Microbiology for Public Health: The Role of Medical Laboratories

1. Microbiology for Public Health:The Role of Medical Laboratories Judy Isaac-Renton MD Director BCCDC Laboratory Services, PHSA Laboratories BCSLS, April 2008

2. Objectives • To describe the different microbiology disciplines • To outline Core Functions of public health labs, outlining some Why, What and Who’s • To list provincial, national and international public health partners • To describe how all microbiology labs collaborate in the public health network • To let you know what BCCDC and what BCCDC Laboratory Services does (your provincial public health reference microbiology labs)

3. Network Example 1: Reference • Late Friday afternoon • Physician (Respirologist) from IHA • On Call Medical Microbiologist • 58 yr old female in ICU, ventilated • Fever, CXR findings, risk factors

4. Network Example 1: Reference • Later Friday afternoon, team convened • CAP? (Bacteriology Program staff) • Viral? (Virology Program staff) • Hantavirus? (ZEP Program staff, NML) • 24/7 specialized expertise • Create knowledge/information (labs impact >80% medical decisions) Hanta? LD?

5. Network Example 2: Public Health • Testing in front-line microbiology labs, hospitals and community labs • 143 cases of disease due to E. coli O157 • 42 persons hospitalized: bloody diarrhea • Children on dialysis: No deaths • Public health galvanized, intervenes • Isolates from front-line microbiology labs, to provincial public health labs (BCCDC) E. coli

6. Network Example 2: Public Health Environmental Health Officer Sleuthing E. coli PFGE All Labs Testing BCCDC Labs Sleuthing Epidemiologists Analysing

7. Network Example 2: Public Health • Front-line labs do patient testing (patient focused) • Public health ref labs (e.g., BCCDC labs) do reference clinical and environmental microbiology testing (focus on specialty tests, link environmental with clinical and population health) • Both create information, Quality Assure it, interpret it, connect with health care workers • Information shared with public health workers in HA, Epi, CPHLN PulseNet WWW

8. Network Example 2: Public Health • Provincial public health labs, member of Canadian Public Health Network (CPHLN) • Link to National Micro Labs and PulseNet • To USA CDC Labs and PulseNet • To Labs world-wide and “PulseNets” • For both patients and populations • Interventions with prevention, a focus • Legislated framework WWW

9. Microbiology Disciplines Include: (From Largest Microbes to Smallest) • Parasitology: worms are large • Mycology: fungi are also large Giant tapeworm Aspergillus

10. Microbiology Disciplines Include: • Bacteriology: bacteria are smaller (light microscope) • Virology: smallest (seen using an electron microscope, not a light microscope) Virus Bacillus

11. Microbiology - Other • Some, such as prions, break all the rules • Communicable diseases (CDs) are the main focus of PH reference labs • All CDs are caused by infectious agents but not all infections are considered CDs

12. Core Functions forPublic Health MicrobiologyLaboratories & Networks • Ten Core Functions for public health laboratory system • CPHLN considers these a minimum requirement for optimal service on behalf of our communities http://www.cphln.ca/CPHLN/src/public_publications.php

13. Core Functions • Communicable disease surveillance, prevention and control • Outbreak and emergency response to communicable diseases • Environmental health and food safety • Reference testing, specialized screening and diagnostic testing • Biosafety, containment, and biohazard response • Integrated communicable disease data management • Public health policy development and evaluation • Laboratory Quality Assurance • Training and education of health care workers • Public health related research and development

14. Surveillance & Outbreak Response Core Function • Systematic data collection & interpretation of clinical and lab info • Multidisciplinary team needed • Labs in community, hospitals, public health all report to local public health • Public health analyses and responds HUS

15. Surveillance & Outbreak Response Core Function Why? • CDs, one important PH function • Ongoing watchfulness • Microbes impact quickly and widely • Microbes know no borders, change quickly • New patterns, novel pathogens, new tests • Alert for early diagnosis, intervention and prevention C. gattii SARS, Walkerton, Pan Flu....

16. Surveillance & Outbreak Response Core Function What? • Reportable Communicable Diseases (RCDs) from clinicians and labs (BC legislation) • Unusual observations (BC legislation) • Sentinel systems (respiratory, environmental) Who? • All microbiology labs to public health in HA • BCCDC Epid works on inter-jurisdictional issues • PH labs works with HA PH, Epi and CPHLN

17. Bioterrorism & Emergency Response Core Function Why? • Bioterrorism world-wide (purposeful release of infections agents) • Special events and natural events • Planning, capacity and response • Expertise, leaders and facilities

18. Environmental Microbiology Core Function Why? • Specialized public health practice of microbiology (very different than clinical) • Surveillance (upstream) and outbreak response • Bioterrorism (global food chain) • Natural emergencies (Fraser Freshet) • Planning, capacity and response • Expertise, leaders and facilities

19. Environmental Microbiology Core Function Who? • Private and public labs PHO approved for DW • Public health audits • Investigation of water-borne outbreaks • BCCDC leaders in Quality Assurance (EWQA)

20. Environmental Microbiology Core Function Who? • Networks with CFIA, Health Canada • Investigation of foodborne outbreaks from schools, restaurants, facilities etc • Food poisoning investigations • Public health food surveillance testing

21. Integrated Data Management Core Function Who? • Linking clinical and environmental testing • Lots of Information Management changes (in BC, it’s PHIP, PLIS) • Impacts of this change • Networks key WWW

22. Research & Training Core Function • Faculty and staff carry out public health research and training • New knowledge about communicable diseases (CDs) • When novel pathogens appear, critical skills (capacity) • Need to keep abreast of rapidly advancing technologies • Many educational/training activities

