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Lab Considerations : Ebola

Ebola testing

• Public Health approval

• HCW safety

• Type of tests

• Specimens

• Permits

• Packaging

Testing during treatment

• In-house

• Reference lab

• Point of care

Lab Waste

Disinfection

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Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach

http://www.cdc.gov/vhf/ebola/hcp/us-hospital-preparedness.htmlDec 2, 2014

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Guidance/Recommendations for a Frontline HCF

•Ebola testing at nearest Laboratory Response Network lab (LRN) in accordance with the state’s plan

•Frontline facility not expected to provide prolonged care (>12–24 hrs) for severely ill patient.

•Ensure there is no care delay for patients by being prepared to test, manage, and treat alternative etiologies (e.g., malaria in travelers) when indicated.

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Laboratory Response Network LRN Ebola testing lab

In order to qualify, a laboratory must have:

• appropriate, functioning biosafety level 3 lab

• the necessary test reagents

• needed PPE to perform the assay safely

A testing lab demonstrates competency by successful completion of a quality assurance panel.

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Laboratory Response Network (LRN)Ebola Testing Laboratories

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Patient presents with Ebola travel historyPatient presents with Ebola travel history

In the early stages, Ebola can be hard to distinguish from other diseases like malaria, typhoid fever, and meningitis

Specimens from patients with active Ebola disease are hazardous

Special laboratory precautions and procedures are needed for safe transportation and handling

From: Top Questions About Ebola © 2014 Association of State and Territorial Health Officials http://www.astho.org/Ebola/

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Existing blood tests are designed to confirm a suspicion of Ebola Person must have Ebola symptoms at time of blood draw

“Screening” prior to symptoms not helpful as the tests will not detect the virus during incubation period

Using the existing Ebola tests to evaluate blood from people who do not have symptoms would cause mistakes.

• Existing Ebola tests require special lab procedures and equipment – FDA Emergency Use Authorization (EUA) for new Ebola tests

• Local and state labs : testing complete within hours

From: Top Questions About Ebola © 2014 Association of State and Territorial Health Officials http://www.astho.org/Ebola/

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Patient with Ebola travel history – to test or not to testPatient with Ebola travel history – to test or not to test

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Ebola 101 for Healthcare Professionals ( 32 slide ppt)http://www.cdc.gov/vhf/ebola/hcp/

Ebola 101 for Healthcare Professionals ( 32 slide ppt)http://www.cdc.gov/vhf/ebola/hcp/

Lag in PCR positivity: virus in blood specimens

Antibody response: IgM and IgG serology

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Standard Ebola Testing (CDC guidance)Standard Ebola Testing (CDC guidance)

• Real Time PCR (RT-PCR) Test

• Diagnose acute infection

• More sensitive than antigen test (e.g. ELISA)

• Identifies select viral genetic fragments

• RT-PCR Samples

• Four (4) mL whole blood

• Plastic collection tubes (not glass or heparinized tubes)

• EDTA tube (whole blood) preferred

• Whole blood preserved with sodium polyanethol sulfonate (SPS), citrate, or with clot activator is acceptable

Standard testing = blood only (other specimens not necessary, only on consultation with CDC)

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Testing for EbolaTesting for Ebola

Patient with risk history/factors, no symptoms• Ebola testing not indicated

• No restriction for non-Ebola testing

• Refrain from donating blood during 21 day incubation period

Patient with risk history/factors AND symptoms• All necessary precautions

• Prior to obtaining any specimens, contact health department

o Person Under Investigation (PUI) determination is made

o Appropriate testing timeframe established

o Obtain specimen - CDC designated testing

NO SPECIMENS WILL BE TESTED FOR EBOLA WITHOUT HEALTH DEPARTMENT CONSULTATION

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Interpreting Negative Ebola RT-PCR Result

If symptoms started ≥3 days before the negative result

EVD is unlikely consider other diagnoses

Infection control precautions for EVD can be discontinued unless clinical suspicion for EVD persists

If symptoms started <3 days before the negative RT-PCR result

Interpret result with caution

Repeat the test at ≥72 hours after onset of symptoms

Keep in isolation as a suspected case until a repeat RT-PCR ≥72 hours after onset of symptoms is negative

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CDC Interim Guidance –Specimen Collection, Transport, Testing and Submissionhttp://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf

