Public health needs: costs, effectiveness, and biosafety requirements for diagnostic procedures

1. Public health needs: costs, effectiveness, and biosafety requirements for diagnostic procedures • Public health needs • Tools utilized • Challenges encountered • Examine the spectrum of available assays • Costs • Effectiveness • Biosafety requirements. Rapporteurs: Alison Hottes, Michael Callahan, and Fran Sharples

2. Breakout #1Human Diseases Part 1 Alison Hottes NAS Staff

3. Avian Influenza Virus Surveillance in South-West Siberia (Russia) • Region contains 3 major flyways and was important to 2005 expansion of H5N1 in Eurasia. • Region could be used as early warning system for HPAI outbreaks in wild birds in Eurasia. • Phylogenetic typing using PCR and sequencing showed a clade change • Possibility due to population immunity pressures.

4. Detection of Emerging and Re-emerging Pathogens in Croatia • Clinical and research work on Hantaviruses, Dengue Virus, Tick-borne Encephalitis, West Nile Virus, Chikunganya Virus, and Influenza A • Tools include: POC tests, ELISA, PCR, sequencing, and culture • Generally follow CDC recommendations (except for U.S. select agents) • Serology: BSL2 in BSC • Molecular Tests: Start with BSL2 and move to molecular lab • Cell culture (typically for research not clinical work): BSL3 (BSL2 for Dengue Virus unless in large quantities)

5. Biosafety Recommendations for Laboratory Testing for TB • TB LAIs usually result from unrecognized production of infectious aerosols • Classified common TB-diagnostics: • Limited risk for aerosol production • Moderate risk for aerosol production • High risk for aerosol production • Generated specific handling guidelines for each risk class • Additional guidelines for known/suspected XDR samples • Use a “systems approach” that avoids mention of traditional BSL levels

6. Challenges, Issues, and Observations • Many labs pay 5-6 times as much for common reagents as U.S. labs. • Culture techniques and access to strain collections are usually more crucial to research than to clinical work. • Difficult to retain trained workers when safer, better-paying opportunities are available. • Shipping, import, and export rules make research and diagnostic collaborations difficult or impossible, • Reliable POC tests are highly useful, especially when supplemented with molecular follow-up

7. Areas for Progress • Many countries avoid culture-based TB diagnostics creating a need to ship many clinical samples • Could be a starting point for a dialog with IADA about defining transport procedures that address actual risks • Many practices could benefit from detailed risk-based guidance (like that for TB) that replaces coarse BSL recommendations.

8. Summary: Human Diseases Part 2 Session IIChair: Peter Palese Distribution Statement

9. Speaker 1 Roger van Doom: Oxford SE Asian Infectious Disease Clinical Research Network presenting on ”Biosafety and SEAICRN” A integrated multi-site research facility that is also building public health capacity in large scale disease outbreak (e.g. pandemic preparedness) Location: located on Hospital for Tropical Diseases in Ho Chi Minh City; additional sites in JKA and elsewhere in SE Asia. 200 employees Funding: Welcome Trust and NIH (plus other intramural grants) Mission: typhoid, malaria, TB , DF, CNS infections, zoonosis and HIV (+Ois) BSL: BSL2 for Diagnostics BLS3 for research (TB and virology) Capability: 454, Sanger, RTPCR, FTA, uN, culture Future: expanding to tropical FUO and influenza (pand preparedness) Cheng Cao, Beijing Inst of Biotechnology Sohail Zaidi, NIH Pakistan Reinhard Burger, Robert Kock Inst, GR Summary: Human Diseases Session IIPeter Palese Distribution Statement

10. Speaker 2 Cheng Cao, Beijing Inst of Biotechnology presenting on “SARS: Diagnostics, antibody responses and Biosafety” Location: primary facility in Beijing, CH Mission: SARS-centric, focusing on rapid Dx technologies and sero-prevalence studies. BSL: BSL2 (inactivated serums) and BLS3 (for SARS culture) Capability: RTPCR, ELISA (3) IFA, culture Key research findings: positive serology to SARS nucleoprotein persists for years; NP implicated in lung injury secondary to C’ activation Distribution Statement

