Laboratory Response
Network Sentinel
Laboratories
Elizabeth A. Macias, Ph.D., D(ABMM)
Gatekeeper, Air Force LRN Laboratories
Air Force Institute for Operational Health
Epidemiological Surveillance Division
(AFIOH/SDE)
Brooks City-Base, TX
What is the Laboratory
Response Network ?
Laboratory Response
Network (LRN)
• Established in 1999 by the Centers for
Disease Control and Prevention (CDC)
• Integrated network of laboratories – state
and local public health, hospital, military,
veterinary, and international
• Respond quickly to biological and chemical
terrorism, as well as emerging infectious
diseases and other public health threats
LRN Structure
AF LRN
August 2007 - National Laboratory Response
Network Policy Letter
• Discusses definition of Basic and Advanced
Sentinel laboratories
• “AFMS laboratories will have the CDC
technical protocols, notification
procedures, and procedures to properly
ship clinical samples in place by 1 October
2007…”
LRN Sentinel Laboratories
If you perform routine diagnostic Microbiology
cultures, then you are a Sentinel laboratory.
Minimum requirements:
- Follow BSL-2 guidelines
- Plate cultures on blood and chocolate agar
- Microscopy capability (Gram stains, wet
mounts)
LRN Sentinel Laboratories
• Perform testing on clinical specimens, not
environmental samples
• Presumptive testing - protocols on American
Society for Microbiology (ASM) website
http://www.asm.org/Policy/index.asp?bid=6342
• Recognize, rule-out, and refer to Reference or
National laboratories for further testing
LRN Structure
Basic Sentinel
Clinical
Laboratory
Advanced Sentinel
Clinical Laboratory
LRN Sentinel Labs
Serve as “sentinels” for early detection of an
agent that cannot be ruled out as a possible
bioterrorism-associated organism
LRN Sentinel Labs
Must utilize standardized testing protocols
designed to utilize conventional tests to
facilitate the “rule out” or “referral” of
suspicious isolates to an LRN Reference lab
ASM website:
http://www.asm.org/Policy/index.asp?bid=6342
LRN Sentinel Labs
LRN Sentinel Labs
LRN Sentinel Labs
Sentinel labs should not accept environmental
(powders, letters, packages), animal, food, or
water specimens for examination, culture, or
transport for bioterrorism-associated agents
Such specimens should be submitted directly
to the nearest LRN Reference laboratory.
X
LRN Sentinel Labs –
Important Reminders
Very likely that the lab will not be
contacted in advance and informed that
one of the potential agents of
bioterrorism is suspected in the patients’
specimens
LRN Sentinel Labs –
Important Reminders
Essential that appropriate safeguards are taken
including:
• All blood cultures should be subcultured in
a biosafety cabinet
• Follow flowcharts for suspicious agents
• Always considering the possibility of
bioterrorist agents.
LRN Sentinel Labs –
Important Reminders
Your lab should know how to assist clinicians
in the diagnosis and management of patients
who have been overtly or covertly exposed to
a BT agent by:
• Promptly providing accurate information
on the selection and collection specimens
LRN Sentinel Labs –
Important Reminders
Your lab must know how to…
• Handle these specimens in a manner that
will result in the greatest probability of
success in establishing a diagnosis
- Collect proper specimens
- Store and transport specimens at
proper temperatures to ensure
stability
LRN Sentinel Labs –
Important Reminders
Your lab must know how to…
• Minimize exposure of hospital personnel
and patients to infectious agents
- Proper PPE
- Lab safety
- Proper packaging and transport of
specimens
LRN Sentinel Labs –
Important Reminders
In a suspected or confirmed BT event,
immediate and effective communication is
imperative
You should notify:
• Appropriate institutional and medical
personnel
• Designated BT coordinator (usually PHO or
Infection Control
LRN Sentinel Labs –
Important Reminders
The Sentinel laboratory is NOT responsible
for and SHOULD NOT make the decision
that a BT event has occurred
That responsibility rests with local, state,
and federal health and law enforcement
officials
LRN Sentinel Labs –
Important Reminders
NOTE: Certain geographic areas are known
to have natural human cases of infection due
to BT agents. For example:
• Tularemia in Nantucket and Martha’s
Vineyard, Massachusetts, as well as
Missouri, Oklahoma, and neighboring areas
• Plague in much of the southwestern United
States, especially New Mexico
COLLEGE OF AMERICAN
PATHOLOGY PROFICIENCY
TESTING (CAP PT)
2007 “Laboratory
Preparedness Survey” (LPS)
2008 “Laboratory
Preparedness Exercise”
(LPX)
CAP Laboratory
Preparedness PT
• Developed as a collaborative effort between
CAP, CDC, and APHL
• Tests the preparedness of labs across the
U.S. to handle potential PH emergencies
related to BT agents
• Labs are sent live organisms that exhibit
characteristics of BT agents and expected to
respond following LRN protocols
Excerpt from 2008 CAP PT catalog
CAP Laboratory
Preparedness PT
• All agents are excluded from the CDC’s
select agent list
• May include strains of B. anthracis, Y. pestis,
F. tularensis, and B. abortus that have been
modified and are safe for testing in a lab that
contains a certified, properly functioning
Class II Biological Safety Cabinet (BSC) and
is capable of handling Category A and B
agents
Excerpt from 2008 CAP PT catalog
CAP Laboratory
Preparedness PT
Placing an order for the Lab Preparedness PT
requires a signature by the Laboratory Director
on a “Certificate of Acceptance” form
• “I have reviewed the list of potential
organisms to be provided …”
• “Our facility has a properly functioning,
certified Class II BSC and we are capable of
handling Category A and B agents….”
