Transcript Lab Training of Handling and Shipping Samples

Laboratory training course:
Proper selection, handling and shipping of
samples for diagnosis of influenza and other
respiratory viruses
SESSIÓN 4: SELECTION, HANDLING
AND CORRECT SHIPPING OF SAMPLES
Objectives
• Know criteria for selection and
characterization of samples
• Review the guidelines for sending
samples to WHO CC
• Review basic concepts of packing and
shipping samples
• Know the requiered documentation for
sending samples
http://www.livescience.com/16382-viruses-raw-sewage.html
What Information is Important about
Influenza Viruses?
• Emergence of novel subtypes
• Mutations among circulating viruses
• Increasing incidence/emergence of antiviral
resistance among circulating viruses
• Comparison of circulating viruses to viruses in
current seasonal vaccine
How can we resolve these questions?
To answer these questions it is necessary to have different laboratory tests
and tools for identification. Some are available at the NICs and others are
performed the WHO CC, among which are the following:
•
•
•
•
•
•
•
Inmunofluorescence
Viral Isolation (MDCK and Embryonated Eggs)
Titration of HA and IHA (Antigenic Characterization)
Microneutralization
Typing and subtyping by qRT-PCR
Pyrosequencing and Sequencing
Bioinformatics analyzes
National Influenza Centers
http://www.who.int/influenza/gisn_laboratory/national_influenza_centres/t
erms_of_reference_for_national_influenza_centres.pdf
WHY, WHERE AND FOR
WHAT SEND SAMPLES?
Why?
Because of the capacity of
transmission and evolution of
influenza viruses, it is necessary to
complement monitoring by more
detailed characterization of
circulating viruses
Where?
Regional Labs to NICs
NICs to WHO CC
WHO CC shares information
and viruses with the Global
Influenza
Surveillance
Network )
For What?
Selection of strains for
vaccine formulation
Antiviral Resistance
WHO-CC
Novel Virus
Mutation detection
CRITERIA FOR SELECTION
OF SAMPLES
Samples for the WHO-CC
Objective
How to Select
Samples
Detect novel subtype
Any unsubtypeable
influenza A virus
Detect anti-viral
resistance
Cases receiving antiviral therapy,
immunosuppressed
cases
Detect mutations
Random
Contribute to vaccine
composition
Random
When to
Send
Samples
Funding Source
to Ship Samples
Immediately 
Routine 
(2-4 times each
year)
 Number of samples is
according to
epidemiological
presentation
 Number of samples
is between 15 to 20
 Based upon influenza
season and by August and
January 15
WHO Global
Shipping Project,
PAHO, CDC,
Country Resources
Random Selection
•
•
•
•
•
•
•
All circulating virus types/subtypes
Different age groups
Varying geographic regions
Ambulatory and hospitalized cases
Deaths
Outbreaks
Recipients of antiviral therapy
Other criteria
- 5 to 10 representative samples of unusual outbreaks (e.g. outside
the expected seasonal)
- Any sample corresponding to unusual cases with inconclusive
results
Sending at any time
Additional Principles in Selecting
Samples to Submit
• Type of sample to send isolates preferred,
also send clinical material
• Time period to select from recent viruses
(1-3 months old)
Objective 1: Detect Novel Subtype
• Which samples to send: any influenza A virus
which is unable to be subtyped
• When to send: immediately
• Public health significance
– Emergence of novel subtype with pandemic
potential
– Introduction of H5 or H7 in the Americas Region
Objective 2: Detect Anti-viral
Resistance
• Which samples to send
– Prioritize
• Cases receiving anti-viral therapy
• Cases who are immunosuppressed
– Part of random selection of 15-20 samples
• When to send
– Routinely (2-4 times each year)
• Public health significance
– Emergence of anti-viral resistant strain
– Fewer options for treatment/chemoprophylaxis
Objective 3: Detect Mutations
• Which samples to send
– Part of random selection of 15-20 samples
• When to send
– Routinely (2-4 times each year)
• Public health significance
– Poor vaccine match
Objective 4: Contribute to Vaccine
Composition Development
• Which samples to send
– Part of random selection of 15-20 samples
• When to send
– Routinely (2-4 times each year)
– Before strain selection meeting (February,
September)
• Public health significance
– Data needed to determine which three/four strains
to include in the seasonal influenza vaccine
Seasonal Influenza Vaccine
• Trivalent or quadrivalent vaccine
– Influenza A (H1)
– Influenza A (H3)
– Influenza B (Yamagata and/or Victoria)
• Southern Hemisphere and Northern
Hemisphere composition
– Southern Hemisphere composition determined in
September
– Northern Hemisphere composition determined in
February
– Recommendations match ~66% of the time
When to Send for Routine
Submission
NH STRAIN SELECTION
SH STRAIN SELECTION
MEETING
MEETING
SH INFLUENZA SEASON


JAN FEB MAR APR MAY JUN JUL AUG
NH INFLUENZA
SEASON
SEPT OCT NOV DEC
NH INFLUENZA
SEASON
TROPICAL COUNTRIES INFLUENZA SEASON
When to Send for Routine
Submission- Southern Hemisphere
NH STRAIN SELECTION
SH STRAIN SELECTION
MEETING
MEETING
SH INFLUENZA SEASON


JAN FEB MAR APR MAY JUN JUL AUG
Offseason
Earlyseason
SEPT OCT NOV DEC
Midseason
Lateseason
When to Send for Routine
Submission- Tropical Countries
NH STRAIN SELECTION
MEETING
SH STRAIN SELECTION
MEETING


JAN FEB MAR APR MAY JUN JUL AUG
Offseason
Earlyseason
SEPT OCT NOV DEC
Midseason
Lateseason
Santa Cruz, Bolivia
Chile
When to Send for Routine Submission
Meeting for the formulation of the vaccine
SH
NH
Selection and sending
Samples
Muestras
sentenviadas
to WHO CC
a los
forCC
additional
OMS para
characterization
caracterización
byadicional
date received
por fecha
and by
recibida
country,
y por 2014
país, 2014
NH
Source: WHO CC data.
