228 HERPES SIMPLEX VIRUS (HSV) ANTIBODY Herpes Simplex IgM Antibody (anti-hsv IgM) Herpes Simplex Virus CF Antibody (anti-hsv total) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute infection, send acute sample for herpes simplex IgM antibody and a second serum taken 14 days later for herpes simplex CF antibody on the pair. (b) For transplant patients, to determine baseline HSV titres, send single sample for herpes simplex CF antibody. Note : Wherever possible, send samples for virus isolation for the diagnosis of herpes simplex virus infections. : Anti-HSV IgM: Immunofluorescence Anti-HSV total: Complement Fixation Test : Primary or First Episode Genital Herpes: HSV IgM positive and 4 fold rise in total antibody. CF (total) Ab will be absent or low (<16) in first sample. Reactivation: IgM usually negative. 4-fold rise in total Ab CF (total) Ab will be present in first sample. Previous (latent) Infection: Total Ab present in the absence of IgM Ab and symptoms. Turnaround time : Anti-HSV IgM : Urgent cases : 3 4 hrs Routine cases : 1 4 days Anti-HSV total : 1 6 days after acute or convalescent serum is received Day(s) test set up : Anti-HSV IgM : Urgent cases : Stat Routine cases : Tuesday and Friday Anti-HSV total : Tuesday and Thursday HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIBODY, SCREENING (includes Confirmation if reactive) Specimen required : 5 ml plain blood. Samples must be double bagged using a plastic bag labelled Biohazard. : Microparticle Enzyme Immunoassay (MEIA), Particle Agglutination (PA) Rapid Tests in urgent situations. Rapid Tests are reported as presumptive and are followed by other screening methods. For confirmation, methods include another MEIA/EIA, PA, line immunoassay and/or Western Blot. : Reported as Reactive or Non-Reactive Turnaround time : Stat screening : 1 hour Routine screening non-reactive report : 1 2 days Confirmation of reactive results : 2 10 days Day(s) test set up : Screening : Monday Saturday Also stat outside office hours for potential organ donors _PathoH_SL.indd 228 4/3/08 1:03:22 PM

21 VIROLOGY HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIBODY, WESTERN BLOT Specimen required : 5 ml plain blood. Samples must be submitted by a referring laboratory and accompanied by screening results unless special indications exist, e.g. for research or life insurance. : Western Blot : HIV status confirmed if there are: (a) Any 2 of p24, gp41, gp120/160 (CDC criteria) OR (b) 2 of 3 env bands with or without gag and/or pol bands (WHO criteria) Indeterminate result: Bands are present that do not meet Positive criteria. Patients should be retested 4 weeks to 6 months later, as indicated on the individual test report; sample should be accompanied by previous test result and laboratory reference number. Inconclusive result: Band profile cannot be definitely characterised as positive, negative or indeterminate. Such a report is accompanied by a request for a second blood sample to be sent 6 weeks later. Turnaround time : 2 10 days Day(s) test set up : Monday MEASLES ANTIBODY Measles IgM or IgG Antibody (anti-measles IgM or IgG) Measles Total CF Antibody (anti-measles total) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute measles infection, send single acute sample for IgM antibody and a second serum taken two weeks later for measles total CF antibody on the pair. (b) To diagnose past infection, send single sample for IgG antibody. : Anti-Measles IgM : Enzyme Immunoassay Anti-Measles IgG : Immunofluorescence Anti-Measles total : Complement Fixation Test : Acute infection : Acute serum positive for IgM and/or paired sera showing 4 fold rise in CF Ab titres Past infection/immunity : Presence of IgG Ab in the absence of specific IgM Turnaround time : Anti-Measles IgM : 1 8 days Anti-Measles IgG : 1 4 days Anti-Measles Total : 1 6 days Day(s) test set up : Anti-Measles IgM : Tuesday or Friday Anti-Measles IgG : Tuesday and Friday Anti-Measles Total : Tuesday and Thursday _PathoH_SL.indd 229 4/11/08 1:29:57 PM

