The Idaho Bureau of Laboratories and

Emergency Preparedness

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Michael Stevenson, Ph.D.IBL Emergency Preparedness Section Manager

stevensm@dhw.idaho.gov

208-334-2235 x269

October 24, 2013

“I wish you’d learn to put the lid on your petri dish,Harry! We came here today with just four kids butnow it looks like we’ve got several million!!”

Objectives• Overview of the Idaho Bureau of Laboratories (IBL)

• Overview of the Laboratory Response Network (LRN)

• Overview of the Select Agent Program

• Emergency Preparedness testing at IBL

• How IBL can assist with infection control

3NO FOOD OR DRINK

WEAR PROTECTIVE

CLOTHING

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The Idaho Bureau of LaboratoriesAs Idaho’s state public health laboratory, IBL provides laboratory services to support the programs within the Department of Health and Welfare, Idaho’s seven Public Health Districts, and other state agencies.

Training• Continuing medical education

seminars and telelectures• Formal presentations at

conferences• State Training Coordinator

Inspection• Clinical and environmental

laboratories• X-ray and mammography units• Air quality monitoring stations

Testing• Communicable disease agents in

clinical specimens• Contaminants or adulterants in

water, food, and soils• Biological and chemical threats

Outreach• Maintenance of Idaho Sentinel

Laboratory Network (ISLN)• Publication/presentation of

applied public health research• Development/validation of new

analytical methods

IBL Statistics• 20,000 square feet laboratory space

• Approximately 40 full-time employees

• ~ 60,000 samples per year• 72% Microbiology

• 26% Environmental

• 2% Emergency Preparedness

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IBL Program OrganizationBureau Chief

Business Operations

Administration

Data

Management

Facilities

Shipping & Receiving

Emergency Preparedness

Biological

Threat (LRN-B)

Chemical

Threat (LRN-C)

Food Testing

Environmental Analysis

Air Quality

Certification

Inorganics

Microbiology

Organics

Laboratory Improvement

Clinical Labs

X-Ray

Microbiology

Bacteriology

Molecular Epidemiology

Myco-bacteriology

Virology-Serology

QA/QC

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Christopher L. Ball, Ph.D., HCLD (ABB)

Emergency Preparedness Section• Michael Stevenson, Ph.D. – Scientist 4, Section Manager• Justin Grant, B.S. – Scientist 2, Chemist• Wendy Loumeau, B.S. – Health Education Specialist, STC• Dan Rousselle, B.A. – Scientist 3, Chemist• Robert Voermans, B.S. – Scientist 3, Microbiologist

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First Responders Post Office BiohazardDetection System (BDS)

Incident

Unknown powders, anthrax threat letters

Evidence

Biosafety Level 3(BSL3) Laboratory

Testing

Conventional methodsB. anthracis culture

Rapid methodsReal-time PCR

Anatomy of a Biological Terrorism EventBoise Fire

Department, HazMat Region IV

Idaho 101st Civil Support Team

FBI

IBL Emergency Preparedness

Section

LRN protocols

The Laboratory Response Network

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Level 3 Level 2 Level 1 CDC

LRN-B LRN-C

CDC, Atlanta, GA

The Laboratory Response Network• The LRN was established by the Department of Health and

Human Services’ CDC in accordance with Presidential Decision Directive 39, which outlined national anti-terrorism policies and assigned specific missions to federal departments and agencies.

• The LRN became operational in August 1999 through a collaborative effort involving LRN founding partners, CDC, FBI and APHL.

• The LRN is the premier system for identifying, testing and characterizing potential agents of bio- and chemical threats.

