Public health needs: costs, effectiveness,
and biosafety requirements for
diagnostic procedures
• Public health needs
– Tools utilized
– Challenges encountered
• Examine the spectrum of available assays
– Costs
– Effectiveness
– Biosafety requirements.
Rapporteurs: Alison Hottes, Michael Callahan, and Fran
Sharples
Breakout #1
Human Diseases Part 1
Alison Hottes
NAS Staff
Avian Influenza Virus Surveillance
in South-West Siberia (Russia)
• Region contains 3 major flyways and was
important to 2005 expansion of H5N1 in
Eurasia.
– Region could be used as early warning system
for HPAI outbreaks in wild birds in Eurasia.
• Phylogenetic typing using PCR and
sequencing showed a clade change
– Possibility due to population immunity
pressures.
Detection of Emerging and Reemerging Pathogens in Croatia
• Clinical and research work on Hantaviruses,
Dengue Virus, Tick-borne Encephalitis, West Nile
Virus, Chikunganya Virus, and Influenza A
• Tools include: POC tests, ELISA, PCR,
sequencing, and culture
• Generally follow CDC recommendations (except
for U.S. select agents)
– Serology: BSL2 in BSC
– Molecular Tests: Start with BSL2 and move to molecular lab
– Cell culture (typically for research not clinical work): BSL3
(BSL2 for Dengue Virus unless in large quantities)
Biosafety Recommendations for
Laboratory Testing for TB
• TB LAIs usually result from unrecognized production of
infectious aerosols
• Classified common TB-diagnostics:
– Limited risk for aerosol production
– Moderate risk for aerosol production
– High risk for aerosol production
• Generated specific handling guidelines for each risk class
• Additional guidelines for known/suspected XDR samples
• Use a “systems approach” that avoids mention of
traditional BSL levels
Challenges, Issues, and Observations
• Many labs pay 5-6 times as much for common
reagents as U.S. labs.
• Culture techniques and access to strain collections
are usually more crucial to research than to
clinical work.
• Difficult to retain trained workers when safer,
better-paying opportunities are available.
• Shipping, import, and export rules make research
and diagnostic collaborations difficult or
impossible,
• Reliable POC tests are highly useful, especially
when supplemented with molecular follow-up
Areas for Progress
• Many countries avoid culture-based TB
diagnostics creating a need to ship many
clinical samples
– Could be a starting point for a dialog with
IADA about defining transport procedures that
address actual risks
• Many practices could benefit from detailed
risk-based guidance (like that for TB) that
replaces coarse BSL recommendations.
Summary: Human Diseases Part 2
Session II
Chair: Peter Palese
3/16/2016
Distribution Statement
8
Speaker 1
Roger van Doom: Oxford SE Asian Infectious Disease Clinical
Research Network presenting on ”Biosafety and SEAICRN”
A integrated multi-site research facility that is also building public health
capacity in large scale disease outbreak (e.g. pandemic preparedness)
Location:
located
Summary: Human
Diseases on Hospital for Tropical Diseases in Ho Chi Minh City;
Session II
Peter Palese sites in JKA and elsewhere in SE Asia. 200 employees
additional
Funding: Welcome Trust and NIH (plus other intramural grants)
Mission: typhoid, malaria, TB , DF, CNS infections, zoonosis and HIV (+Ois)
BSL: BSL2 for Diagnostics
BLS3 for research (TB and virology)
Capability: 454, Sanger, RTPCR, FTA, uN, culture
Future: expanding to tropical FUO and influenza (pand preparedness)
3/16/2016
9
Distribution Statement
Speaker 2
Cheng Cao, Beijing Inst of Biotechnology presenting on
“SARS: Diagnostics, antibody responses and Biosafety”
Location: primary facility in Beijing, CH
Mission: SARS-centric, focusing on rapid Dx technologies and seroprevalence studies.
BSL: BSL2 (inactivated serums) and BLS3 (for SARS culture)
Capability: RTPCR, ELISA (3) IFA, culture
Key research findings: positive serology to SARS nucleoprotein persists
for years; NP implicated in lung injury secondary to C’ activation
3/16/2016
10
Distribution Statement
Speaker 3
Sohail Zaidi, NIH Pakistan National Institute of Health
Islamabad:
“Crimean-Congo hemorrhagic fever in Pakistan”
Mission: CCRF phylogenetics, measles, influenza including H5N1
BSL:
BSL2 with enhanced PPE for certain tasks (CCRF)
SOPs : restricted access, trained personnel, all Dx cultures are inactivated
at Receiving prior to entering lab
Capability: RTPCR, ELISAs,
Future: seeking to develop a Core Facility to support expanded
sequencing; Seeking guidelines for lab diagnostics.
