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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. 10-085, 16 Mar 10. USAFSAM “EPI Lab”. USAFSAM’S H1N1 SURGE PLAN. SSgt Anthony Lowman SSgt Rhonda Sullivan Lucinda Sinclair.

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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. 10-085, 16 Mar 10

  2. USAFSAM “EPI Lab” USAFSAM’S H1N1 SURGE PLAN SSgt Anthony Lowman SSgt Rhonda Sullivan Lucinda Sinclair Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  3. USAFSAM “EPI Lab” Molecular Diagnostics Climate PRE-H1N1 Surge Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  4. MOLECULAR/VIROLOGY • USAFSAM/ PHE Molecular and Virology Department work hand-in-hand • Viral Sample is Received Via Central Operations • 1 aliquot goes to Molecular for testing • 1 aliquot goes to Virology for testing • remaining aliquots are archived • Flu A and Flu B Results Are Correlated • Acts as a checks and balances system • Increases result confidence Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  5. SEASONAL INFLUENZA • Seasonal Influenza (SI) viruses • Influenza A, Subtype H1 • Influenza A, Subtype H3 • Influenza B • SI Typically Peaks Jan-Feb • 09’ Molecular Lab-8700 samples • 08’ Molecular Lab-12000 samples Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  6. Nucleic Acid Extraction • Automated methods • M48 (48 specimens) • MDX (96 specimens) • Manual methods • QIAamp DNA Blood Mini Kit • RNAqueous-Micro Kit Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  7. TEST METHODS • X-TAGRESPIRATORYVIRAL PANEL (RVP) • Luminex Platform • 13 target real-time multiplex assay • 11 viral targets, 1 run control, and 1 internal control Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  8. TRADITIONAL RT-PCR • Traditional Polymerase Chain Reaction (PCR) • specific primer sets for specific targets • used for Flu B, Flu A (H1/H3), and Adenovirus 14 Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  9. PROCESSING TIMES • Automated extractions (sample prep to nucleic acid) • M48-approx. 4 hrs. for 48 samples • MDX-approx. 5 hrs. for 96 samples • Traditional PCR (sample prep. to results) • approx. 6 hrs for a full 96 well plate • Luminex X-Tag RVP (sample prep. to results) • approx. 9 hrs for a full 96 well plate Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  10. OPS TEMPO • Molecular 2009 1st Quarter Personnel • 6 contractors, 4 military, and 1 civilian • Sample # processed prior to H1N1 surge • Jan 09’-4500 • Feb 09’-4200 • Mar 09’-6000 • Work Shifts (Peak) • Two 9 hr. shifts • 0700-2100 Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  11. Enter -H1N1 H1N1 hits, USAFSAM’s viral sample workload almost TRIPLES. Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  12. USAFSAM “EPI Lab” • Normal Virology Operations/ Pre-Surge Testing • Respiratory Culture Workload • Virology H1N1 Surge Operations Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  13. Normal Virology Ops/ Pre-Surge Testing • Receive 10-50 respiratory samples / day • Molecular pulls first Aliquot • Respiratory Sample Testing: • Aliquot 3 cryo vials for specimen archiving • Inoculate: • 1 PMK Tube • 1 A-5 Tube • 1 PMK Shell Vial Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  14. Normal Ops/ Pre-Surge Testing • Respiratory Sample Testing Cont… • Work up Shell Vials on Day 2 (48 hrs) • Read Tubes for CPE average of 5 times • Positive Tubes/SV identify virus by DFA staining • Archive Isolates of Positive samples • Negative Tubes Day 10: • Perform Hemadsorption (HAd) for R/O • <2 yrs old – Resp. Pool DFA Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  15. Respiratory Culture Workload Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  16. Virology H1N1 Surge Ops • Dropped “Cadillac Method” • Utilized frozen ready cells • Read tubes minimum of 3 times • HAd’s only on questionable tubes • Called Suppliers ASAP for overages • Augmented staff w/ techs from local area • Trained on “easy tasks” to free up Viro Techs Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  17. Virology H1N1 Surge Ops • Combined Molecular aliquoting w/ Viro • 2 step hr process to a 1 step ½ hr process • Upped