Laboratory Results Laboratory Results and Operations and Operations in in

WHO Phase 6 WHO Phase 6 Dr. Attaporn Dr. Attaporn

TaweetungtragoonTaweetungtragoonCYBELES CYBELES

Phnom Penh, CambodiaPhnom Penh, Cambodia

October 12-15, 2009October 12-15, 2009

World Health Organization, Regional Office for The Western Pacific

1 10 20 30Days after first case

30

20

10

No. of cases per day

Too Late to Contain?

Laboratory Testing during WHO Phase 6 is not “Business as Usual”

BackgroundBackground The Protocols are based on Detection, The Protocols are based on Detection,

Investigation, and ReportingInvestigation, and Reporting Rapid Response and ContainmentRapid Response and Containment The strategy is geographically based The strategy is geographically based Containment and Buffer zone operations Containment and Buffer zone operations

includeinclude Surveillance and on going laboratory testingSurveillance and on going laboratory testing Containment communications Containment communications Antiviral administrationAntiviral administration

Containment/Buffer Zone Containment/Buffer Zone ChecklistChecklist

Identification of LaboratoriesIdentification of Laboratories Field Response TeamsField Response Teams Sample CollectionSample Collection Specimen testing and reportingSpecimen testing and reporting Specimen shippingSpecimen shipping Specimen storageSpecimen storage Logistical supportLogistical support

Early Detection and Rapid Early Detection and Rapid responseresponse

Reliable Laboratory testing can provide Reliable Laboratory testing can provide resource focus, disease patterns, and patient resource focus, disease patterns, and patient contact/educationcontact/education

Buffer zone testing is also indicated as part of Buffer zone testing is also indicated as part of the Surveillance programthe Surveillance program

Buffer zone lab testing will continue as long Buffer zone lab testing will continue as long as the containment is on goingas the containment is on going

Containment and Buffer Zone key tasksContainment and Buffer Zone key tasks --Extensive antiviral prophylaxis and --Extensive antiviral prophylaxis and

treatment --Surveillance and treatment --Surveillance and LABORATORY LABORATORY

TESTINGTESTING --Assessment of the novel virus--Assessment of the novel virus

What do we need for setting up PCR/ qRT-PCR lab for

Flu tests Instruments Supplies

Cold reagents Room temperature supplies

Well trained lab staffs

Illustrated PCR Illustrated PCR WorkflowWorkflow

Prepare the RNA template

Extraction of Nucleic Acid (RNA/DNA)

Prepare the RT-PCR reactions

Run the experiment

Design and set up PCR experiment

Amplification plot

Interpretation of the result

Manual RNA extractionAutomatic extraction

System Software

RNA /DNA Extraction Systems

Small Scale Extraction System (8 samples/run)

Big Scale Extraction System (96 samples/run)

Variety of PCR and Real-Variety of PCR and Real-Time RT-PCR InstrumentsTime RT-PCR Instruments

Small scale laboratory InstrumentPCRPCR

Big scale laboratory instrumentReal-Time PCRReal-Time PCR

SENSOQUEST

Real-Time RT-PCR System Software

Interpretation of Interpretation of ResultsResults

Target Pathoge

n Internal control

Negative control

Positive control

Interpretat

ion

POS POS NEG POS POS

NEG POS NEG POS NEG

NEG NEG NEG NEG INVALID

POS POS POS POS INVALID

Sample collectionSample collection methods are poor methods are poor Lack of refrigeration in Lack of refrigeration in shipping and shipping and

storagestorage process process RT-PCRRT-PCR testing done testing done incorrectlyincorrectly Positive results are Positive results are not identified not identified Results are not reported in a Results are not reported in a timely mannertimely manner Results are not Results are not numbered and storednumbered and stored

correctlycorrectly Leaders do not understand the meaning of Leaders do not understand the meaning of

the results because they are not the results because they are not displayed displayed correctlycorrectly

The results are not acted in time because the The results are not acted in time because the leaders do not understand how important the leaders do not understand how important the results are.results are.

What can go wrong with What can go wrong with Laboratory results? Laboratory results?