22 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS MUMPS ANTIBODY Mumps IgM or IgG Antibody (anti-mumps IgM or IgG) Mumps CF Total Antibody (anti-mumps total) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute infection, send single acute sample for mumps IgM antibody and a second serum taken two weeks later for mumps CF total antibody on the pair. (b) To diagnose past infection, send single sample for mumps IgG antibody. : Anti-Mumps IgM or IgG : Immunofluorescence Anti-Mumps total : Complement Fixation Test : Acute infection : Acute serum positive for IgM Ab and/or paired sera showing 4 fold rise in CF Ab titres Past infection/immunity : Presence of IgG Ab in the absence of specific IgM Turnaround time : Anti-Mumps IgM or IgG : 1 4 days Anti-Mumps Total : 1 6 days Day(s) test set up : Anti-Mumps IgM or IgG : Tuesday and Friday Anti-Mumps Total : Tuesday and Thursday MYCOPLASMA PNEUMONIAE TOTAL ANTIBODY Specimen required : 3 5 ml plain blood. Do not freeze. Send an acute sample for total antibody. If the titre of the first sample is <320, a second sample, to be sent two weeks later, will be requested. : Particle Agglutination : Acute infection : 4 fold rise of titre in paired sera. A single sample having a titre of 320 is suggestive of a recent infection. Turnaround time : 1 4 days Day(s) test set up : Monday, Wednesday and Friday NEUROTROPIC VIRUS ANTIBODY PANEL Total CF antibody against herpes simplex, measles, mumps and Japanese encephalitis viruses are tested. Total CF antibody to varicella-zoster virus, although not included in the panel, can also be requested. Specimen required : 3 5 ml plain blood or 1 2 ml CSF. Do not freeze. Send sera two weeks apart for rising titire. For CSF, see Virology Section, General Guidelines for Virus Serology. : Complement Fixation Test : Paired sera showing 4 fold rise in titre or single samples having titres of 128 to any of the tested viruses are considered to have significant titres to that virus _PathoH_SL.indd 230 4/3/08 1:03:23 PM

23 VIROLOGY Turnaround time Day(s) test set up NIPAH VIRUS IgG ANTIBODY Specimen required Turnaround time Day(s) test set up : Single sample: 1 6 days Paired sample: 1 6 days after receipt of second sample : Tuesday and Thursday : 3 5 ml plain (clotted) blood. Do not freeze. (a) To diagnose acute infection, send blood two weeks apart. (b) To diagnose past infection, send a single sample. : Enzyme Immunoassay : Acute infection : Paired sera showing seroconversion Past infection : Presence of IgG antibody in a single sample : 2 30 days : Once every month PARVOVIRUS ANTIBODY Parvovirus B19 IgM Antibody Parvovirus B19 IgG Antibody In acute Parvovirus B19 infection, both IgM and IgG tests are recommended Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute parvovirus infection, send acute sample for IgM and IgG antibody, and a second sample two weeks later for IgM and IgG. (b) To diagnose past infection, send one sample for IgG antibody. : Enzyme Immunoassay : Acute infection : Presence of specific IgM in acute serum and/or convalescent serum and/or seroconversion to IgG Past infection/immunity : Presence of IgG antibody in the absence of specific IgM Turnaround time : IgM or IgG : 1 8 days Day(s) test set up : IgM or IgG : Thursday RESPIRATORY VIRUS ANTIBODY Adenovirus CF Antibody Influenza Virus CF Antibody Parainfluenza Virus CF Antibody Respiratory Syncytial Virus CF Antibody Specimen required : 3 ml plain blood for a single test. 6 8 ml for all tests indicated above. Do not freeze. To diagnose acute infection, send paired sera taken two weeks apart. Send paired sera also for varicella-zoster virus antibody and cytomegalovirus antibody if pneumonia is suspected to be due to these viruses. : Complement Fixation Test _PathoH_SL.indd 231 4/3/08 1:03:23 PM

