Proficiency Testing Webinar - APHL...Brucella abortus RB51 during a laboratory proficiency...

Analysis. Answers. Action. www.aphl.org

Lessons Learned from Proficiency Testing and ExercisesOctober 11, 2017

Dial-In Number: 866.740.1260 or 303.248.0285Access Code: 4852701


Funding

This webinar was supported by Cooperative Agreement #NU60OE000103 funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC or the Department of Health and Human Services.


Continuing Education Credits

The Association of Public Health Laboratories (APHL) is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E.® Program. Participants who successfully complete this program will be awarded 1 P.A.C.E. contact hour.


ModeratorPhilip A. Lee, MSc

Lead Biological Defense Coordinator Bureau of Public Health Laboratories – JacksonvilleFlorida Department of Health


PresentersPatricia Bennie, BS, MT(ASCP)

Biological Safety Outreach OfficerGeorgia Public Health Laboratory Georgia Department of Public Health

Marie-Claire Rowlinson, PhD, D(ABMM)Assistant Laboratory DirectorBureau of Public Health Laboratories – JacksonvilleFlorida Department of Health


Objectives

• Provide background on and explain the importance of utilizing the College of American Pathologists Laboratory Preparedness Exercise to improve practices in sentinel clinical laboratories.

• Describe a case study highlighting potential laboratorian exposure to Brucella abortus RB51 during a national proficiency test.



APHL Biosafety and Biosecurity Resources

Please visit aphl.org/biosafety


Additional Resources

• Biothreat Agent Bench Cards and Poster for the Sentinel Clinical Laboratory

• Sentinel Clinical Laboratory Definition

• Packaging and shipping training, other workshops

https://www.aphl.org/programs/preparedness/Documents/APHL-Sentinel-Laboratory-Biothreat-Bench-Cards.pdf#search=bench%20cards

https://www.aphl.org/programs/preparedness/Documents/PHPR_2012Oct_Sentinel-Clinical-Laboratory-Definition.pdf#search=sentinel%20laboratory%20definition

https://www.aphl.org/training/Pages/default.aspx


APHL Resources• Virtual Knowledge

Assessment

• ASM Sentinel Level Clinical Laboratory Protocols For Suspected Biological Threat Agents and Emerging Infectious Diseases

https://www.aphl.org/conferences/proceedings/Documents/2017/NLTC-9/Friday/Pentella,%20Virtual%20Knowledge%20Assessment.pdf#search=virtual%20knowledge%20assessment

https://www.asm.org/index.php/guidelines/sentinel-guidelines


Utilizing the Laboratory Preparedness Exercise to Improve Practices In Sentinel Clinical Laboratories

Pat Bennie, MT(ASCP)Biosafety Outreach OfficerGeorgia Public Health Laboratory


LABORATORY PREPAREDNESS EXERCISE


Partnerships

Developed in 2003 and refined in 2005 as a collaborative effort:

• College of American Pathologists (CAP), • Association of Public Health Laboratories

(APHL), • Center of Disease Control and Prevention

(CDC).


BackgroundIn 2003 • “Mimic” organisms for bioterrorism agents • Photomicrograph challengesIn 2005• MOU signed among CAP, APHL and CDCIn 2007• Included attenuated strains of actual

bioterrorism agents.In 2008• Name changed to: Laboratory Preparedness

Exercise(LPX)


Laboratory Preparedness Exercise CAP/LPX• Test the preparedness of laboratories

across the United States to handle potential public health emergencies related to bioterrorism agents.

• Identify gaps in emergency response systems for state and local public health laboratories so that appropriate laboratory bioterrorism training and education can be developed and offered.

The LPX is a voluntary “proficiency-testing” program designed to exercise standard operating procedures for “rule out” or “referral” of potential biothreat agents in Sentinel Clinical Laboratories.

- *not an official PT


What is a Sentinel Clinical Laboratory?

https://www.asm.org/images/PSAB/Sentinel-Clinical-Laboratory-Definition_2013.pdf


CAP/LPX

Provides:• Realistic biothreat agent challenge

exercise• Educational exercise that will test

most aspects of a laboratory bioterrorism response.


Realistic Challenge Exercise

Potential culture challenges may include: The agents of Bioterrorism- surrogates and

attenuated. In addition, other organisms that may pose a

public health emergency or organisms that mimic bioterrorism agents may be provided.

