Transcript USAFSAM Epidemiology Laboratory Service

USAFSAM
Epidemiology
Laboratory Service
Distribution Statement A: Approved for Public release; distribution is unlimited. 311 ABG/PA No. 10-084, 12 Mar 2010
USAFSAM “EPI Lab”
DoD’s only Clinical Reference Laboratory
220+ DoD Customers
2.0+ Million Tests per Year
Microbiology
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Virology
Bacteriology
Parasitology
Immunodiagnostics
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HIV, Hepatitis
Infectious Disease Serology
Molecular Diagnostics
LIS
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Programs
• Influenza Surveillance
• USAF HIV Testing/Repository
• USAF Recruit Health Testing
• Clinical Infections Disease Testing
• LRN Reference Lab
CST (Customer Service Team)
LIS (Lab Information Systems)
COPS (Central Operations)
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Laboratory Information
Systems
Customer Service Team (CST)
Lab Information Systems (LIS)
Central Operations (COPS)
Personnel = 3 CST, 3 LIS, 20 COPS
Handle customer/specimen problems
Customer newsletters
Customer satisfaction surveys
Generate customer feedback reports
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Central Operations
Boxes arrive in lab
Specimens delivered to sections
Accessioned into CHCS
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Boxes opened,
specimens sorted
Information verified
Central Operations
Receive ~ 5000 specimens/ 8 hr day (~2.0
million/year)
Could easily ramp up to ~ 3x that volume
by adding shifts
Boxes usually arrive at ~ 0800
Delivered to testing sections in batches
every half hour
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EpiLab Web site
https://kx.afms.mil/epi/
Shipping Instructions
Shipping Material Ordering Information
Lab Guide
Import certificate
CLIP and CAP certificates
List of tests
Training videos
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EpiLab Web site
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Immunodiagnostics
BIOPLEX 2200
Tests Performed:
ANA – Positive Screen Reflexes
to SSA, SSB, Sm, RNP, dsDNA,
and Centromere
Syphilis – Reactives Sent to IFA
Section for Confirmation by
VDRL and FTA-ABS
EBV IgG, IgM, EBNA IgG - No
Reflex or Confirmation Testing
Performed
NEW: HSV-1 & HSV-2 IgG
(Moved to Bioplex on 22 Dec 2009)
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EIA
Helicobacter pylori IgG –Discontinue serum test
replacing with stool test 1April 10
Cytomegalovirus (CMV) IgG, IgM
Lyme Disease (Borrelia burgdorferi)
Mumps IgG
Measles (Rubeola) IgG
Varicella IgG
DSX instrument
Manual tests include:
Cardiolipin IgG, IgM – Discontinued test 1 Oct 09
Coccidioides Immunodiffusion Test
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IFA & MANUAL
Autoantibody Profile (AMA, ASMA, APCA)
Mycoplasma pneumoniae IgM
Cytomegalovirus (CMV) IgM
Lyme Disease (Borrelia burgdorferi) IgG,
IgM Western Blot
Rickettsia IgM
Q Fever (Coxiella burnetti) IgG, IgM
VDRL Slide Test
FTA-ABS Double Stain (performed on nonreactive VDRL’s)
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HIV
Tests Performed:
HIV 1/2/O
HIV Type 1 Western Blot (manual)
Siemens Centaur XP
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POSITIVE HIV SCREENS
SENT FOR WESTERN BLOT
2009
Total HIV Screens
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
TOTALS
35999
31858
34502
35803
32275
33686
33842
29410
32169
31004
25054
30004
385606
Positive Screens
580
Screen Positivity Rate
0.15%
Positive Western Blots
131
WB Positivity Rate
0.03%
63
65
W
E
S
T
E
R
N
B
L
O
T
S
A
M
P
L
E
S
60
55
56
55
54
55
50
45
Western Blot Average
Percentage Rate
Negative 70.2%
Indeterminate 7.2%
Positive 14.7%
Prev/Conf 7.9%
43
40
52
48
38
40
39
35
37
30
25
20
15
10
5
0
Neg
Indeterminate
Positive
Prev/Conf
Total Western Blots
JAN
21
6
7
6
40
FEB
40
10
10
3
63
MAR
37
7
6
5
55
APR
38
5
9
4
56
MAY
39
3
6
6
54
JUN
28
0
12
3
43
JUL
40
4
8
3
55
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AUG