CAP PT –
LPS-B 2007
Biohazard
Warning –
p.1, bold font
CAP PT –
LPS-B 2007
LPS – B, Shipped October 2007
Kit Instructions state on page 1, “Biohazard
Warning”:
• Your lab must have a properly functioning
Class II Biological Safety Cabinet in order to
participate in this Survey
• All specimens in this Survey should be
handled in a Biological Safety Cabinet with
BSL-3 primary barriers and safety equipment
CAP PT –
LPS-B 2007
Biohazard Warning (continued):
• These strains are attenuated but they
represent potentially dangerous pathogens
and should be handled as if they are capable
of transmitting disease.
• Participants should wear gloves and
protective clothing with a solid-front and
perform all manipulations in a Class II BSC
CAP PT –
LPS-B 2007
Biohazard Warning (continued):
• Additional information on laboratory safety
and agent specific precautions can be found
on the CDC website:
http://www.cdc.gov/od/ohs/biosfty/biosfty.htm
CAP PT –
LPS-B 2007
CAP PT –
LPS-B 2007
All five specimens (LPS06 – LPS10) had the
following for testing instructions: “Labs are
instructed to follow the LRN procedures to
rule out or refer potential BT agents….”
• Bottom line: Labs were notified up front
that these were potential BT agents
• More often than not, we will not have that
happen with actual clinical specimens.
Brucella Exposure
Overview
• CAP LPS-B survey sent 15 Oct 2007
• CDC notified on 27 Nov by the New York
State Dept of Health (NYSDOH) of potential
exposures to the Brucella RB51 strain
during the LPS exercise
• Exposure initially occurred after a RB51
specimen was mislabeled as a routine
patient specimen and submitted to the
NYSDOH lab
Brucella Exposure
Overview
• Personnel (24) exposed in the NYSDOH lab
• Survey conducted by NYSDOH of their
sentinel labs determined that 17 LPS
participating labs did not handle the survey
correctly
• As of 14 January, 2008, follow up in labs
across the U.S. identified a total of 916 lab
workers in 254 labs with potential RB51
exposure
Brucella Exposure
Overview
Some examples of how the exposures occurred:
• Improper shipping and handling of isolates
• Subculturing of isolates on routine lab
bench
• Sniffing subcultures
• Setting up susceptibility tests on routine
bench
• Spilling blood culture bottles
• Aerosol generation from ruptured
centrifuge tubes
Brucella Exposure
Overview
• Brucella abortus RB51 is an attenuated
veterinary vaccine strain that rarely causes
infections in humans
• Risk assessment tools, post-exposure
prophylaxis and follow up guidelines were
sent to LRN sentinel labs
Lessons Learned
• Read all PT kit instructions
• Emphasize adherence to biosafety practices
 Annual biosafety training+ +
 Include proper use of biosafety cabinet
 Frequent spot checks to ensure personnel
are using PPE and safety equipment
properly
 Perform risk assessments if you isolate a
highly pathogenic organism (i.e., Brucella
or Francisella)
Lessons Learned
Lab readiness should include training in the
characteristics of particular agents (i.e.,
Brucella) and the biosafety recommended for
handling and testing
• For example, if Gram-negative
coccobacilli are seen on a Gram stain,
Brucella and Francisella should be
thought of, especially if the patient has
compatible symptoms
Lessons Learned
Brucella spp. Gram stain characteristics:
CDC/PHIL
• Poorly staining
• Small gram-negative
coccobacilli (0.5-0.7 x
0.6-1.5 um)
• Mostly seen as single
cells and appearing
like "fine sand"
Lessons Learned
Brucella spp. colony characteristics:
• Fastidious
• Usually not visible at 24h
• Grows slowly on most
standard laboratory media
(e.g. SBA, choc and TSA)
• Pinpoint, smooth, entire
translucent, nonhemolytic at 48h
CDC/PHIL
BMBL
http://www.cdc.gov/od/ohs/biosfty/bmbl5/bmbl5toc.htm
Pandemic/Avian Influenza Information
Influenza testing
Pandemic Influenza Plans – HHS, DoD,
State-specific, WHO, … .
Appendix 4, from the HHS Pandemic
Influenza Plan: “Laboratory Biosafety
Guidelines for Handling and Processing
Specimens or Isolates of Novel Influenza
Strains”
Influenza testing
(novel strains)
• Commercial antigen detection testing for
influenza may be conducted under BSL-2
containment conditions if a Class II
biological safety cabinet is used
• Clinical specimens from suspected novel
influenza cases may be tested by RT-PCR
using standard BSL-2 work practices in a
Class II biological safety cabinet for initial
processing of patient specimens
Influenza testing
(novel strains)
• If a specimen is confirmed positive for
influenza A (H5N1) by RT-PCR, additional
testing should be performed only under BSL3 conditions with enhancements
• CDC’s Influenza Branch should be informed
immediately by contacting the CDC
Director’s Emergency Operations Center
(DEOC) at 770-488-7100
Lab Safety Summary
• All clinical labs can potential handle highly
pathogenic organisms
• High emphasis must be placed on training
and risk management
Questions?
Elizabeth A. Macias, Ph.D., D(ABMM)
Laboratory Director
Air Force Institute for Operational Health,
Epidemiological Surveillance Division (AFIOH/SDE)
2730 Louis Bauer Drive
Brooks City-Base, TX 78235-5132
COMM: 210.536.1271
DSN:
240.1271
Email: elizabeth.macias@brooks.af.mil