Key Research findgings: phylogenetics analysis indicates Pakistan CCRF
has homology with Asian Type I; and epidemiology shows a trend for
3/16/2016
11
Distribution Statement
CCRF expansion to new cities.
Speaker 4
Reinhard Burger, Robert Kock Inst, GR
“Enterohemorrhagic E.Coli 0104:H4 in Germany in 2011”
Dr Bruger presented the timeline and epidemiologic investigation of the
recent enteroaggressive Ecoli with HUS that occurred last month in
Northern Germany.
Mission: public health investigation (described in this briefing)
Key research findings: there were over 3322 cases with high
incidence of HUS involving a previously unknown strain with
mixed virulence factors; there was unexpectedly high
incidence of young professional women affected.
Interesting points: novel integrated epi investigation made
use
of media, digital pictures 12and pictures of menus
3/16/2016
Distributionto
Statement
improve history taking.
• Was the EcoliKey
a lab Discussion
creation? (unlikely)
• Will more BSL-2 labs need to adopt BSL3
procedures during high demand
• Can NGO funds be used during disease outbreak
to assist local public health
• Q2 : Doubts about viability of international
restrictions on national containment facilities;
each nation has the right to plan strategies for
countering local strains and health threats.
• Q3: sample archives are not the problem. In
3/16/2016
Distribution
Statement
endemic
regions sample13 collections are
common
3. Animal and Livestock
Diseases
Chair: David Franz
High Security Animal Disease Laboratory,
Bhopal, India: Gaya Prasad
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Commissioned in 2000, in continuous operation since; modern BSL3+
Hazardous animal pathogen diagnostics and molecular research on diagnostic
development, control mechanisms, data bank on livestock diseases, training
17 scientists (microbiologists, public health, biotech and molecular genetics,
research fellows and PhD candidates)
Monitor for exotic diseases: rabbit hemorrhagic disease, avian influenza (AI),
bovine viral diarrhea, malignant catarrhal fever, bird flu, Nipah
AI H5N1 first isolated in poultry in 2006, isolated almost every year since
from chickens, ducks, goose, and crow; OIE reference lab for AI
Swine flu: diagnostic preparedness, surveillance, molecular characterization of
new isolates
Linkages with FAO, MCEIRS, WHO, ICAV, SEPRL, pharmaceutical
industries for vaccines, etc.
1 vet/20,000 animals in India, but all vet hospitals are government, thus
unusual diseases detected in livestock population are brought to government
notice quickly
Mexican Laboratory Network
Marco Antonio Rico Gaytan
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Network of labs (21throughout Mexico) to protect animals in Mexico from exotic
diseases
Establish and coordinate surveillance, diagnostics, promote disease reporting,
provide technical training, epidemiology, outbreak response
Old (1949) lab in Mexico City recently remodeled, certified BSL3 in accordance
with US and Canadian guidelines; biosecurity measures, e.g., access control
(fingerprints)
2005-2011: remodeled 7 facilities for diagnosis of BSE, AI, ND, etc.; network of 16
regional labs, with newest being molecular biology labs (13), BSL2 with
improvements, diagnostic tests (PCR, sequencing, etc); all labs have same design;
Large number of people in field regularly sample animals on farms, check health of
transported animals; samples taken and sent to government labs
Currently working 33 different diseases using 20 tests; 110 different tests for all
diseases
Annual costs estimated at $27 million US
Coping with deadly viruses: Supaporn
Wacharapluesadee, Chulalongkorn
University, Thailand
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Partners: Thai Red Cross, DARPA, Naval Health Research Center, EcoHealth
Alliance, FAO/UN
Established as WHO training center in 2009 on viral zoonoses; surveillance of
animals for rabies, Nipah, Lyssaviruses, corona viruses, recent new pathogen
focus
Have developed novel and safe ways to collect rabies from brains using
“cards” and “trucut” needles to provide enough tissue for PCR
Interesting work on Nipah: BSL4 agent, but no BSL4 lab in Thailand;
developed PCR test to detect Nipah in bat specimens, use BSL2 labs to study;
capture bats with mist nets, collect urine, put into lysis buffer in field, take to
lab for PCR
New pathogens: collected bat saliva, looked for viruses, archaea, bacteria;
have found SIV-like retroviruses at about 7% level, possibly from primates
living in bat areas
Conclusions
• Animal health needs also provide important rationale for
high containment laboratories
• Indian lab serves other countries in region (Nepal, Bhutan)
that lack capabilities if Indian government approves
• Mexico has established extensive network of labs, with full
high containment capabilities in Mexico City and