Note: Each color represents one country.
SH
Samples sent to WHO CC for additional characterization by Region and month
received, 2014
Source: WHO CC data.
SENDING SAMPLES
Transport of Dangerous Goods
International
Regulations
UN Committee of Experts on
the Transport of Dangerous
Goods (UNCETDG)
Transport of dangerous
goods
International Regulations
Air
Rail
• The International Air Transport
Association (IATA)
• Regulations concerning the
International Carriage of Dangerous
Goods by Rail (RID)
Road
• The European Agreement concerning
the International Carriage of Dangerous
Goods by Road (ADR)
Sea
• The International Maritime
Dangerous Goods Code published
by the International Maritime
Organization (IMO)
Consequences of improper
packaging
Exposure to
infectious
substances
Errors and
delays in
delivery
Difficulting
finding
transport
Panic
incident
Consequences
Civil or
criminal
lawsuits
Shipment
detained
by
customs
Sender responsibilities
Coordinate
with carrier
and receiver
Responsibility
of the sender
Complete
documentation
Ensure
Clasification
of the
substance
Label
Packaging
Good to know…
-Categorization
-appropriate packaging
-appropriate labeling
-Documentation Required
-Format Air Shipping
-Statement of dangerous goods (A)
-Certificate Training
Categorization
Classes of Dangerous Goods
•
Class 2: Gases
•
Class 3: Flammable liquids
•
Class 6: Toxic and infectious substances
Division 6.1: Toxic substances
Division 6.2: Infectious substances
•
Class 9: various dangerous goods and
articles, including environmental substances
Substances class 6
Class 6: Toxic and Infectious substances
Division 6.2: Infectious substances
1.
2.
3.
4.
5.
6.
7.
8.
Infectious substances (Category A)
Biological substances (Category B)
Biological products
Genetically modified organisms
Clinical or Medical wastes
Live and infected animals
Human samples/animal samples exemptions
Other exemptions
Categorization (Division 6.2)
CATEGORY A
• Any infectious substance
that could generated
disability, life threatening or
fatal disease in healthy
humans or animals
Proper shipping name:
UN 2814 "INFECTIOUS
SUBSTANCE,
AFFECTING HUMANS"
UN 2900 "INFECTIOUS
SUBSTANCE,
AFFECTING ANIMALS
ONLY"
CATEGORY B
• Any biological substance
that does not meet the
criteria for Category A.
Proper shipping name :
UN 3373: "BIOLOGICAL
SUBSTANCE, CATEGORY
B"
A 3291: "CLINICAL
WASTE, UNSPECIFIED"
Flow for the classification of
infectious substances
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Categorization (division 6.2)
• Category A (Infectious Substances)
• Category B (Biological Substances)
• Exemptions:
1. Samples without infectious components or with low probability of
causing disease in humans or animals
2. Substances with non-pathogen agents for humans or animals
3. Neutralized or inactivated substances
Categorization (division 6.2)
• Category A (Infectious Substances)
Highly pathogenic avian influenza virus (viral culture)
• Category B (Biological Substances)
Highly pathogenic avian influenza virus (patient sample)
• Exemptions:
1. Samples without infectious components or with low probability of
causing disease in humans or animals
2. Substances with non-pathogen agents for humans or animals
3. Neutralized or inactivated substances
Some infectious goods included in
category A
Packaging
Packaging
• Use three layers of packaging
• The first container must be resistant to seepage
• Use absorbent material in each container
Primary
container
Secondary container
http://upload.wikimedia.org/wikipedia/commons/2/28/Tripe_embalaje.png
Outer
container
Packaging Category A
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Packaging Category A
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.1
2_eng.pdf?ua=1
•
All
Category
A
infectious
substances must comply with the
instructions for packaging the
United Nations (UN), P620 .
