Learning Objectives Know the basic components of specimen
collection kits for use with suspect avian influenza cases Know
what specimens to collect, how to collect them, store them, and
transport them to the laboratory Discuss diagnostic tests and
laboratory data management
Slide 3
The Specimen Collection Kit
Slide 4
Specimen Collection Kit Personal protective equipment
Collection vials with VTM Polyester fiber- tipped applicators
Tongue depressors Items for blood collection Secondary container/
cooler Ice packs Suspect case forms A pen or marker for labeling
samples Labels
Slide 5
How to Manage Kits Store specimen collection kits in a dry,
cool place Store specimen collection kit where it will be
accessible after hours and on weekends
Slide 6
How to Safely And Correctly Collect Specimens Image obtained
from www.nlm.nih.gov Target region for seasonal influenza Target
region for H5N1 detection
Slide 7
What to Collect Preferred specimens Oropharyngeal swabs Lower
respiratory tract specimens Bronchoalveolar lavage or tracheal
aspirates Other specimens Nasopharyngeal swabs Nasal swabs and
aspirates Acute and convalescent sera Sputum specimens Collect
samples on several different days
Slide 8
When to Collect Respiratory Specimens As soon as possible after
symptoms begin Ideally before antiviral medications are
administered Collect multiple specimens on multiple days
Slide 9
Updated Interim Guidance for Laboratory Testing of Persons with
Suspected Infection with Avian Influenza A (H5N1) Virus in the
United States Testing for avian influenza A (H5N1) virus infection
is recommended for a patient who has an illness that: requires
hospitalization or is fatal; AND has or had a documented
temperature of 100.4 F; AND has radiographically confirmed
pneumonia, acute respiratory distress syndrome (ARDS), or other
severe respiratory illness for which an alternate diagnosis has not
been established; AND has at least one of the following potential
exposures within 10 days of symptom onset:
Slide 10
A) History of travel to a country with influenza H5N1
documented in poultry, wild birds, and/or humans, AND had at least
one of the following potential exposures during travel: direct
contact with (e.g., touching) sick or dead domestic poultry; direct
contact with surfaces contaminated with poultry feces; consumption
of raw or incompletely cooked poultry or poultry products; direct
contact with sick or dead wild birds suspected or confirmed to have
influenza H5N1; close contact (approach within 1 meter [approx. 3
feet]) of a person who was hospitalized or died due to a severe
unexplained respiratory illness;
Slide 11
B) Close contact (approach within 1 meter [approx. 3 feet]) of
an ill patient who was confirmed or suspected to have H5N1; or C)
Worked with live influenza H5N1 virus in a laboratory.
Slide 12
Case by Case Considerations! Mild or atypical disease
(hospitalized or ambulatory) with one of the exposures listed above
Severe or fatal respiratory disease whose epidemiological
information is uncertain, unavailable, or otherwise suspicious but
does not meet the criteria above
Slide 13
Personal Protective Equipment Gloves Mask Gown Eye
protection
Slide 14
Suspect Case Form Patient name Unique identification number
Patient symptoms and date of onset Specimens and collection date
Whether or not patient is hospitalized Patient contact information
Patient demographic information
Slide 15
Specimen Tracking System Maintain a database to track:
Identification number Subject information Type of specimen Specimen
collection date Specimen collection location Date of laboratory
receipt of specimen Date tested Diagnostic test results
Slide 16
Specimen Storage, Handling, and Transportation
Slide 17
How to Store Specimens For specimens in VTM and Sera: Transport
to laboratory as soon as possible Store specimens at 4 C before and
during transportation within 48 hours Store specimens at -70 C
beyond 48 hours Do not store in standard freezer keep on dry ice or
in refrigerator Avoid freeze-thaw cycles Better to keep on ice for
a week than to have repeat freeze and thaw
Slide 18
All diagnostic specimens should be shipped on dry ice.
Double-bag specimens if dry ice is used. For short distances can
keep specimens at 4 C Fill a cooler with ice packs or coolant packs
Double-bag specimens if you use dry ice Include an itemized list of
specimens with identification numbers and laboratory instructions
Packing Specimens for Transportation
Slide 19
Transporting Specimens Initial testing at State Public Health
Laboratory Call CDC Hotline before sending specimens for reference
testing 770-488-7100 Send overnight or using appropriate means
based on recommendations from the State Department of health or CDC
Include inventory sheet and CDC case ID number Coordinate with the
laboratory
Slide 20
Laboratory Biosafety Laboratory testing of suspected novel
influenza viruses should be conducted in biosafety level 3 (BSL-3)
laboratories Infectious agents that may be transmitted via the
airborne route PPE for laboratory personnel may include
respirators
Slide 21
Managing Laboratory Data
Slide 22
Data Management Rules Double check data entry accuracy Include
unique identification numbers Keep subject names confidential Track
testing dates and results Back up the database
Slide 23
Computer Software Epi-info (CDC) Free, at
http://www.cdc.gov/epiinfo/http://www.cdc.gov/epiinfo/ Microsoft
Excel and Access Oracle MySQL Filemaker Pro
Slide 24
How to Present Results Report: Time and place of the outbreak
Prevalence of infection Clinical information about cases Epidemic
curve Share results with local health officials and CDC
Slide 25
Laboratory Tests
Slide 26
Laboratory Diagnosis for Influenza Tests for respiratory
samples: PCR-based techniques Virus isolation Immunofluorescence
Rapid antigen detection Blood used for: Measurement of specific
antibodies (Most common for influenza, sera is used) Viral
isolation (whole blood if viremia is a consideration) PCR-based
techniques (sera)
Slide 27
Laboratory Tests for Avian Influenza A (H5N1) PCR Based
Techniques- recommended Sensitivity depends on the particular test,
the influenza strain, and the type of specimen used Virus Isolation
Technically difficult Requires a BSL-3 laboratory with
enhancements
Slide 28
Serological Samples Paired serum samples are most useful Acute
sample Within 7 days after symptom onset Convalescent sample 2 to 4
weeks after acute sample
Slide 29
Summary When handling infectious materials in the laboratory or
in the field, take safety precautions. Proper specimen storage,
handling, and shipping are vital to successful laboratory tests.
Maintain adequately stocked specimen collection kits and store them
properly when they are not in use.
Slide 30
Summary Oropharyngeal swabs and lower respiratory specimens are
the best specimens to collect for avian influenza A (H5N1). Collect
multiple specimens (respiratory and blood) on multiple days. Keep
track of information on the specimens collected in a database or
logbook. Properly dispose of any infectious material.
Slide 31
Laboratory Practice Exercise May, 2007
Slide 32
References and Resources Recommended laboratory tests to
identify avian influenza A virus in specimens from humans. World
Health Organization, June, 2005.
http://www.who.int/csr/disease/avian_influenza/guide
lines/avian_labtests2.pdf
http://www.who.int/csr/disease/avian_influenza/guide
lines/avian_labtests2.pdf WHO guidelines for the collection of
human specimens for laboratory diagnosis of avian influenza
infection, 12 January 2005.
http://www.who.int/csr/disease/avian_influenza/guide
lines/humanspecimens/en/index.html
http://www.who.int/csr/disease/avian_influenza/guide
lines/humanspecimens/en/index.html