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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. Microbiology Virology Bacteriology Parasitology Immunodiagnostics HIV, Hepatitis Infectious Disease Serology

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USAFSAM Epidemiology Laboratory Service

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  1. USAFSAMEpidemiology Laboratory Service Distribution Statement A: Approved for Public release; distribution is unlimited. 311 ABG/PA No. 10-084, 12 Mar 2010

  2. Microbiology Virology Bacteriology Parasitology Immunodiagnostics HIV, Hepatitis Infectious Disease Serology Molecular Diagnostics LIS CST (Customer Service Team) LIS (Lab Information Systems) COPS (Central Operations) Programs Influenza Surveillance USAF HIV Testing/Repository USAF Recruit Health Testing Clinical Infections Disease Testing LRN Reference Lab USAFSAM “EPI Lab” • DoD’s only Clinical Reference Laboratory • 220+ DoD Customers • 2.0+Million Tests per Year

  3. 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

  4. Central Operations Boxes opened, specimens sorted Boxes arrive in lab Information verified Accessioned into CHCS Specimens delivered to sections

  5. 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

  6. 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

  7. EpiLab Web site

  8. BIOPLEX 2200 Immunodiagnostics 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)

  9. 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 • CoccidioidesImmunodiffusion Test

  10. 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 non-reactive VDRL’s)

  11. HIV Tests Performed: • HIV 1/2/O • HIV Type 1 Western Blot (manual) Siemens Centaur XP

  12. 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) • Hep B Core AB IgM (HBcAb-IgM) • Hep C (HCV) AB • Hep B Surface AG (HBsAg) • AB to Hep B Surface AG(HBsAb) • Hepatitis B Envelope Ab, Ag (manual test) Siemens ADVIA Centaur

  13. Immunodiagostics Additional tests performed on the Centaur: • Rubella IgG, IgM • Toxoplasma IgG, IgM • Thyroid Panel

  14. 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 (Borreliaburgdorferi)

  15. TAT-HIV Days

  16. TAT-Hepatitis Days

  17. TAT-EIA Days

  18. Parasitology • Manual testing • Specimen = Stool • Ova & Parasites • Trichrome Stains • Concentrations • Turn-around- time – 9 hours • Worm Identification • Turn-around-time < 24 hours Trichuris trichiura ova Schistosoma haematobium ova

  19. Parasitology • Enzyme immunoassay (EIA) for: • Giardia Specific Antigen • CrytosporidiumSpecific Antigen • Turn around time – 9 hours • Acid Fast Stain for: • Cyclospora species • Isosporaspecies • Turn around time – 9 hours • Pinworm Identification • Turn around time – 9 hours Giardia lamblia (trophozoite) Enterobius vermicularis (ova) E. vermicularis (adult worm)

  20. Virology • Herpes Simplex Virus testing - ELVIS • Enzyme Linked Virus Inducible System • A culture-based test for HSV only ELVIS results in ~ 17 hrs

  21. Virology • Routine clinical specimens for viral detection • Tissue culture and fluorescent antibody stains • TAT = 2-14 days

  22. Respiratory Viral Cultures • Influenza virus A • Influenza virus B • Adenovirus • Parainfluenza virus 1-3 • Respiratory Syncytial Virus • Enterovirus TAT = 2-10 days Detection in tissue culture Confirming by FA stain Positive influenza isolates sent to Molecular Diagnostics for sequencing

  23. The “Swine Flu” Team to the Rescue

  24. 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

  25. TAT – GC/Chlamydia Days

  26. 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

  27. 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

  28. Target Detection • Real time RT PCR • - 7500 DX (New Norovirus) • Traditional RT PCR • - 9700 (for Sequencing) • Multiplex PCR (xTag RVP) • - Luminex (not currently utilized)

  29. Strain Analysis Sanger Sequencing Pyrosequencing

  30. Influenza Surge Testing

  31. Bacteriology • Currently, limited bacteriology service Helicobacter pylori stool antigen test

  32. 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

  33. H. pyloriDisease Overview

  34. ACG Guidelines • The AGA released new guidelines for managing dyspepsia in 2005… and the American College of Gastroenterology revised their guidelines in 2007. • In 2007, the American College of Gastroenterology revised their guidelines to include: "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." 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

  35. 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 • The AGA and ACG guidelines do recommend using Stool Antigen Test or Urea Breath Test for the detection of H. pylori • 50% of patients that have a positive serology test do not have “active” infection(false positive for active infection)

  36. 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 Why Not Serology?

  37. 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 H. pylori Antigen Test

  38. 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

  39. 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

  40. BRAC • Lab – Open construction of entire lab space • Design facilitates movement of specimens • Lab work areas are moveable for mission flexibility

  41. USAFSAM EPI Lab

  42. 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: epilab.help@brooks.af.mil 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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