Ebola 101 for Healthcare Professionals

CDC : PowerPoint Slides for U.S. Healthcare Workers November 21, 2014on CDC webpage http://www.cdc.gov/vhf/ebola/hcp/

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Specimen Collection

• Phlebotomy by HCW in PPE as appropriate per patient assessment – i.e. same PPE as caregiver (nurse, doctor)

– Gloves, water-resistant gowns, full face shield or goggles, and masks to cover all of nose and mouth. Additional PPE may be required in certain situations. http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html

– Consider delegating specimen collection to patient’s care provider (minimize number of HCWs providing care)

• Disinfect outer part of blood tubes, drop into biohazard specimen bag, seal bag

• Place specimens in a durable, leak-proof secondary container for careful transport of specimen to lab.

• Do not use pneumatic tube system

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Specimen Processing

Full Ebola PPE protocols, including trained doffing and donning , apply when in the patient care area.

Lab staff who receive and package specimens in the laboratory should wear appropriate clinical laboratory PPE (e.g. gloves, mask, face shield, impermeable gown).

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

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Specimen Processing and TestingSpecimen Processing and Testing

Laboratory Ebola PreparednessAs appropriate, work in “containment” environment, i.e. one engineered to control risk of exposure

o work in a class II Biosafety cabinet, or

o work behind a Plexiglass splash guard

Risk Assessment of relevant manual and automated processes regarding risk of aerosolization and splash during testing

Any manual or automated process in which aerosolization and splashing cannot be controlled/eliminated is not to be used

Documented training and competency

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Laboratory Findings : Symptomatic Ebola

Thrombocytopenia (50,000–100,000/L range)

Leukopenia followed by neutrophilia

Transaminase elevation: elevation serum aspartate amino-transferase (AST) > alanine transferase (ALT)

Electrolyte abnormalities from fluid shifts

Coagulation: PT and PTT prolonged

Renal: proteinuria, increased creatinine

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Initial Lab Tests – Clinical Assessment

Malaria test Influenza Group A Strep

CBC Liver Function Tests Coagulation tests

Electrolytes Renal Function Tests

Cultures - see guidance from ASM

• For confirmed Ebola, preferred lab response is point of care (POC) and rapid methods in satellite lab inside or near patient isolation room.

• Verify that all lab instrument manufacturer-installed safety features are in place and functional

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Special considerations

• Ebola virus is regulated as select “Tier 1” agent per HHS Select Agent regulations (42 CFR Part 73):

Tier 1 subset presents greatest risk for deliberate misuse with significant potential for mass casualties or devastating effect to the economy, critical infrastructure, or public confidence; poses a severe threat to public health and safety

Persons Under Investigation (PUI) – specimens to be managed as Tier 1 agent if confirmed to be Ebola

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Can you ship the specimen?Can you ship the specimen?

Ebola virus is classified as a Category A infectious substance by the Department of Transportation (DOT)http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

• Contact state and/or local health department* to determine the proper category for shipment (per clinical history and risk assessment)

*State guidelines may differ and state or local health departments should be consulted prior to shipping.

• NO specimens will be accepted without prior consultation with appropriate health authorities. (Additional consultation CDC Emergency Operations Center (EOC) at 770-488-7100)

http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html

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Can you ship the specimen?Can you ship the specimen?

FedEx may accept PUI delivery to public health lab

FedEx will not accept proven ( by molecular or other confirmatory test) Ebola positive patient specimen – arrange for courier who accepts risk group 4 in Category A package

oWorld Courier is an example commercial courier service currently accepting known Ebola samples  http://www.worldcourier.com/

oPrivate Courier –may transport Category A substances if they are appropriately trained and able to transport a select agent (if known to be Ebola)

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Blood specimens for Ebola DiagnosisBlood specimens for Ebola Diagnosis

• Store and transport at correct temperature o 2-8°C or frozen on cold-packs

• Standard label on each specimen tube• Do not centrifuge specimen

• Do not open or manipulate specimen (pipette, pour-off, split)

• Fill out CDC specimen form: CDC test directory code CDC -10309 - Ebola Identification

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Specimen Collection and Processing: Packaging and Shipping Category A Samples

• Obtain special packaging prior to needing it!– basic triple packaging system :