30
2
4
3
39
SEP
26
3
3
5
37
OCT
39
0
6
3
48
NOV
27
1
6
4
38
DEC
42
1
8
1
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Hepatitis Testing
Tests Performed:
Hep A Virus AB IgM (HAV-M)
Hep A Virus AB Total (HAV-T)
Hep B Total Core AB (HBcAb-T)
Siemens
ADVIA
Hep B Core AB IgM (HBcAb-IgM)
Centaur
Hep C (HCV) AB
Hep B Surface AG (HBsAg)
AB to Hep B Surface AG(HBsAb)
Hepatitis B Envelope Ab, Ag (manual test)
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Immunodiagostics
Additional tests performed on the Centaur:
Rubella IgG, IgM
Toxoplasma IgG, IgM
Thyroid Panel
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Changes in
Immunodiagnostics
Tests moving to Bioplex 2200 pending
FDA approval:
Mumps IgG
Measles (Rubeola) IgG
Varicella IgG
Cytomegalovirus (CMV) IgG, IgM
Rubella IgG, IgM
Toxoplasma IgG, IgM
Lyme Disease (Borrelia burgdorferi)
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TAT-HIV
Days
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TAT-Hepatitis
3
2.5
2
1.5
Days
1
0.5
0
Jan
Feb
Mar
Apr
May
Jun
CY08
July
Aug
Sept
CY09
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Oct
Nov
DEC
TAT-EIA
Days
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Parasitology
Manual testing
Specimen = Stool
Ova & Parasites
• Trichrome Stains
• Concentrations
• Turn-around- time – 9 hours
Worm Identification
• Turn-around-time < 24 hours
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Trichuris trichiura ova
Schistosoma
haematobium ova
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Parasitology
Enzyme immunoassay (EIA) for:
• Giardia Specific Antigen
• Crytosporidium Specific Antigen
• Turn around time – 9 hours
Acid Fast Stain for:
• Cyclospora species
• Isospora species
• Turn around time – 9 hours
Pinworm Identification
• Turn around time – 9 hours
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Giardia lamblia
(trophozoite)
Enterobius
vermicularis (ova)
E. vermicularis
(adult worm)
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Virology
Herpes Simplex Virus testing - ELVIS
Enzyme Linked Virus Inducible System
A culture-based test for HSV only
ELVIS results in ~ 17 hrs
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Virology
Routine clinical
specimens for
viral detection
Tissue culture and
fluorescent
antibody stains
TAT = 2-14 days
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Respiratory Viral Cultures
Influenza virus A
Influenza virus B
Adenovirus
Parainfluenza virus
1-3
Respiratory
Syncytial Virus
Enterovirus
Detection in
tissue culture
Confirming by
FA stain
Positive influenza
isolates sent to
Molecular Diagnostics
for sequencing
TAT = 2-10 days
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The “Swine Flu” Team to the Rescue
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Chlamydia/GC Testing
Nucleic Acid Amplification Testing (NAAT)
Three TIGRIS walk away instruments
(Gen-Probe, Inc.)
~18,000 month (36,000 reportable results)
All positives confirmed by a supplemental
test that detects a different target
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TAT – GC/Chlamydia
Days
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Molecular Diagnostics
Nasal wash specimens preferred:
Allows for concurrent molecular and culture
analysis
Allows for enough leftover specimen for
archiving - additional testing may be requested
by the CDC
Also, original specimens may be requested by
the CDC for use as potential seed virus for
influenza vaccine production
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Nucleic Acid Extraction
Automated: easyMAG
Off board lysis (safer)
Excellent in side by side comparisons with
other automated extractors (especially with
stool)
Manual: RNA Ambion
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Target Detection
Real time RT PCR
- 7500 DX (New Norovirus)
Traditional RT PCR
- 9700 (for Sequencing)
Multiplex PCR (xTag RVP)
- Luminex (not currently utilized)