WHO Laboratory WHO Laboratory ConfirmationConfirmation

#http://www.who.int/countries/en/ J Laboratory in Laboratory in

CambodiaCambodia The WHO Representative in Camb The WHO Representative in Camb

odiaodia - No. 177 179 corner Streets Pasteu - No. 177 179 corner Streets Pasteu

r (51) and 254 PO Box 1217 Phnom r (51) and 254 PO Box 1217 PhnomPPPPPPPP Cambodia Cambodia

Laboratory in ThailandLaboratory in Thailand The The WHO Representative WHO Representative

Soi Bamrasnaradoon Soi Bamrasnaradoon, , Permanent Se Permanent Se cretary Building 3, 4th Floor Tiwano cretary Building 3, 4th Floor Tiwano

nd Road nd Road Nonthaburi 11000 Nonthaburi 11000 Thailand

Laboratory in JapanLaboratory in Japan WHO Technology Transfer P WHO Technology Transfer P

rogramme Office rogramme Office c/o International Medical Ce c/o International Medical Ce

ntre of Japan ntre of Japan- - -1 21 1 Toyama, Shinjuku ku- - -1 21 1 Toyama, Shinjuku ku

TokyoTokyo JAPAN JAPAN

Host Nation Host Nation Laboratory that Laboratory that is Ministry of is Ministry of Health operatedHealth operated

Laboratory Testing and Laboratory Testing and preparednesspreparedness

Testing all suspected cases is preferred Testing all suspected cases is preferred but may not be possiblebut may not be possible

Potential large numbers will be tested if Potential large numbers will be tested if Containment operations are initiated Containment operations are initiated requiring local, state and federal requiring local, state and federal coordinationcoordination

Equipment and consumable supply Equipment and consumable supply requirementsrequirements

WHO collaborating centers and other WHO collaborating centers and other reference Labs will perform molecular reference Labs will perform molecular and genetic studiesand genetic studies

National Pandemic National Pandemic planning for Laboratory planning for Laboratory

operationsoperations Identify all Laboratories in the Identify all Laboratories in the

country and list their capabilitiescountry and list their capabilities Identify Labs that can perform Novel Identify Labs that can perform Novel

virus testingvirus testing Test all Laboratory proficiencies Test all Laboratory proficiencies

annually with WHOannually with WHO Work with WHO as a regional Work with WHO as a regional

partnerpartner

Laboratory Field Laboratory Field Response TeamsResponse Teams

Establish fast responseEstablish fast response Laboratory Laboratory teams (May include military component)teams (May include military component)

Must have vaccinations, passportsMust have vaccinations, passports Team members must have Team members must have training in training in

influenza diagnostics, safe specimen influenza diagnostics, safe specimen handling, and dangerous goods handling, and dangerous goods packaging & shippingpackaging & shipping

National authorities must stockpile National authorities must stockpile adequate adequate PPE, specimen collection PPE, specimen collection and transportation materials, and and transportation materials, and swabs.swabs.

Specimen Collection, Specimen Collection, Shipping, Reporting, & Shipping, Reporting, &

StorageStorage Develop a consistent and Develop a consistent and systematic systematic

method to label specimensmethod to label specimens that links that links them to patients and them to patients and epidemiological data.epidemiological data.

Ensure import and export Ensure import and export documentsdocuments are in are in place in advance.place in advance.

Determine which Determine which staff can interpret and staff can interpret and report the results.report the results.

Develop a plan & Develop a plan & capacity for storing capacity for storing representative specimensrepresentative specimens, isolates, and , isolates, and nucleic extracts for research and evaluating nucleic extracts for research and evaluating mutationsmutations

SummarySummary Laboratory testing is on going from Laboratory testing is on going from

pre pandemic to recoverypre pandemic to recovery Supplies and equipment must be Supplies and equipment must be

utilized in training activities utilized in training activities Field and in-house Lab testing is a Field and in-house Lab testing is a

critical component of Containment critical component of Containment and Buffer zone operationsand Buffer zone operations

Laboratory testing will determine Laboratory testing will determine effectiveness of operations and drive effectiveness of operations and drive decision-making at all levelsdecision-making at all levels