Analyte Challenges/Shipment Number of Specimens

Number of Labs

Live organisms 3 Two shipmentsper year

~1400/exercise


Education through Practice

Rule-out and referral of potential bioterrorism agents (both surrogates and attenuated “real” organisms) using appropriate Sentinel Level Clinical Microbiology Laboratory Guidelines found on the American Society of Microbiology website:

https://www.asm.org/index.php/science-skills-in-the-lab/sentinel-guidelines


Public Health Lab/Sentinel Clinical Laboratory• Test Communications

• Packaging and Shipping Drills

• Administrative Controls/Work practices


Test Communications



Final Critique and Summary Report


Participation and Results of LPX

• Allow the Georgia Public Health Laboratory to measure Georgia’s preparedness to respond to a BT event if it should occur.

• Results are used to improve training, outreach tools, and resources.


CAP/LPX Participation in Georgia

• 68% of Georgia Laboratories participated in 2017

• Sentinel Clinical Laboratory participation has increased 22%

• The percentage of Sentinel Clinical Laboratories that report the intended response on all three challenge set organisms has increased


Bioterroism Agents /Select Agents

Brucella sp. abortus, suis, melitensisBacillus anthracisBurkholderia pseudomallei Bukholderia malleiYersinia pestisFrancisella tularensis


Brucella• Most common cause of Laboratory Acquired

Infections

• Brucella is identified in Georgia as many as 12 cases a year

• It is a rare and unusual organism

• Laboratorians often do diagnostic testing on the open bench because they do not suspect a Brucella organism


Brucella

• Route of transmission – In Laboratory-Inhalation-Aerosols

• The importance of Education and Training to laboratorians- Mitigate the Risk of exposure

• Post Exposure Prophylaxis is costly both to the individual and the facility.



Funding Sources for LPX Purchase


Benefits and Value

TimeExpense??


Thank You!

Pat [email protected] 404 327-7949

Lessons Learned from an unexpected organism identified in a Proficiency Testing panel

Marie-Claire Rowlinson, PhD D(ABMM)Florida Bureau of Public Health Laboratories

October 2017

35

At the end of this session participants will be able to:• Discuss the challenges with the identification of Brucella spp. in the

diagnostic laboratory • Describe lessons learned from a recent proficiency testing sample

sent to clinical and public health laboratories• List changes that can be made to improve safety in the microbiology

laboratory

Objectives

36

Laboratory acquired infections (LAI)• LAIs are not monitored at a national level, and therefore, it is hard

to determine the extent of LAI and lapses in biosafety at diagnostic microbiology laboratories

• States do capture information regarding Brucella spp. exposures because it is a select agent and a reportable disease

• Brucella spp. have an increased risk of causing laboratory acquired infections:• Easily transmitted by aerosol• Commonly misidentified

Brucella – laboratory acquired infections

37

Brucella LAIs and exposures in Florida• Florida is one of the top five states for reported laboratory acquired

infections and exposures due to Brucella spp. Brucella suis is endemic in the feral swine population in Florida

Brucella exposures in the state of Florida

Year Reported Cases

FL residentsCases

non-FL residentsTotal Lab Exposures

2012 17 0 17 >26

2013 8 1 9 16

2014 3 1 4 26

2015 8 2 10 25

2016 2 1 3 31

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Challenges with Brucella species identification• Brucella spp. is commonly isolated in the clinical microbiology

laboratory by the automated blood culture system but the organism may be isolated from other sources

• There are some general characteristics of Brucella spp. that may provide hints to microbiology laboratory technologists that they are dealing with Brucella spp.• Slower growth (blood culture turns positive at 3+days)• Slower growth on solid media, pinpoint colonies after 24 hours

incubation• No growth on MacConkey• Gram negative coccobacilli

Identification of Brucella species in the microbiology laboratory

39

Challenges with Brucella species identification• Most widely-used identification methods in clinical laboratories may

not accurately detect Brucella spp.• Automated microbial identification systems e.g. Vitek, Microscan• MALDI-TOF

• No indication may be given to microbiology laboratory staff that there is suspicion of Brucella spp. and the specimens should be handled with care

• Training and education are needed (refresher training!) and following most up-to-date ASM Sentinel Guidelines

Identification of Brucella species in the microbiology laboratory

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Risk of Exposure and Infection• Risk of exposure is high for Brucella spp. therefore it is important to

assess and mitigate that risk• Mitigate risk:

1. Have an up-to-date biosafety plan2. Perform a risk assessment and implement any necessary changes

that are identified3. Ensure staff are trained and competent4. Be prepared

Risk! – Potential for Exposure and Infection

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Brucella abortus RB51 Strain• RB51 is an attenuated live bacterial vaccine strain used for

vaccination in veterinary practice and for research• In 2004, CDC performed passive surveillance for accidental

inoculation with the RB51 vaccine to evaluate whether it was associated with human disease, evaluate the efficacy of post-exposure prophylaxis (PEP) and develop recommendations for management in such cases

Reference: Adverse events in humans associated with accidental exposure to the livestock brucellosis vaccine RB51. Ashford D et al. Vaccine. 2004 Sep 3;22(25-26):3435-9

Brucella abortus RB51

42

Brucella abortus RB51 Strain• This is a rough strain and exposure to this strain of Brucella spp.

cannot be determined by the gold standard serology, Brucellamicroagglutination testing (BMAT)• A lack of serological monitoring means that exposure cannot be

determined and one cannot track whether post-exposure prophylaxis (PEP) has been successful – active symptom monitoring is important

• B. abortus RB51 is resistant to rifampin which is one of the drugs that is routinely used for treatment of Brucella spp. infection

Brucella abortus RB51

43

Brucella abortus RB51 Strain – CAP Preparedness Exercise 2007• In 2007 CAP LPX sent out a survey to sentinel and reference clinical

microbiology laboratories• NYS detected Brucella spp. in the proficiency test (PT) and alerted

CDC and APHL so that notification could be sent out to all laboratories that had received the survey

• 17 of 25 laboratories reported potential exposures

Reference: Update: potential exposures to attenuated vaccine strain Brucella abortus RB51 during a laboratory proficiency test--United States and Canada, 2007. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2008 Jan 18;57(2):36-9.

Haven’t we seen Brucella abortus RB51 somewhere before?

44

Brucella abortus RB51 Strain – CAP Preparedness Exercise 2007• A 2008 MMWR provided several tools and recommendations:

1) Tool 1: Questionnaire to assess biosafety practices— Emphasizes importance of adhering to biosafety practices during

PT and when handling specimens routinely, annual review is essential

— Follow diagnostic procedures, SOP (including ASM Sentinel Guidelines)

2) Tool 2: Risk Assessment3) Survey

• The event highlighted the “potential vulnerability of laboratorians during large-scale events involving highly lethal infectious agents, even when the agent is recognized.”

Haven’t we seen Brucella abortus RB51 somewhere before?

45

On 2/14 AAB PTS sends out a PT• The American Association of Bioanalysts Proficiency Testing Service

(AAB PTS) 1st Quad 2017 Bacteriology Program is sent out to 138 laboratories across the U.S.

• Organisms for the PT were provided by Gibson Laboratories• There were five samples containing various bacterial organisms for

identification on the panel

Brucella abortus RB51 in 2017

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Brucella abortus RB51 in 2017: Timeline

February 2017

2/14

AAB PTS send out 1St Quad 2017 Bacteriology Program to 138 labs

47

BPHL receives the PT - sample #5 is a swab specimen with instructions to identify all organisms isolated


February 2017

2/14 2/16


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February 2017

2/14 2/16


An experienced tech works on specimen #5 on the open bench, performing work over several hours/days. Two organisms grow: 1) Rapidly identified as Listeria monocytogenes, 2) Fastidious and hard to separate and purify. An additional sample #5 is requested from AAB PTS on 2/20

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February 2017

2/14 2/16 2/22



DNA sequencing is requested on the un-identified organism

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February 2017

2/14 2/16 2/22 2/23




The additional sample is received and work-up begins

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February 2017

2/14 2/16 2/22 2/23 2/24





Sequencing identifies the organism as “Brucella suis”, LRN PCR protocol confirms Brucella spp. identification

52



February 2017

2/14 2/16 2/22 2/23 2/24

Potential exposures over 8 days






53



February 2017

2/14 2/16 2/22 2/23 2/24

Potential exposures over 8 days






Communication with FDOH, CDC and APHL

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Confirmation• BPHL (state public health laboratory) is a Laboratory Response

Network (LRN) reference laboratory. BPHL can perform LRN protocols for the detection and confirmation of Brucella spp.