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Strain Analysis
Sanger Sequencing
Pyrosequencing
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Influenza Surge Testing
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Bacteriology
Currently, limited bacteriology service
Helicobacter pylori
stool antigen test
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H. pylori: Introduction
Isolated by Warren and Marshall from gastric
biopsies in 1983
Gram-negative organism, produces urease
Prevalence varies depending on age,
socioeconomic class, issues related to
sanitation and hygiene, and country of origin
Causes 75% to 80% of peptic ulcer disease
Approximately 20% of people under 40 and
50% of people over 60 are infected
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H. pylori
Disease Overview
DISEASE
CONTRIBUTORY ROLE FOR
H. PYLORI?
EFFECT OF H. PYLORI ERADICATION
Peptic ulcer disease
Yes
Reduces ulcer recurrence rate
Gastric adenocarcinoma
Yes
Uncertain
MALT lymphoma
Yes
Partial or complete remission in more than
half of patients
Uninvestigated dyspepsia
Yes, in some patients
Symptom improvement in some
Iron-deficiency anemia
Likely
May lead to anemia resolution when H.
pylori is the cause
Idiopathic thrombocytopenic purpura
Yes, in some patients
Platelet count improves after eradication
Nonulcer dyspepsia
Controversial
Little effect, if any
NSAID-induced ulcer
Controversial; perhaps only in naïve
NSAID users
May reduce ulcer incidence in Asian naïve
NSAID users
GERD
Unlikely, at least for most patients; H.
pylori may protect against GERD
Uncertain
Pancreatic cancer
Uncertain
Unknown
Coronary artery disease
Unlikely
Probably none
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ACG Guidelines
The AGA released new guidelines for managing
dyspepsia in 2005… and the American College of
Gastroenterology revised their guidelines in 2007.
"Patients 55 years of age or younger without alarm features
should receive H. pylori test and treatment followed by acid
suppression if symptoms remain. H. pylori testing is optimally
performed by a stool antigen test or 13C urea breath test."
In 2007, the American College of Gastroenterology
revised their guidelines to include:
The test and treatment strategy for H. pylori infection is a proven
management strategy for patients with uninvestigated dyspepsia
who are under the age of 55 yr and have no "alarm features“.
* Assuming a 20% H. pylori prevalence
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ACG Guidelines
Both AGA and ACG now recommend that serology
testing no longer be performed to test for H. pylori
because it only tests for the antibody and does not
test for “active” infection
50% of patients that have a positive serology test do not
have “active” infection (false positive for active infection)
The AGA and ACG guidelines do recommend using
Stool Antigen Test or Urea Breath Test for the
detection of H. pylori
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Why Not Serology?
Serology does not test for “active” infection tests for antibody not antigen
A patient with a false positive serology test or
with positive serology but an inactive
infection can lead to:
• Unnecessary treatment (and expense)
• Increased antibiotic resistance
• Increased incidence of side effects from
treatment
• Increased patient anxiety over implications
of a positive test
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H. pylori Antigen Test
Freeze unpreserved stool specimens
immediately store upon receipt at -20⁰C and
ship frozen
Minimum volume: 5gms/5mL
Order in CHCS - Helicobacter pylori Ag
Validation contact – Ms. Annette Compton
(DSN 240- 6622)
Turnaround time – 24 hours
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BRAC
Seamless transition to customers
Relocation of Immunodiagnostics first
Phase 1 – ADVON team (June & Oct 2010)
Phase 2 – December 2010
Phase 3 – January 2011
Complete relocation: May-Sep 2011
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BRAC
Upfront plans completed prior to relocation
Interop CHCS test files
Contracts – Equipment (new and reagent
rental, Personnel, Supplies)
Accreditations (CAP, CDC, etc.)
OIs/SOPs, Policies, Procedures
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BRAC
Lab – Open construction of entire lab space
Design facilitates movement of specimens
Lab work areas are moveable for mission
flexibility
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USAFSAM EPI Lab
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Questions?
United States School of Aerospace Medicine
Epidemiology Laboratory Service
(USAFSAM/PHE)
2730 Louis Bauer Drive
Brooks City-Base, TX 78235-5132
EPI Lab Customer Service Team
DSN: 240-8378
Commercial: 210.536.8378
Email: [email protected]
Website: https://kx.afms.mil/epi/
Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 09-062, 12 Feb 2009
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