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• Typically hospital/clinical laboratories - voluntary

• Broadly, all laboratories analyzing or referring specimens that may contain microbial agents or toxins

• Rule out or refer to nearest LRN Reference Laboratory if potential select agent

Laboratory Response Network for Biological Threats (LRN-B)

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Idaho Sentinel Laboratory Networkin the seven Public Health Districts

LRN-B Reference Laboratories • Typically are public health

laboratories

• Receive isolates from Sentinel Laboratories for confirmation

• Perform conventional and rapid molecular biological agent testing

• Process environmental samples

• Receive mandatory LRN proficiency test samples

• IBL is Idaho’s LRN-B reference labBiosafety Level-3 laboratory

Registered Select Agent entity13

LRN-B National Reference Laboratories

• CDC (Atlanta)

• USAMRIID (Frederick, MD)

• Have highest biosafety level(BSL4) to work with highly dangerous/infectious agents (smallpox, Ebola)

• Have advanced methods to further characterize isolates of biological agents, i.e. “microbial forensics”

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Under United States law, select agents are bacteria, toxins, viruses, or fungi which have been declared by the U.S. Department of Health and Human Services or by the U.S. Department of Agriculture to have the potential to pose a severe threat to public health and safety.

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Select Agents

Cutaneous anthraxBubonic plague

Tularemia

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Select Agents

Anthrax

Plague

Brucellosis

Tularemia

Environmental Threats:

Threat letter

Terrorism:

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www.selectagents.gov

Code of Federal Regulations (CFR)Title 42 – Public HealthPart 73 – Select Agents and Toxins

• Centers for Disease Control and Prevention (CDC), Division of Select Agents and Toxins (DSAT)

• Animal and Plant Health Inspection Services (APHIS), Agricultural Select Agent Program

Select Agent Program

• The Select Agent Program is administered by CDC and APHIS, and regulates laboratories that may possess, use, or transfer select agents within the United States.

• The Select Agent Program was established to satisfy requirements of the USA PATRIOT Act and the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, which were enacted in the wake of the September 11, 2001 attacks and the subsequent 2001 anthrax attacks.

• IBL is a registered entity with the Select Agent Program.

• www.selectagents.gov

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Select Agent Program

Bacterial Select Agents• Bacillus anthracis

• Botulinum neurotoxin producingspecies of Clostridium

• Brucella abortus

• Brucella melitensis

• Brucella suis

• Burkholderia mallei

• Burkholderia pseudomallei

• Coxiella burnetii

• Francisella tularensis

• Rickettsia prowazekii

• Yersinia pestis

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Burkholderia pseudomallei

Brucella

Viral Select Agents• Crimean-Congo haemorrhagic fever virus

• Eastern Equine Encephalitis virus

• Ebola virus

• Lassa fever virus

• Monkeypox virus

• South American Haemorrhagic Fever viruses

• Tick-borne encephalitis complex (flavi) viruses

• Variola major virus (Smallpox virus)

• Nipah Virus

• Rift Valley Fever Virus

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Ebola virus

Monkeypox virus

Toxin Select Agents

• Abrin

• Botulinum neurotoxins

• Conotoxins

• Ricin

• Staphylococcal enterotoxins

• T-2 toxin

• Tetrodotoxin

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Rosary peas abrin

Castor beans ricin

Laboratory Response Network for Chemical Threats (LRN-C)

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Level 362 labs• Work with hospitals/labs• Comprehensive CTresponse plan

• Competency in SCPaS

Level 246 labs• Level 3 activities• Proficient in CT analyses(e.g. cyanide, VOC)

• Surge capacity lab

Level 110 labs• Level 2 activities• Proficient in more CTanalyses (e.g. mustards)

• Conduct CDC research

CDC

Analytical Capability

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Level 2 Labs

Level 3 Labs

Level 1 Labs

Level 3American SamoaChicagoGuamMicronesiaLos AngelesMarshall Is.N. Mariana Is.New York CityPalauPuerto RicoUS Virgin Islands

Level 2District ofColumbia

2004

LRN-C Laboratories

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Chemical Agents - Classes

• Pulmonary Agents: Chemicals that cause severe irritation/swelling of the respiratory tract• Phosgene (respiratory distress, choking)