molecular diagnostics and other capabilities at field to
monitor health of animals nationwide
• Thai lab has come up with creative ways to do research on
hazardous agents without BSL4 capabilities
PM Sessions
Identifying Areas of Action
Rapporteurs:
Craig Reed, Ben Rusek, Jennifer Gaudioso
Breakout Sessions (Group 3)
• Generate strategies and suggestions for
countries building/improving or considering
building/improving labs
• Consider what data on biosafety would be
most useful to generate
• Identify areas where current biosafety
practices are not well matched to actual
needs
Rapporteurs: Craig Reed, Ben Rusek, and Jennifer Gaudioso
Allan Bennett
Health Protection Agency, UK
Evidence-Based Biosafety: Ensuring Precautions are Adequate and
• Appropriate
Generally, biosafety regulations haven’t kept pace with equipment,
materials and codes of practice.
• Good microbiological practices
– critical to effective biosafety
– actually result in fewer aerosolization events
– far less expensive than engineering controls
• Improperly/Incompletely inactivated infectious materials may become
major source of infection in future due to increased adoption of advanced
clinical diagnostics.
• Data from multiple studies
– 2006: Direct relationship between titre and aerosol concentration.
– 2008: Heavy rubber gloves used in a Class III cabinet and in BSL4
substantially reduce hand and finger dexterity; latex gloves do not.
– Historical review: If you don’t wear gloves in the lab you WILL infect yourself
and probably others.
• Observation: Still have major problems with compliance to simple costeffective protective measures (glove use, hand washing)
• Observation: Working in a cabinet actually creates a different hazard – not
from aerosols but, rather, from splashes.
Uwe Muller-DobliesDVM
Pirbright Laboratory, Institute for Animal Health, UK
Risk-based Design of Facilities for High Consequence Pathogens
• What is the acceptable risk of accidental release? Zero: not
achievable. How often are we prepared to accept a consequential
event, assuming appropriate controls reduce risk to an acceptable
residual level? 1 event per 25 facilities per 20 years = 1 per 500 facility
yrs
• Bow-Tie Risk Management Model:
Threats –> Threat Control Measures –> Hazard Release –>
Recovery/Mitigation Measures –> Consequences
Onder Ergonul, MD
Koc University School of Medicine, Infectious Diseases Dept., Istanbul
Infection Control in Emerging Infections
• Discussion of emergent/re-emergent arboviral diseases of humans
– CCHF in Turkey vs. Iran, Bulgaria, Tajikistan, Greece, Russia, global
distribution
• Effectiveness of ribovirin better during Pre-Hemorrhagic period vs
Hemorrhagic period
• Discussed high human-human transmission rate of CCHF and impact
on healthcare worker infection
– Transmission risk to HCW in Africa
• Needlesticks 33%
• Contaminated blood exposure 8.7%
– No evidence of aerosol infection in HCW in Turkey
• HCW are at risk but Standard Precautions are most appropriate for in
clincial setting
Breakout #2:
Improving Organizational
Culture and Practices
Ben Rusek
NAS Staff
Enlightened Laboratory Leadership: More
Powerful than Guns Gates and Guards
• Emphasize the benefit of science, prevent overregulation
• The insider threat is a very difficult problem to solve, we
may have to live with the risk
• We are living with the regulation. The US Select Agent
rules and personnel reliability measures were implemented
in response to insiders
• Where will these regulations take us? It could take 5-10
years to realize that we have an overregulation problem
and 20 years to turn it around
• Laboratory leadership is critical. Include some smart
security but lead with science, trust and transparency
Singapore’s Response to Biorisk Events at
Home and Abroad
• SARS was the wakeup call in Singapore. In addition to the loss
of life, the outbreak had a massive economic impact on the
country
• Today’s biosafety and biosecurity laws were developed in
response to outbreaks in the late 90s and the US anthrax
mailings in 2001
• Responded with legislation: Strategic Goods (Control) Act, in
2002 created Tradenet and passed the Biological Agents and
Toxins Act (BATA) in 2005. These regulations add extensive
enforceable security measures for biological security
• Also address the threat through Institutional Biosafety
Committees and Biosafety/Biorisk Associations in Singapore
and in the Asia Pacific region
OIE Laboratory Twinning: A Tool to Improve
Global Disease Security
• The World Organisation for Animal Health (OIE) has 220 OEI
reference laboratory (RL) in 178 member countries. Each RL is
assigned a specific disease, the network helped to eradicate
Rinderpest worldwide this year
• “Twinning” partnership is a way to enhance capacity and
expertise by supporting a link between an OIE RL and a
national laboratory (candidate) that helps OIE expand the global
network. Over 30 active in the world.