24 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS 232 : Acute infection : Paired sera showing 4 fold rise in antibody titre. A single sample having a titre of 128 to any of the viruses tested is suggestive of a recent acute infection. Turnaround time : Single sample : 1 8 days Paired sample : 1 8 days after receipt of second sample Day(s) test set up : Thursday RUBELLA ANTIBODY Rubella IgM Antibody (anti-rubella IgM) Rubella IgG Antibody (anti-rubella IgG) Rubella Total HI Antibody (anti-rubella total) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute rubella infection, send an acute serum for rubella IgM antibody, and a second serum taken 7 10 days later for rubella total HI antibody on the pair. (b) To evaluate a pregnant contact of a case of rubella, send first sample immediately after exposure and second sample four weeks after exposure for rubella total and IgM antibody. (c) To determine the immunity status to rubella, send a single sample for rubella IgG antibody. : Anti-Rubella IgM : Enzyme Immunoassay Anti-Rubella IgG : Microparticle Enzyme Immunoassay Anti-Rubella total : Haemagglutination Inhibition : Acute infection: Rubella IgM antibody present and confirmed by 4 fold rise of total Ab titres in the paired sera. Immunity status: Serum having rubella IgG antibody 15 IU/mL Turnaround time : 1 8 days Day(s) test set up : Anti-Rubella IgM : Wednesday Anti-Rubella IgG : Thursday Anti-Rubella total : Wednesday SARS-CORONAVIRUS (SARS-COV) ANTIBODY SARS-CoV IgM (anti-sars IgM) SARS-CoV IgG (anti-sars IgG) SARS-CoV Total Antibody (anti-sars total) Specimen required : 6 8 ml plain blood in acute infection; 3 5 ml plain blood to diagnose past infection. Do not freeze. (a) To diagnose acute SARS, send acute sample for IgM and total antibody, and a second sample two to three weeks later for IgM, IgG and total antibody. (b) To diagnose past infection, send one sample for IgG antibody. : Anti-SARS IgM : Immunofluorescence Anti-SARS IgG : Immunofluorescence Anti-SARS total : Enzyme Immunoassay _PathoH_SL.indd 232 4/3/08 1:03:23 PM

25 VIROLOGY : Acute infection : SARS IgM positive and confirmed by 4 fold rise of total Ab titres in the paired sera or IgG seroconversion. Past infection : SARS IgG positive Turnaround time : Anti-SARS IgM or IgG : 1 4 days Anti-SARS total (Positive report) : 3 7 days Anti-SARS total (Negative report) : 1 4 days Day(s) test set up : Anti-SARS IgM : Tuesday and Friday Anti-SARS IgG : Tuesday and Friday Anti-SARS total : Tuesday and Friday VARICELLA-ZOSTER VIRUS (VZV) ANTIBODY VZV IgM Antibody (anti-vzv IgM) VZV IgG Antibody (anti-vzv IgG) VZV Total CF Antibody (anti-vzv total) VZV IgG Antibody (anti-vzv IgG ELFA) Specimen required : 3 5 ml plain blood. Do not freeze. (a) To diagnose acute varicella infection, send single acute sample for VZV IgM antibody and a second serum taken two weeks later for VZV total CF antibody on the pair. (b) To diagnose past infection and immunity, send single sample for VZV IgG antibody. (c) For urgent screening for immunity, send sample for VZV IgG antibody (ELFA). : Anti-VZV IgM : Immunofluorescence Anti-VZV IgG : Enzyme Immunoassay Anti-VZV total : Complement Fixation Test Anti-VZV IgG (ELFA) : Enzyme linked fluorescence assay (for urgent testing) : Acute infection : Single sample positive for VZV IgM Ab and/or paired sera showing 4 fold rise in total CF Ab titres Immunity : VZV IgG Ab present by EIA. Where antibody levels are low, this will be indicated on the report. Turnaround time : Urgent cases: Anti-VZV IgM : 3 4 hrs Anti-VZV IgG (ELFA) : 1 2 hrs Routine cases: Anti-VZV IgM : 1 4 days Anti-VZV IgG : 1 8 days Anti-VZV total : 1 6 days after acute or second sample Day(s) test set up : Anti-VZV IgM/IgG (ELFA) : Stat for urgent cases Anti-VZV IgM : Tuesday and Friday Anti-VZV IgG : Tuesday Anti-VZV total : Tuesday and Thursday _PathoH_SL.indd 233 4/3/08 1:03:23 PM

