Lessons Learned from Proficiency Testing and Exercises

Analysis. Answers. Action. www.aphl.org Lessons Learned from Proficiency Testing and Exercises October 11, 2017 Dial-In Number: 866.740.1260 or 303.248.0285 Access 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. Analysis. Answers. Action. www.aphl.org

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. Analysis. Answers. Action. www.aphl.org

Moderator Philip A. Lee, MSc Lead Biological Defense Coordinator Bureau of Public Health Laboratories Jacksonville Florida Department of Health Analysis. Answers. Action. www.aphl.org

Presenters Patricia Bennie, BS, MT(ASCP) Biological Safety Outreach Officer Georgia Public Health Laboratory Georgia Department of Public Health Marie-Claire Rowlinson, PhD, D(ABMM) Assistant Laboratory Director Bureau of Public Health Laboratories Jacksonville Florida Department of Health Analysis. Answers. Action. www.aphl.org

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. Analysis. Answers. Action. www.aphl.org

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APHL Biosafety and Biosecurity Resources Please visit aphl.org/biosafety Analysis. Answers. Action. www.aphl.org

Additional Resources Biothreat Agent Bench Cards and Poster for the Sentinel Clinical Laboratory Sentinel Clinical Laboratory Definition Packaging and shipping training, other workshops Analysis. Answers. Action. www.aphl.org

APHL Resources Virtual Knowledge Assessment ASM Sentinel Level Clinical Laboratory Protocols For Suspected Biological Threat Agents and Emerging Infectious Diseases Analysis. Answers. Action. www.aphl.org

Analysis. Answers. Action. www.aphl.org Utilizing the Laboratory Preparedness Exercise to Improve Practices In Sentinel Clinical Laboratories Pat Bennie, MT(ASCP) Biosafety Outreach Officer Georgia Public Health Laboratory

LABORATORY PREPAREDNESS EXERCISE Analysis. Answers. Action. www.aphl.org

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). Analysis. Answers. Action. www.aphl.org

Background In 2003 Mimic organisms for bioterrorism agents Photomicrograph challenges In 2005 MOU signed among CAP, APHL and CDC In 2007 Included attenuated strains of actual bioterrorism agents. In 2008 Name changed to: Laboratory Preparedness Exercise(LPX) Analysis. Answers. Action. www.aphl.org

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. Analysis. Answers. Action. www.aphl.org

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 Analysis. Answers. Action. www.aphl.org

CAP/LPX Provides: Realistic biothreat agent challenge exercise Educational exercise that will test most aspects of a laboratory bioterrorism response. Analysis. Answers. Action. www.aphl.org

Realistic Challenge Exercise Analyte Challenges/Shipment Number of Specimens Live organisms 3 Two shipments per year Number of Labs ~1400/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. Analysis. Answers. Action. www.aphl.org

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 Analysis. Answers. Action. www.aphl.org

Public Health Lab/Sentinel Clinical Laboratory Test Communications Packaging and Shipping Drills Administrative Controls/Work practices Analysis. Answers. Action. www.aphl.org

Test Communications Analysis. Answers. Action. www.aphl.org

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Final Critique and Summary Report Analysis. Answers. Action. www.aphl.org

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. Analysis. Answers. Action. www.aphl.org

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 Analysis. Answers. Action. www.aphl.org

Bioterroism Agents /Select Agents Brucella sp. abortus, suis, melitensis Bacillus anthracis Burkholderia pseudomallei Bukholderia mallei Yersinia pestis Francisella tularensis Analysis. Answers. Action. www.aphl.org

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 Analysis. Answers. Action. www.aphl.org

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. Analysis. Answers. Action. www.aphl.org

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Funding Sources for LPX Purchase Analysis. Answers. Action. www.aphl.org

Benefits and Value Time Expense?? Analysis. Answers. Action. www.aphl.org

Thank You! Pat Bennie Patricia.Bennie@dph.ga.gov 404 327-7949 Analysis. Answers. Action. www.aphl.org

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

Objectives 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 35

Brucella laboratory acquired infections 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 36

Brucella exposures in the state of Florida 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 Year Reported Cases FL residents Cases non-fl residents Total 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 37

Identification of Brucella species in the microbiology laboratory 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 38

Identification of Brucella species in the microbiology laboratory 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 39

Risk! Potential for Exposure and Infection 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 plan 2. Perform a risk assessment and implement any necessary changes that are identified 3. Ensure staff are trained and competent 4. Be prepared 40

Brucella abortus RB51 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 postexposure 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 41

Brucella abortus RB51 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, Brucella microagglutination 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 42

Haven t we seen Brucella abortus RB51 somewhere before? 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. 43

Haven t we seen Brucella abortus RB51 somewhere before? 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 Assessment 3) Survey The event highlighted the potential vulnerability of laboratorians during large-scale events involving highly lethal infectious agents, even when the agent is recognized. 44

Brucella abortus RB51 in 2017 On 2/14 AAB PTS sends out a PT The American Association of Bioanalysts Proficiency Testing Service (AAB PTS) 1 st 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 45

Brucella abortus RB51 in 2017: Timeline AAB PTS send out 1 St Quad 2017 Bacteriology Program to 138 labs 2/14 February 2017 46

Brucella abortus RB51 in 2017: Timeline AAB PTS send out 1 St Quad 2017 Bacteriology Program to 138 labs BPHL receives the PT - sample #5 is a swab specimen with instructions to identify all organisms isolated 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 DNA sequencing is requested on the un-identified organism 2/14 2/16 2/22 February 2017 49

Confirmation of Brucella species in a PT sample 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 realtime 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 54

Response 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 55

Response - How many other labs received the PT? 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 56

Response 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 57

Response 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 58

Response 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 59

Response temperature monitoring 60

Rapid response! 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 61

Lessons learned 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 prepared 5. Learn from mistakes... 62

Actions taken 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 63

Actions taken 1. Improve communication with colleagues and supervisors e.g. daily huddle 2. Develop other resources for training and preparedness activities 64

Actions taken 1. Review your biosafety program annually a. Biosafety manual b. Biosafety training c. Perform risk assessments 2. Utilize the Biosafety Outreach Officers 65

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 66

Thank you! Questions? Acknowledgements Susanne Crowe, Interim BPHL Bureau Chief/ Jacksonville Lab Director Phil Lee, and BPHL BT and Microbiology Staff Danielle Stanek, Bureau of Epidemiology