11. Speaker 3 Sohail Zaidi, NIH Pakistan National Institute of Health Islamabad: “Crimean-Congo hemorrhagic fever in Pakistan” Mission: CCRF phylogenetics, measles, influenza including H5N1 BSL: BSL2 with enhanced PPE for certain tasks (CCRF) SOPs : restricted access, trained personnel, all Dx cultures are inactivated at Receiving prior to entering lab Capability: RTPCR, ELISAs, Future: seeking to develop a Core Facility to support expanded sequencing; Seeking guidelines for lab diagnostics. Key Research findgings: phylogenetics analysis indicates Pakistan CCRF has homology with Asian Type I; and epidemiology shows a trend for CCRF expansion to new cities. Distribution Statement

12. Speaker 4 Reinhard Burger, Robert Kock Inst, GR “Enterohemorrhagic E.Coli 0104:H4 in Germany in 2011” Dr Bruger presented the timeline and epidemiologic investigation of the recent enteroaggressive Ecoli with HUS that occurred last month in Northern Germany. Mission: public health investigation (described in this briefing) Key research findings: there were over 3322 cases with high incidence of HUS involving a previously unknown strain with mixed virulence factors; there was unexpectedly high incidence of young professional women affected. Interesting points: novel integrated epi investigation made use of media, digital pictures and pictures of menus to improve history taking. Distribution Statement

13. Key Discussion • Was the Ecoli a lab creation? (unlikely) • Will more BSL-2 labs need to adopt BSL3 procedures during high demand • Can NGO funds be used during disease outbreak to assist local public health • Q2 : Doubts about viability of international restrictions on national containment facilities; each nation has the right to plan strategies for countering local strains and health threats. • Q3: sample archives are not the problem. In endemic regions sample collections are common in part because accessing international reference strains, antiseras, primers and support reagents is so difficult. • Q4: Biosafety/Biosecurity operating procedures are felt to impact routine research and public health response efforts but are felt by attendees to be helpful/necessary • How do we know that biocontainment systems work if we cannot compare data before and after implementation and if there is no centralized and non-prejudicial reporting system (e.g for accidents and near misses) . • Why are we pushing uniform risk standards globally when risk varies remarkably from region to region. Distribution Statement

14. 3. Animal and Livestock Diseases Chair: David Franz

15. High Security Animal Disease Laboratory, Bhopal, India: Gaya Prasad • Commissioned in 2000, in continuous operation since; modern BSL3+ • Hazardous animal pathogen diagnostics and molecular research on diagnostic development, control mechanisms, data bank on livestock diseases, training • 17 scientists (microbiologists, public health, biotech and molecular genetics, research fellows and PhD candidates) • Monitor for exotic diseases: rabbit hemorrhagic disease, avian influenza (AI), bovine viral diarrhea, malignant catarrhal fever, bird flu, Nipah • AI H5N1 first isolated in poultry in 2006, isolated almost every year since from chickens, ducks, goose, and crow; OIE reference lab for AI • Swine flu: diagnostic preparedness, surveillance, molecular characterization of new isolates •  Linkages with FAO, MCEIRS, WHO, ICAV, SEPRL, pharmaceutical industries for vaccines, etc. • 1 vet/20,000 animals in India, but all vet hospitals are government, thus unusual diseases detected in livestock population are brought to government notice quickly

16. Mexican Laboratory NetworkMarco Antonio Rico Gaytan • Network of labs (21throughout Mexico) to protect animals in Mexico from exotic diseases • Establish and coordinate surveillance, diagnostics, promote disease reporting, provide technical training, epidemiology, outbreak response • Old (1949) lab in Mexico City recently remodeled, certified BSL3 in accordance with US and Canadian guidelines; biosecurity measures, e.g., access control (fingerprints) • 2005-2011: remodeled 7 facilities for diagnosis of BSE, AI, ND, etc.; network of 16 regional labs, with newest being molecular biology labs (13), BSL2 with improvements, diagnostic tests (PCR, sequencing, etc); all labs have same design; • Large number of people in field regularly sample animals on farms, check health of transported animals; samples taken and sent to government labs • Currently working 33 different diseases using 20 tests; 110 different tests for all diseases • Annual costs estimated at $27 million US