• Chlorine, Chlorpicrin, Diphosgene

• Blood Agents: Poisons that affect the body by being absorbed into the blood • Hydrogen Cyanide (vertigo, tachycardia)

• Carbon Monoxide, Hydrogen Sulfide

• Biotoxins: Poisons that come from plants or animals• Ricin (respiratory distress, fever, coughing)

• Abrin, Strychnine

http://emergency.cdc.gov/chemical/

• Nerve Agents: Highly poisonous chemicals that work by preventing the nervous system from working properly• Sarin (diarrhea, miosis, bradycardia)

• Soman, Tabun, VX

• Vesicants: Chemicals that bliser the eyes, respirator tract, and skin on contact• Sulfur Mustard (itching, yellowish blisters)

• Nitrogen Mustard, Phosgene Oxime

• Industrial Chemicals: raw materials to convert into thousands of products• Metals (mercury, lead, arsenic, cadmium)

• Volatile Organic Compounds (VOCs)

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Chemical Threat Agents Tested at IBL

• Cyanide

• Toxic Metals(Cd, Hg, Pb)

• Volatile Organic Compounds(benzene, carbon tetrachloride, chloroform, 1,2-dichloroethane, ethylbenzene, styrene, tetrachloroethene, toluene, o-, m-and p-xylene)

• Abrine (abrin marker)

• Ricinine (ricin marker)

• HNPAA (explosive metabolite)

• Tetramine (rat poison)

• Metabolic Toxins(monochloroacetate, monofluoroacetate)

• Organophosphate Nerve Agents(sarin, soman, cyclohexylsarin, VX, Russian VX)

• Toxic Metals(As, Ba, Be, Cd, Pb, Tl, U)

BLOOD URINE

Emergency Preparedness Testing

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Proficiency Tests• LRN-B: swabs, powders, HEPA socks, sponges• LRN-C: blood, serum, urine, powders, liquids• Food Emergency Response Network (FERN)

• Arsenic in apple juice• Tetramine in beer• Yersinia pestis in hot dogs• Unknown agents in milk

Clinical• cultures, swabs, tissues• ticks, horse blood

Environmental• biothreat letters (3 sent to Boise government offices)• consumer products (arsenic in contact lens solution)• ultrafiltration of large volume water samples (Salmon River outbreak)

Food: posole soup, chicken, ice cream, fruit, peanut butter, salsa

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How IBL Can Assist with Infection Control

http://www.cdc.gov/phpr/zombies.htm

“If you are generally well equipped to deal with azombie apocalypse you will be prepared for ahurricane, pandemic, earthquake, or terrorist attack.”

28• Laboratory-Acquired Human Glanders [Burkholderia mallei] – Maryland,

2000. MMWR (2000), 49(24), 532-5.

Laboratory Acquired Infections (LAI)

• Laboratory-Acquired Brucellosis – Indiana and Minnesota, 2006. MMWR (2008), 57(02), 39-42.

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Center for Infectious Disease Research and Policy www.cidrap.umn.edu/

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www.cdc.gov/salmonella/pdf/CDC_LAI_Prevention_Poster_012313_508.pdf

Infection Control: Scientist POVproper biosafety practices, training

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Standard Microbiological Practices: DO NOT’s

Unauthorized entry

Mouth pipetting Eating, drinking, smoking, applying

cosmetics, handling contact lenses

Poor housekeeping

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Mechanical pipetting

Disinfect work areas

Vigorous hand washing with mild soap for

several seconds

Sharps containers

(10% bleach made fresh daily)

Standard Microbiological Practices: DO’s

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IBL Biosafety Level PPE

NO LAB WORK

LOW RISK

HIGH RISK

PAPR or N/P-100

LOW RISK

HIGH RISK

PAPR

Donning• don lab coat when entering lab• don gloves and safety glasses before working

Doffing• dispose of gloves in biohazard container• remove lab coat before leaving lab

Donning and Doffing procedures are given to authorized staff who work in the BSL-3 suite.