• OIE standards give guidance on developing a risk assessment
based on the pathogen in that environment. For instance
standards are not as strict in places where FM is endemic.
• We don’t know how many OEI partners do work in high
containment labs. We might start to collect this information
Conclusion
• Regulations should provide practical guidance based on risk
assessments for the individual lab
• Difficult but not impossible to legislate human behavior
although it will never eliminate all risk
• Individual “champions” can take up the cause and spread the
message in countries and regions and convince their life science
community that these are serious issues that need practical
solutions
• Education throughout the life science training spectrum can help
create good practices in biosafety and change culture, attitude
and behavior
• More thinking needs to be done about how to enforce national
and international regulations in local labs, implementation is
missing in many places
Design and operational options for
improving sustainability,
biosafety, and biosecurity
Chair: Willy Tonui
Maintenance, certification and costsaving issues for BSL3 labs in SE
Asia
• Planning aspects routinely underestimated
– Write specifications for compliance upfront and get all parties to sign
– Think about workflows from the start
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Consultants/contractors overestimate their expertise
Can’t just reverse a clean room
Budget & contingencies
Emphasized BSL3 energy costs
Client (lab owner) needs to be knowledgeable about what they want
Need awareness / education on need for maintenance
– EX: BSC in service for 20 years with daily use but never been tested or maintained
• EX: 2 years each to design and build labs in Laos and Thailand
The BSL3 Lab at Institut Pasteur du
Maroc
• Decided to build because of concern about possibility for emerging
epidemics
• No local contractor capable to build the BSL3
• Ministry of Finance wanted to do open tender but ultimately hired
same supplier that was installing 2 other BSL3 labs in Morocco
– To facilitate building up common pool of operations and maintenance expertise in
country
• Designed to be small to save on energy costs
• Annual maintenance budget: $30K regardless of whether they do any
work
• Not used a lot but they have it when needed. Also used for training but
that is also costly
A rational and attainable approach to
successfully implementing biosafety
in lab settings worldwide
• THINK OUTSIDE THE BOX
– Flexible to find best solutions for a specific situation
– Do the risk assessment to determine what controls are needed
• Balance of practices/protocols, facilities (protects neighbors), and
equipment
• Examples:
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Sealable for gas decontamination versus surface wipe down if needed
Many demands on autoclaves: flaming loops outside BSC; chemical waste decon
How necessary is redundant design? (ie what downtime can your facility sustain?)
ACH : determine what’s needed for your own facility given your heat loads,
activities, standby mode
Engineering control: Challenges in
maintaining BSL3 (Indonesia)
• Need : Diagnose diseases in shortest possible time, prevent diseases
(vaccine development), and cure diseases (drug development)
• Due to local situation, decided on modular BSL3
– Started process in 2005, operational in 2009
• Specialized human capacity to run the facility is a major focus across
spectrum of BS&S topics
– advocacy/regs; training workshops; assessment; management; facilities
– Have had to develop series of biorisk training programs
– Especially lack of expertise on engineering side which impacts
maintenance/validation/certification of equipment
Common themes from talks &
discussion
• Time to go from idea to operation
– 2 – 4 years
• Need to understand why building a BSL3 to optimize the expensive
lab footprint
– When can work be done on inactivated pathogens
• Energy costs
– Green designs may help but limitations to safety concerns, mold, humidity, etc
• Lack of engineering / maintenance expertise
– Need to work with local craftsmen and train them on construction and maintenance
details if the facility is going to be sustainable
• No one size fits all solution
• Possibility for regional labs to enable pooling of resources but many
countries will still have their own priorities/needs