17. Coping with deadly viruses: Supaporn Wacharapluesadee, Chulalongkorn University, Thailand • Partners: Thai Red Cross, DARPA, Naval Health Research Center, EcoHealth Alliance, FAO/UN • Established as WHO training center in 2009 on viral zoonoses; surveillance of animals for rabies, Nipah, Lyssaviruses, corona viruses, recent new pathogen focus • Have developed novel and safe ways to collect rabies from brains using “cards” and “trucut” needles to provide enough tissue for PCR • Interesting work on Nipah: BSL4 agent, but no BSL4 lab in Thailand; developed PCR test to detect Nipah in bat specimens, use BSL2 labs to study; capture bats with mist nets, collect urine, put into lysis buffer in field, take to lab for PCR • New pathogens: collected bat saliva, looked for viruses, archaea, bacteria; have found SIV-like retroviruses at about 7% level, possibly from primates living in bat areas

18. Conclusions • Animal health needs also provide important rationale for high containment laboratories • Indian lab serves other countries in region (Nepal, Bhutan) that lack capabilities if Indian government approves • Mexico has established extensive network of labs, with full high containment capabilities in Mexico City and molecular diagnostics and other capabilities at field to monitor health of animals nationwide • Thai lab has come up with creative ways to do research on hazardous agents without BSL4 capabilities

19. PM Sessions Identifying Areas of Action Rapporteurs: Craig Reed, Ben Rusek, Jennifer Gaudioso

20. Breakout Sessions (Group 3) • Generate strategies and suggestions for countries building/improving or considering building/improving labs • Consider what data on biosafety would be most useful to generate • Identify areas where current biosafety practices are not well matched to actual needs Rapporteurs: Craig Reed, Ben Rusek, and Jennifer Gaudioso

21. Allan BennettHealth Protection Agency, UKEvidence-Based Biosafety: Ensuring Precautions are Adequate and Appropriate • Generally, biosafety regulations haven’t kept pace with equipment, materials and codes of practice. • Good microbiological practices • critical to effective biosafety • actually result in fewer aerosolization events • far less expensive than engineering controls • Improperly/Incompletely inactivated infectious materials may become major source of infection in future due to increased adoption of advanced clinical diagnostics. • Data from multiple studies • 2006: Direct relationship between titre and aerosol concentration. • 2008: Heavy rubber gloves used in a Class III cabinet and in BSL4 substantially reduce hand and finger dexterity; latex gloves do not. • Historical review: If you don’t wear gloves in the lab you WILL infect yourself and probably others. • Observation: Still have major problems with compliance to simple cost-effective protective measures (glove use, hand washing) • Observation: Working in a cabinet actually creates a different hazard – not from aerosols but, rather, from splashes.

22. Uwe Muller-DobliesDVMPirbright Laboratory, Institute for Animal Health, UKRisk-based Design of Facilities for High Consequence Pathogens • What is the acceptable risk of accidental release? Zero: not achievable. How often are we prepared to accept a consequential event, assuming appropriate controls reduce risk to an acceptable residual level? 1 event per 25 facilities per 20 years = 1 per 500 facility yrs • Bow-Tie Risk Management Model: Threats –> Threat Control Measures –> Hazard Release –> Recovery/Mitigation Measures –> Consequences

23. Onder Ergonul, MDKoc University School of Medicine, Infectious Diseases Dept., IstanbulInfection Control in Emerging Infections • Discussion of emergent/re-emergent arboviral diseases of humans • CCHF in Turkey vs. Iran, Bulgaria, Tajikistan, Greece, Russia, global distribution • Effectiveness of ribovirin better during Pre-Hemorrhagic period vs Hemorrhagic period • Discussed high human-human transmission rate of CCHF and impact on healthcare worker infection • Transmission risk to HCW in Africa • Needlesticks 33% • Contaminated blood exposure 8.7% • No evidence of aerosol infection in HCW in Turkey • HCW are at risk but Standard Precautions are most appropriate for in clincial setting

24. Breakout #2: Improving Organizational Culture and Practices Ben Rusek NAS Staff

25. Enlightened Laboratory Leadership: More Powerful than Guns Gates and Guards • Emphasize the benefit of science, prevent overregulation • The insider threat is a very difficult problem to solve, we may have to live with the risk • We are living with the regulation. The US Select Agent rules and personnel reliability measures were implemented in response to insiders • Where will these regulations take us? It could take 5-10 years to realize that we have an overregulation problem and 20 years to turn it around • Laboratory leadership is critical. Include some smart security but lead with science, trust and transparency