23. How Do PH Labs Core Functions Relate to Our Labs Work? • Communicable disease surveillance, prevention and control • Outbreak and emergency response to communicable diseases • Environmental health and food safety; • Reference testing, specialized screening and diagnostic testing • Biosafety, biocontainment, ER • Integrated communicable disease data management • Public health policy development and evaluation • Laboratory Quality Assurance • Training and education of health care and public health workers • Public health related research and development. Other Core Functions ? Some Core Functions Day-to-Day Work

24. Partners in Public Health • Local Medical Health Officers, CD Nurses, Environmental Health Officers • Epidemiology, STIC, TBC, EH • All health care workers • Provincial Health Officer • Ministry of Health

25. Partners in Public Health Lab Network? • Community and hospital microbiology labs: front line partners • PH Labs: reference and specialty labs • Share basics • Focus, hence roles, differ but work on Communicable Diseases together • Satellite public health labs

26. National Public Health Lab Network International (WHO, CampyNet etc)

27. BCCDC

28. Overview of BCCDC • British Columbia’s Centre of Excellence for the prevention, detection and control of communicable diseases (CDs) • Affiliated with University of British Columbia • Partners with the province’s public health workers in all Health Authorities as well as with MOH • Provides support and tools to respond to emergencies, outbreaks and unusual events related to communicable diseases (CDs)

29. BCCDC Divisions • Environmental Health • Epidemiology • Hepatitis Services • Laboratory Services • STI/AIDS Control • TB Control • Vaccine & Pharmacy

30. BCCDC Laboratory Services,PHSA Laboratories Programs: • Bacteriology & Mycology • Biosafety Biocontainment • Central Processing Receiving • Environmental Microbiology • Parasitology • Quality • TB/Mycobacteriology • Translational Research • Virology • Zoonotic Emerging Pathogens

31. Bacteriology & Mycology Program Program Head: Linda Hoang Section Head: Ana Pacaggnella Team: 30 staff Research: • Emerging pathogens • Healthcare acquired infections • New and unusual bugs • International medicine • Bacterial BT agents Linda Hoang, MD, DTM&H, FRCPCProgram Head Clinical Assistant ProfessorDept of Path & Lab MedicineUniversity of British Columbia Email: linda.hoang@bccdc.ca

32. Bacteriology & Mycology Program • Reference tests for bacteria with new molecular assays (PCR, 16S) • Identification and typing of isolates to detect, monitor and control outbreaks • Linked electronically with all other public health labs to assess PFGE patterns • Examine specimens for fungal systemic infections (deep mycoses) • Diagnosis of sexually transmitted diseases such as Chlamydia trachomatis, GC, and other CDs by nucleic acid testing, PCR.

33. Biosafety Biohazard Containment • BCCDC Labs Biosafety Biohazard Containment Program (TDG, WHMIS, CL3, ERAP, BRAT..) • Program Head Biosafety Officer: Neil Chin • Containment Level 3 Suites on 3 floors • Bioterrorism & Emergency Response Team for labs • Links with Emergency management at HA, provincial and national levels (Bi-Ex Field exercise)

34. Environmental Microbiology Program Head: Judy Isaac-Renton Section Head: Joe Fung Research: • Water Microbiology • Norovirus DNA`Sequencing • Botulism • Giardiasis • Microbial Source Tracking Judy Isaac-Renton, MD, DPH, FRCPCDirector, BCCDC Laboratory Services Professor Dept Path & Lab Medicine, University of British Columbia Email: judy.isaac-renton@bccdc.ca

35. Environmental Microbiology • Detection of protozoan parasites (Giardia, Cryptosporidium),in water • Developing PCR tests for specific pathogens • Test drinking, pool, beach water samples • Investigation of foodborne or waterborne outbreaks • Leaders in Provincial Health Officer program (EWQA) • Food poisoning investigations • Norovirus RT-PCR and DNA sequencing Photo courtesy University of Alberta, Public Health

36. TB Mycobacteriology Program Program Head: Patrick Tang Section Heads: Mabel Rodrigues Staff: 20 Research: • Molecular diagnostics • Microarrays and bioinformatics • Discovery of novel infectious agents Patrick K.C. Tang, MD, PhD, FRCPCClinical Assistant ProfessorDept Path & Lab MedicineUniversity of British Columbia Email: patrick.tang@bccdc.ca

37. Mycobacteriology/TB Program • Prepare smears (acid-fast stains, fluorescent) for diagnosis of TB • Liquid culture (automated process) and solid culture on Lowenstein Jensen media -Identification of all Mycobacterium species • Detect M.tb directly on smear positive sediments by molecular methodology • Biochemical identification and drug sensitivities in CL3 • Fingerprinting by RFLP and PCR VTRU to evaluate clusters of infection

38. Parasitology Program • Examination of samples for parasites of medical importance • Examination for intestinal parasites from SAF preserved stools (concentration, stained smears) • Outbreak investigation and surveillance • Examination for Blood/Tissue parasites such as malaria, Acanthamoeba and Leishmania • Specialized procedures (cultures, Baermann) • Tick identification • Mosquito surveillance for West Nile virus monitoring

39. Translational Research in Microbiology • Development and adaptation of molecular diagnostic methods for use in all laboratories • DNA sequence identification of all organisms • Compilation of sequence databanks available to outside laboratories • Rigorous program for monitoring Molecular Quality Control • Education and training in new molecular methods • Network for public health: technology transfer