26 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS ALPHABETICAL TEST LISTING ANTIGENS CYTOMEGALOVIRUS ANTIGEN Specimen required : 6 ml unclotted blood in EDTA bottle. Nasopharyngeal aspirate, broncho-alveolar lavage, sputum, biopsy samples, urine. Refrigerate samples except EDTA blood for CMV pp65 Ag which should be kept at room temperature until transport to laboratory. Do not freeze. If virus isolation is required as well, send above samples except blood and urine in VTM. Otherwise, send all above except blood and urine in clean bottles with 1 2 ml of sterile saline added. Send blood and urine without VTM. : Immunofluorescence : Reported as Negative or Positive Turnaround time : 1 2 days DENGUE VIRUS ANTIGEN Specimen required Turnaround time Day(s) test set up : 3 5 ml plain blood, within 9 days of onset of illness : Enzyme immunoassay : Report as positive or negative : 1 4 days : Tuesday and Friday HERPES SIMPLEX VIRUS AND VARICELLA-ZOSTER VIRUS ANTIGEN Herpes Simplex Virus Antigen Varicella-Zoster Antigen Sample Required : Fluid and scraping from vesicles on skin or mucosa including conjunctivae and genitalia Biopsy samples Sputum, nasopharyngeal aspirate, bronchoalveolar lavage If virus isolation is required as well, send all above in VTM. Otherwise, send all above in clean bottles with 1 2 ml of sterile saline added. Refrigerate samples until transport to laboratory. Do not freeze. : Immunofluorescence : Reported as Negative or Positive Turnaround time : 1 2 days _PathoH_SL.indd 234 4/11/08 1:30:58 PM

27 VIROLOGY MEASLES AND MUMPS ANTIGEN Measles Antigen Mumps Antigen Specimen required : Measles : Nasopharyngeal aspirate in 2 ml sterile saline Mumps : Nasopharyngeal aspirate or saliva in 2 ml sterile saline, CSF (1 2 ml, without saline) if neurological symptoms present Note : As direct antigen detection is less sensitive than isolation for mumps, saliva should be sent in VTM so that isolation can be carried out on the sample at the same time. Refrigerate samples until transport to laboratory. Do not freeze. : Immunofluorescence : Reported as Negative or Positive Turnaround time : 1 2 days NOROVIRUS ANTIGEN Specimen Required Turnaround time Day(s) test set up : 1 ml of liquid stool or cherry-size solid stool in a clean plain screw-capped container, collected preferably within 3 days of onset of illness : Enzyme Immunoassay : Reported as Negative or Positive : 1 7 days : Tuesday RESPIRATORY VIRUS ANTIGEN Viruses tested : Respiratory syncytial virus, influenza A and B, parainfluenza types 1 3, adenovirus Specimen required : Sputum, nasopharyngeal aspirate, bronchoalveolar lavage Lung biopsy or autopsy sample If virus isolation is required as well, send all above in VTM. Otherwise, send in clean bottles with 1 2 ml of sterile saline added. Refrigerate samples until transport to laboratory. Do not freeze. : Immunofluorescence : Reported as Negative or Positive Turnaround time : 1 2 days _PathoH_SL.indd 235 4/3/08 1:03:23 PM

28 SECTION 4: SAMPLE COLLECTION & HANDLING SPECIAL INSTRUCTIONS & LAB TESTS ROTAVIRUS ANTIGEN Specimen required Turnaround time Day(s) test set up : Stool (cherry size) in a clean screw-capped container. Do not freeze. : Chromatographic Immunoassay : Reported as Negative or Positive : 1 day : Monday Saturday _PathoH_SL.indd 236 4/3/08 1:03:23 PM