26. Singapore’s Response to Biorisk Events at Home and Abroad • SARS was the wakeup call in Singapore. In addition to the loss of life, the outbreak had a massive economic impact on the country • Today’s biosafety and biosecurity laws were developed in response to outbreaks in the late 90s and the US anthrax mailings in 2001 • Responded with legislation: Strategic Goods (Control) Act, in 2002 created Tradenet and passed the Biological Agents and Toxins Act (BATA) in 2005. These regulations add extensive enforceable security measures for biological security • Also address the threat through Institutional Biosafety Committees and Biosafety/Biorisk Associations in Singapore and in the Asia Pacific region

27. OIE Laboratory Twinning: A Tool to Improve Global Disease Security • The World Organisation for Animal Health (OIE) has 220 OEI reference laboratory (RL) in 178 member countries. Each RL is assigned a specific disease, the network helped to eradicate Rinderpest worldwide this year • “Twinning” partnership is a way to enhance capacity and expertise by supporting a link between an OIE RL and a national laboratory (candidate) that helps OIE expand the global network. Over 30 active in the world. • OIE standards give guidance on developing a risk assessment based on the pathogen in that environment. For instance standards are not as strict in places where FM is endemic. • We don’t know how many OEI partners do work in high containment labs. We might start to collect this information

28. Conclusion • Regulations should provide practical guidance based on risk assessments for the individual lab • Difficult but not impossible to legislate human behavior although it will never eliminate all risk • Individual “champions” can take up the cause and spread the message in countries and regions and convince their life science community that these are serious issues that need practical solutions • Education throughout the life science training spectrum can help create good practices in biosafety and change culture, attitude and behavior • More thinking needs to be done about how to enforce national and international regulations in local labs, implementation is missing in many places

29. Design and operational options for improving sustainability, biosafety, and biosecurity Chair: Willy Tonui

30. Maintenance, certification and cost-saving issues for BSL3 labs in SE Asia • Planning aspects routinely underestimated • Write specifications for compliance upfront and get all parties to sign • Think about workflows from the start • Consultants/contractors overestimate their expertise • Can’t just reverse a clean room • Budget & contingencies • Emphasized BSL3 energy costs • Client (lab owner) needs to be knowledgeable about what they want • Need awareness / education on need for maintenance • EX: BSC in service for 20 years with daily use but never been tested or maintained • EX: 2 years each to design and build labs in Laos and Thailand

31. The BSL3 Lab at Institut Pasteur du Maroc • Decided to build because of concern about possibility for emerging epidemics • No local contractor capable to build the BSL3 • Ministry of Finance wanted to do open tender but ultimately hired same supplier that was installing 2 other BSL3 labs in Morocco • To facilitate building up common pool of operations and maintenance expertise in country • Designed to be small to save on energy costs • Annual maintenance budget: $30K regardless of whether they do any work • Not used a lot but they have it when needed. Also used for training but that is also costly

32. A rational and attainable approach to successfully implementing biosafety in lab settings worldwide • THINK OUTSIDE THE BOX • Flexible to find best solutions for a specific situation • Do the risk assessment to determine what controls are needed • Balance of practices/protocols, facilities (protects neighbors), and equipment • Examples: • Sealable for gas decontamination versus surface wipe down if needed • Many demands on autoclaves: flaming loops outside BSC; chemical waste decon • How necessary is redundant design? (ie what downtime can your facility sustain?) • ACH : determine what’s needed for your own facility given your heat loads, activities, standby mode

33. Engineering control: Challenges in maintaining BSL3 (Indonesia) • Need : Diagnose diseases in shortest possible time, prevent diseases (vaccine development), and cure diseases (drug development) • Due to local situation, decided on modular BSL3 • Started process in 2005, operational in 2009 • Specialized human capacity to run the facility is a major focus across spectrum of BS&S topics • advocacy/regs; training workshops; assessment; management; facilities • Have had to develop series of biorisk training programs • Especially lack of expertise on engineering side which impacts maintenance/validation/certification of equipment

34. Common themes from talks & discussion • Time to go from idea to operation • 2 – 4 years • Need to understand why building a BSL3 to optimize the expensive lab footprint • When can work be done on inactivated pathogens • Energy costs • Green designs may help but limitations to safety concerns, mold, humidity, etc • Lack of engineering / maintenance expertise • Need to work with local craftsmen and train them on construction and maintenance details if the facility is going to be sustainable • No one size fits all solution • Possibility for regional labs to enable pooling of resources but many countries will still have their own priorities/needs