• On 2/24, the bioterrorism defense (BT) section performs the real-time PCR and confirms it is positive for Brucella species DNA. Confirmation of species is made by culture and is pending

• At the same time, the microbiology supervisor contacts AAB who state that a Brucella abortus RB51 has been sent out to laboratories as part of this proficiency

Confirmation of Brucella species in a PT sample

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Communication• Bureau of Public Health Laboratories (BPHL) calls AAB PTS Scientific

Director• BPHL calls Florida Department of Health (FDOH) Bureau of

Epidemiology to coordinate a response• FDOH Bureau of Epidemiology contacts Centers for Disease Control

and Prevention Bacterial Special Pathogens Branch• CDC notifies and distributes exposure assessment and management

guidance to State Epidemiologists and State Public Health Veterinarians nationally on 2/24/2017

• National call held on 3/1/2017• BPHL contacts APHL’s Public Health Preparedness and Response

program

Response

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Communication to all laboratories• AAB PTS provided a list of

laboratories that received the PT

• APHL sends out communication to all labs that received the PT

Response - How many other labs received the PT?

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Exposures at BPHL• Several people were potentially exposed at BPHL

• 2 high risk exposures – tech who worked extensively with this organism on the bench and not in a biological safety cabinet and tech who sits directly opposite, and within 5 feet of the bench

• 1 high risk exposure from tech who had transient exposure but is at higher risk due to an immune compromising condition

• 11 low risk exposures present in the lab (probably not within 5 feet).

• There could have been more high-risk exposures if vortexing or other aerosol-generating procedure had been performed on this organism

Response

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Exposures in Florida• Bureau of Epidemiology performed the investigation, with list of

laboratories who may have received PT from AAB PTS• 15 laboratories received the PT

• 10 laboratories stated they either had not received the PT yet or had not opened the package or started working with samples

• 5 laboratories had worked on the sample and had exposures – most extensively at BPHL in Jacksonville with 14 exposures

• BPHL in Miami had 2 exposures• Three sentinel clinical laboratories had exposures, one had 2

exposures and two had 1 exposure each

Response

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Exposures• All exposed personnel were advised about fever watch• The three higher-risk exposures at BPHL Jacksonville were advised

about seeking medical care and post-exposure prophylaxis on 2/24 through Workers Compensation

Reference: Perspectives for the treatment of brucellosis in the 21st century: the Ioannina recommendations. Ariza J et al. PLoS Med. 2007 Dec;4(12):e317

Response

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Response – temperature monitoring

61

Communication to all laboratories• Fortunately many laboratories had not started working on the

organism and were told to destroy the sample• Early and effective notification of this PT certainly prevented

exposures in other laboratories

Rapid response!

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1. A specimen may come in as regular specimen with no notification that it could be something highly infectious

2. If it’s a PT it should be treated as a regular specimen – even if the organism you are looking for is listed

3. If something doesn’t seem right, confer with colleagues

4. Be prepared5. Learn from mistakes...

Lessons learned

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1. Perform all set-up in a Biological Safety Cabinet (BSC)

2. Treat all specimens like patient specimens with unknown organisms potentially present

3. Additional training of staff in the microbiology laboratory

Actions taken

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1. Improve communication with colleagues and supervisors e.g. daily huddle

2. Develop other resources for training and preparedness activities

Actions taken

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1. Review your biosafety program annuallya. Biosafety manualb. Biosafety trainingc. Perform risk assessments

2. Utilize the Biosafety Outreach Officers

Actions taken

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Hot off the press!

• There is a current investigation regarding exposures to Brucella abortus RB51 through consumption of raw milk/raw milk products from a dairy in Texas• A person who drank unpasteurized milk was hospitalized with

brucellosis caused by RB51 and milk samples from this dairy have tested positive for RB51

• A Health Alert Notification (HAN) was sent out to alert laboratories and physicians 9/13/2017• Laboratories are advised about: the submission of samples and

potential for laboratory infections; the importance of adhering to biosafety practices; and following ASM Sentinel Guidelines for submission of suspect Brucella spp. isolates to LRN Reference laboratories

Thank you! Questions?

Acknowledgements

Susanne Crowe, Interim BPHL Bureau Chief/ Jacksonville Lab Director

Phil Lee, and BPHL BT and Microbiology StaffDanielle Stanek, Bureau of Epidemiology

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