DCLS Influenza Laboratory Testing

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DCLS Influenza Laboratory Testing

• Denise M. Toney, Ph.D.
• Commonwealth of Virginia
• Division of Consolidated Laboratory Services
• H M Panel May 2009

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Division of ConsolidatedLaboratory Services
(DCLS)Current Role in Influenza Testing

• Virginias state laboratory serving a large
  number of local, state, and federal agencies
• Tests human specimens for influenza virus
  year-round according to VDH guidelines
• Seasonal influenza surveillance (Sentinel
  physicians, OCME)
• Investigation of respiratory illness outbreaks
• Surveillance for novel influenza virus in humans
• If case meets VDH and CDC clinical and
  epidemiologic criteria for possible novel
  influenza infection, including avian influenza
• CDC and LRN protocols validated

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DCLS - Public Health MissionPandemic Influenza
Testing

• NOT Diagnostic testing!!!
• Determine when and where influenza viruses are
  circulating
• Determine how much influenza activity is
  occurring
• Identify types and strains of circulating
  influenza viruses in addition to the pandemic
  strain
• Monitor for mutations in the influenza virus
  strains
• Detect unusual events
• Infection by unusual viruses
• Unusual syndromes caused by influenza viruses
• Unusual large/severe outbreaks of influenza
• Increased mortality

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Laboratory Tests for Seasonal and Novel Influenza
Viruses

• Virus Isolation
• Technically difficult TAT issues
• Good sensitivity and specificity
• Typically not performed for avian or novel
  influenza (requires a BSL-3 laboratory with
  enhancements)
• Immunofluorescence (DFA)
• Rapid limited specificity and sensitivity
• PCR Techniques
• Rapid and specific
• Sensitivity depends on the test used, the
  influenza strain, and the type of specimen tested
• Rapid antigen detection
• not performed at DCLS

Influenza
Influenza RNA
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DCLS Influenza Surge Plan
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Existing DCLS Capabilities

• Infrastructure available from ongoing
  preparedness efforts and planning
• Multiple Biosafety level 3 (BSL3) suites
• Dedicated molecular suite
• Multiple real time PCR instruments and platforms
• Laboratory Response Network (LRN) certified and
  CDC IVD qualified
• Highly experienced molecular and virology staff
• Statewide courier
• 24 hours a day, 7 days a week emergency response
  capability
• Dedicated collection kit preparation department
• All staff classified as essential personnel

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Novel Influenza Strain DetectionLaboratory
Testing Timeline
DCLS validated the CDC rtRT-PCR assay and
implements for seasonal surveillance purposes
CDC updated protocols to reduce variability and
to initiate efforts at obtaining FDA approval.
Assay released through MTA to state labs
CDC obtained EUA and releases NEW swine flu assay
to states Lab verification required
2004 2005
2006 2007
2008 2009
CDC distributed rtRT-PCR assay for detection and
characterization of influenza through APHL
CDC MTA assay received FDA approval to be used
for diagnosis of human Influenza
infections IVD-rtRT-PCR Flu Panel A/H1, A/H3,
A/H5 and B
MTA assay DOES NOT detect the influenza A/H1
(swine-like) viral subtype
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EUA CDC Swine Flu AssayDCLS Testing Algorithm

• Before assay release
• Specimens tested using culture, DFA and rtRT-PCR
  for influenza A/H1, A/H3 and B
• Specimens positive for influenza A but negative
  by rtRT-PCR for seasonal H1 and H3 reported as
  probably swine-flu and forwarded to CDC for
  confirmation
• Seasonal isolates and negatives were reported as
  usual
• After assay release
• Approved specimens tested using the 4 target EUA
  Swine flu rt-RT-PCR assay viral culture
  performed
• 4 Targets Seasonal Flu-A, Swine Flu-A, Swine H1
  and RP (control)
• Seasonal Flu A () specimens reflex tested for
  seasonal subtypes
• Influenza B testing not performed

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Interpretation of Swine Flu Results
Note Influenza B testing NOT PERFORMED
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Assay Implementation Issues

• Required VDH screening of specimens prior to DCLS
  testing
• SWF numbers ?
• Slight delay in obtaining testing reagents and
  supplies from CDC
• Stock Pan-flu supplies beneficial
• Swine-flu assay required verification using 5
  positive specimens prior to receiving approval to
  report confirmatory results
• No interpretation for results provided
• EUA method very restrictive as authorized
• Not validated for DCLS preferred robotics
• Seasonal surveillance role unclear
• Flu Bs
• Continue culture?

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Current DCLS Pandemic Testing Capacity

• Well..it depends ????
• Capacity 800 PCR tests/day in a perfect
  scenario assuming limited targets, unlimited
  reagents, full staffing, no reporting deadlines
• Capacity is dictated by critical testing reagents
  and supplies
• Changing technologies, Limited shelf life,
  Restocking of expired reagents is expensive and
  cost ongoing
• Specimen collection kits for rapid deployment
• Implemented a LIMS to streamline result reporting
  and data tracking ongoing
• Cross-trained personnel in BSL-3 and PCR methods
  ongoing

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Challenges thankfully NOT encountered THIS TIME

• Limitations or absence of lab reagents, supplies,
  PPE, etc
• Worker absenteeism (ie. personal illness, family
  issues, quarantine)
• Disruptions of medical and community services
• Need to suspend other critical lab services
• Exceeding bio-safety level 3 containment
• High demand for diagnostic testing for the
  worried well
• Successful HD screening of suspect cases (SWF) to
  limit testing and conserve critical reagents and
  supplies

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DCLS - Public Health MissionPandemic Influenza
Testing

• NOT Diagnostic testing!!!
• Determine when and where influenza viruses are
  circulating
• Determine how much influenza activity is
  occurring
• Identify types and strains of circulating
  influenza viruses in addition to the pandemic
  strain
• Monitor for mutations in the influenza virus
  strains
• Detect unusual events
• Infection by unusual viruses
• Unusual syndromes caused by influenza viruses
• Unusual large/severe outbreaks of influenza
• Increased mortality

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Contact Information Denise M. Toney, Ph.D. 600
North 5th Street Richmond, VA 23219 Phone
804-648-4480 ext 282 Blackberry 804-641-6960