Donning• don lab coat when entering lab

Doffing• remove lab coat before leaving lab

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Instructions for Shipping Blood/Urine Samples

Centers for Disease Control and PreventionAttn: Lt. Ernest McGahee4770 Buford Hwy/Building 110 Loading DockAtlanta, GA 30341(770) 488-7579

sample box with adsorbent pad

UN 3373 label(blood and urine)

seal lid on; return addressshipping manifest in bag

sample, cushioning, more coolantline with coolantadsorbent pad in shipper boxseal with evidence tape and initial

place in white envelopewrap box in pad; tape; seal into bagseal with evidence tape and initial

blood

initials half off tape

urinedry ice

bloodice packs

Class 9/UN 1845 label(for dry ice only) FedEx to CDC or IBL

Idaho Bureau of LaboratoriesAttn: CT Lab Coordinator2220 Old Penitentiary RdBoise, ID 83712(208) 334-2235

urine

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• A “fever watch” is recommended for all laboratory personnel who have worked with select agents.

• Affected staff should be aware if they develop an unexplainable febrile illness or abnormal body temperatures within two weeks of working withthese agents.

• Notify supervisor and/or seek medical care.

Fever Watch

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If working with a slow-growing, Gram negative, coccobacillusbacteria, move work into a biosafety cabinet.

Infection Control: Scientist POV

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Look-alike OrganismsSelect Agent Organism Resembling Select Agent

Bacillus anthracis Could be disregarded as a lab contaminant

Brucella species Haemophilus influenza

Burkholderia mallei or B. pseudomallei Burkholderia cepacia

Francisella tularensis Actinobacillus species

Yersinia pestis Shigella species or Y. entercolitica

AVOID CONFUSION

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Automated ID Systems: Mis-Identification

Most automated systems carry an inherent risk for the productionof infectious aerosols. Using these systems with a potentialbiothreat agent is not recommended.

Example: Yersinia pestis may key out instead as Shigella, H2S-negative Salmonella, Acinetobacter, or Y. pseudotuberculosis.

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Automated ID Systems: Mis-Identification

Four different clinical laboratories attempted to identify the isolate. Three different commercial automated systems identified the organism as Acinetobacter lwoffii, Pseudomonas luteola, and Yersinia pseudotuberculosis, respectively. However, 25 days after specimen collection, the isolate was identified as Y. pestis … at the Spokane (Washington) Regional Health District Laboratory, prompting notification of the Oregon Health Authority.

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DescriptionIdaho Bureau of Laboratories (IBL) will conduct a workshopthat provides an overview of the sentinel laboratory’s rolein the presumptive identification of agents of biologicalthreat. Participants will review the Laboratory ResponseNetwork (LRN) and sentinel laboratory protocols for rulingout suspect agents. Laboratory demonstrations will outlinethe microbiology of these agents to recognize the culture,staining, and biochemical characteristics.

RegistrationRegister online at www.keysurvey.com/f/542874/2603/Please register by October 29th.

Sentinel Laboratory

Biothreat Preparedness Workshop

November 5, 20139:00 am - 5:00 pmIdaho Bureau of Laboratories2220 Old Penitentiary Road

Boise, ID 83712208-334-2235

www.statelab.idaho.gov

Contact Wendy Loumeau with questionsPhone: 208-334-2235 x 258Fax: 208-334-4067Email: Loumeauw@dhw.idaho.gov

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Emergency Preparedness SectionMichael Stevenson, x269, stevensm@dhw.idaho.gov

Justin Grant, x252, grantj@dhw.idaho.gov

Wendy Loumeau, x258, loumeauw@dhw.idaho.gov

Dan Rousselle, x270, rousseld@dhw.idaho.gov

Robert Voermans, x255, voermanr@dhw.idaho.gov

Idaho Bureau of Laboratories2220 Old Penitentiary Rd

Boise, ID 83712208-334-2235

www.statelab.idaho.gov

Questions? Thank you!