• primary container (sealable specimen bag) wrapped with absorbent material

• secondary container (watertight, leak-proof)

• an outer shipping package

• Train* lab personnel on packaging and shipping Category A samples per Ebola (and bioterrorism) preparedness

*shippers (e.g labs) must have trained staff with documented shipping training (USDOT and USPS Regulations for Packaging and Labeling Infectious Substances)

https://hazmatonline.phmsa.dot.gov/services/publication_documents/Transporting%20Infectious%20Substances%20Safely.pdf

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Lab staff training and competency: Category A Lab staff training and competency: Category A

Laboratory is responsible for certifying staff in packaging and shipping:

Keeps training records on packaging and shipping •general awareness•function specific• safety•security awareness, and •in-depth security training

Provides documentation on competency in each area of training required for packaging and shipping certification.

Retrains and assesses competency, documented every 2 years and whenever changes to the regulations occur.

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Packaging & Shipping Clinical Specimens to CDC for Ebola Testing

http://www.cdc.gov/vhf/ebola/hcp/packaging-diagram.html

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Waste generated during laboratory testing

Lab waste captured in leak-proof containment

To minimize contamination of the exterior of waste bag, place in a rigid waste container

Lab waste from confirmed Ebola patient requires special treatment (e.g. incineration)

Collaborate with facility waste handler

For equipment that drains directly into the sewer system, the U.S. sanitary sewer system handling processes (e.g., anaerobic digestion, composting, disinfection) will safely inactivate infectious agents. However, check with your state's medical waste program for more guidance http://www.epa.gov/epawaste/nonhaz/industrial/medical/programs.htm

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DisinfectionEPA-registered disinfectants

http://www.epa.gov/oppad001/list-l-ebola-virus.html

Disinfectant must have claim for at least one of the common non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus)

Lab instruments – capable of safely testing specimens with bloodbornepathogens

However, check with manufacturer regarding warranty issues , maintenance, service calls if used for Ebola confirmed specimens

Consider ramifications of a blood spill or lab accident when making decisions to test in main lab

ASM suggested practices: Specimen Processing

Specimen removal from patient’s room and transport of samples to laboratory should be kept to a minimum

Specimen processing may be performed in any of the following:• in the patient’s room• nearby in a contained testing area• inside a biological safety cabinet in negative pressure room• inside a BSC in an isolated area of the laboratory

https://www.asm.org/images/PSAB/Ebola9-10-14.pdfInterim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) American Society for Microbiology (ASM) September 10, 2014 (2nd version*)

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Main ResourcesInterim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approachhttp://www.cdc.gov/vhf/ebola/hcp/us-hospital-preparedness.html

CDC Interim Guidance – Specimen Collection, Transport, Testing and Submissionhttp://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf

Ebola 101 for Healthcare Professionals CDC PowerPoint Slides for U.S. Healthcare Workers November 21, 2014 (found on CDC webpage) http://www.cdc.gov/vhf/ebola/hcp/

Top Questions About Ebola © 2014 Association of State and Territorial Health Officials http://www.astho.org/Ebola/

Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV) American Society for Microbiology (ASM) September 10, 2014 (2nd version*)

https://www.asm.org/images/PSAB/Ebola9-10-14.pdf

PHL Guidance for Clinical Laboratories Using FDA Authorized Diagnostic Assays for Ebola Zaire Virus Detection (see above). Developed a template to assist laboratories in conducting risk assessments of their facilities. http://www.aphl.org/aphlprograms/preparedness-and-response/Documents/APHL-Template.pdf

Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV)

American Society for Microbiology (ASM)September 10, 2014 (2nd version*)

• ASM agrees with the CDC that all laboratory testing must follow standard precautions

• In addition, ASM has developed enhanced precautions – HCF labs may choose to adopt these in an abundance of caution as one

possible approach to testing safety

• As always, contact your State Health Laboratory regarding Ebola Testing and submission of specimens to the CDC

https://www.asm.org/images/PSAB/Ebola9-10-14.pdf

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PPE Selection Matrix for Occupational Exposure to Ebola ...https://www.osha.gov/.../...Occupational Safety and Health Administration to Ebolavirus and that workers are not exposed to harmful levels of chemicals used for ... OSHA PPE Selection Matrix for Occupational Exposure to Ebola Virus.

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