Saturday Ops • Received/Processed Saturday Samples • Asked WHMC to send courier • Reduced Isolate Backlog • Assigned 2 new techs to manage Archiving/Freezer works • Utilized augmentees Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  18. Virology H1N1 Surge Ops • BSL 2 + precautions • CDC requirement • BSL 2 hood w/ additional PPE • N95 respirator mask • Fit Test requirements Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  19. Virology Lessons Learned • Communication, Communication, Communication! • Logistics, Management, Public Health • Capable of higher Ops than projected • 300 VS. 200 Samples per day • Surge plan adequate/flexible • Training is key • Utilizing BSL2 Hood space Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  20. USAFSAM’S VIROLOGY LAB Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  21. 2009 P H1N1 Surge Plan Can you spell… • How it all started • Surge Strategy • 2008 • 2009 • Lessons Learned S E T - U P Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  22. WHAT HAD HAPPEN’D WAS • 16 & 17 Apr 09 – requests are winding down • Unusual subtyping results …..Contact CDC • 21 Apr 09 • CDC-have you heard about Mexico • Ship Tues…BTW we contacted TDHHS…Gee, thanks • 22 Apr 09 - Emergency courier….aaaarrrrr! • Does Brooks have an air strip?? • 25 Apr 09 • Test 9 RAFB suspect specimens…Full MOPP • Run’s done @ 10:30pm…COOL!; • Sorta kinda need you to repeat, tonight….Not Cool! Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  23. WHAT ARE WE DOING??? • 27 Apr 09 • Did you hear….how’re YOU feeling • 27 Apr – 1 May 09 All initial unsubtypables: • Quarantine • Repeat • Shipment….notify CDC • Lab Director/PHR • 250 specimens…1-7500….2 hr test…WHAT DO YOU WANT!! All stressed out, and no one to choke! Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  24. 2008 SURGE PLAN, 200/DAY • 1 Inputs Viro/Mole • Continued focus • Virology Lab = 8 • 6 trained on 7500 • New procedure & processes, cross-training not implemented • Good idea, but ….No need • Central OPs = 20 • CustServiceTeam = 3 • Virology Lab = 8 • Mole = 11 • Personnel from other sections are cross– trained • Suspend other testing Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  25. NEW STRATEGY, 400/DAY • Testing: • New Swine Flu assay • OIC ordering from home, new lab assistant • Equipment: • Easy Mag - get 2 more • 3 more 7500s coming • Personnel • Training • Schedules Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  26. LIMITATIONS • Laboratory Footprint – Unidirectional Flow • Processing Area • Extraction Area/PCR Set-up • MasterMix • Logistics/ Storage- specimens, supplies • Working Conditions • Full MOPP – lose dexterity, scope of vision • Ambient temps – too hot for full MOPP • Training Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  27. WHATEVER THE ROYAL COURT SAYS GOES!! Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  28. 2009 P H1N1 SURGE PLANIMPLEMENTED • Trained Augmentees- • 2- WHMC (JBAIDS trained) • 2- Advanced Tech Center (Mole experienced) • Addtn’l Central OPs • Outsourced Specimen Processing- • Managed by Immunology – • Augmented by USAFSAM Chemistry Div • Commandeered lab space (Bacti) • 3 Easy Mags • 2 hoods for extraction prep • Extended lab coverage – 15 crept up to 24hr • Streamlined Testing – Dropped InfB Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  29. LESSONS LEARNED • Trained Augmentees- • Next time start in-house (Maybe) • Outsourced Specimen Processing- • 3-day training…slow down • Lab space (Bacti) • Great!! Could not have done it • Extended lab coverage – 15 crept up to 24hr • Better usage of augmentees • Streamlined Testing – Dropped InfB • Sooner • 29 vs 45 specimens/plate...$400 kit/100 tests Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  30. SO, ARE YOU LOOKING FOR YOUR SET-UP S E T - U P • Trusted laboratorians/scientist to perform testing • Detected 2nd strain CDC used as reference • Trusted to roll-out DoD training program • Trusted specimens for annual vaccine production Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

  31. QUESTIONS? Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

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