•
This guarantees the packaging
has passed stringent stress tests
(pressure, stacking, punching,
etc.)
•
The outer container must indicate
the sign of the United Nations,
ensuring quality packaging to
officials
Labeling Category A
Labeling Category A
Information on the outer container :
• Name and address of the sender
• Telephone number responsible for
shipping
• Name and address of consignee
• Proper shipping number (UN 2814
or UN 2900)
• Temperature requirements (optional)
• If dry ice or liquid nitrogen is used:
technical name, UN number and
total amount.
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.1
2_eng.pdf?ua=1
Labeling Category A
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Labeled Category A
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Labeled Category A
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Packaging Category B
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Labeled Category B
Each shipment must have the following
information :
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
•
Airway: name, phone number and
address of the sender
•
Phone of person responsible for
emergency contact
•
Name, telephone number and
address of the recipient .
•
Proper name, visible:
(“BIOLOGICAL SUBSTANCE,
CATEGORY B")
•
Optional: Special requirements for
temperature
Documentation of Category B
Air waybill:
• A packing list format or the
address of the consignee, the
number of packages to send,
weight and detail of the content.
• Declaration or import/export
permit (if required).
• Sending Format (air waybill)
where the content is detailed
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1
Documentation of Category B
These documents must be prepared
and signed by the sender:
Declaration of Dangerous Goods
•
Declaration of Dangerous Goods
•
A packing list format or the address of the
consignee, the number of packets to
send, weight and detail of the content.
•
Declaration or permit import/export (if
required).
•
Appropriate documents (waybill) for
shipments by rail, road or sea.
http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.1
2_eng.pdf?ua=1
Documentation of Category B
Declaration of Dangerous Goods
Final recomendations…
• Ensure cold chain.
• Include details of sending
samples, identification
number and
epidemiological data
References
 Blanton,L., Brammer,L., et al.(2011) Influenza. Manual for the surveillance of vaccinepreventable
diseases.
5th
Edition.
Available
online
at:
http://www.cdc.gov/vaccines/pubs/surv-manual/chpt06-influenza.pdf
 World Health Organization (WHO). (2006) Collecting, preserving and shipping specimens for
the diagnosis of avian influenza A(H5N1) virus infection. Guide for field operations. Available
online
at:
http://www.who.int/csr/resources/publications/surveillance/CDS_EPR_ARO_2006_1.pdf?ua=
1
 World Health Organization (WHO). (2004) Guidelines for the collection of clinical specimens
during
field
investigation
of
outbreaks.
Available
online
at:
http://www.who.int/csr/resources/publications/surveillance/whocdscsredc2004.pdf
 World Health Organization (WHO).(2009) Instructions for storage and transport of suspected
or confirmed human and animal specimens and virus isolates of pandemic (H1N1). Available
online
at:
http://www.who.int/influenza/gisrs_laboratory/logistic_activities/transport_storage_specimens
_isolates/en/
References (2)
 World Health Organization (WHO). Laboratory biosafety manual, Biosafety guidelines. Third Edition
(2004). Available online at:
http://www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf?ua=1
 World Health Organization (WHO). Manual for the laboratory diagnosis and virological surveillance of
influenza. Available online at:
http://whqlibdoc.who.int/publications/2011/9789241548090_eng.pdf?ua=1
 World Health Organization (WHO). Nasopharyngeal and Oropharyngeal Swabs. Available online at:
http://www.youtube.com/watch?v=mfZYAMDpGNk
 World Health Organization (WHO). Selection of clinical specimens for RT-PCR and virus isolation and
of viruses for shipment from National Influenza Centres to WHO Collaborating Centres. Available
online at:
http://www.flu.mn/mgl/images/stories/Sudalgaa_shinjilgee/GISN2010/suppl.03.%20Selection%20on%
20clinical%20specimens%20for%20PCR,%20virus%20isolation%20and%20shipment%20for%20NIC
s.pdf
 World Health Organization (WHO). WHO information for molecular diagnosis of influenza virus in
humans – update (2012). Available online at:
http://www.who.int/influenza/gisrs_laboratory/molecular_diagnosis_influenza_virus_humans_update_2
01211.pdf
 World Health Organization (WHO). Personel Protective Equipment (PPE). Available at: World Health
Organization (WHO).
Thank you!