Challenges in Diagnostic

Support Services:
Laboratory Services
 Role of The Laboratory

1. Support for rapid investigation of

disease outbreaks

2. Support for improved surveillance

3. Provide early warning system for

emergence/reemergence pathogens
 Main Challenges to the Laboratory

1. Analyse data and provide feedback of the

results to public health authorities

2. Develop and maintain testing resources,

standard procedures and quality
assurance

3. Provide technical support, training,

guidance and quality assurance to all
laboratories within the country
 Specific demands when
investigating outbreaks

Unexpected event

Need to investigate quickly

Pressure for answers

Multiple agencies

Work carried out at many levels

In the media spotlight
Data:
Report

Lab confirmed

Clinical specimen

Seek medical attention

Symptoms

Infected

Exposed
 Outbreak Detection and Response
First
Case
Detection/ Opportunity
Reporting for control
90
Confirmation
80 Investigation
70
Response
60
CASES 50
40
30
20
10
0
10

13

16

19

22

25

28

31

34

37

40
1

DAY
 Responsibilities of Hospital Labs

Identification of infectious agent using

standard procedures and reagents

Refer to the National Ref lab for
isolate identification and/or serotyping

Reporting results

Coordination with case investigators

Coordination and implementation of
containment activities
Responsibilities of National Reference Labs (1)

Identification of infectious agent by

serology and/or isolation using standard
procedures and reagents

Referral of isolates (eg: influenza) to
the Global Specialized Labs / WHO
Collaborating Centre

Reporting results in a timely manner

Serve as centre for training the
laboratory personnel from hospital
laboratories
Responsibilities of National Reference Labs (2)

Provide guidelines for proper specimen

collection, transportation and laboratory
testing

Coordination and implementation of
containment activities

Coordination with case investigators
 Responsibilities of Global Specialized Labs

Definitive identification of isolates using

all available technologies, including
genetic characterization, to reveal the
origin of isolates

Preparation and distribution of relevant
standards, reference reagents and
training materials

Provision of consultants to evaluate and
advise on lab services and provide
specialized training
 Effective laboratory support requires:

that health-care professionals are aware

of the system and its requirements

appropriate specimens are collected and
sent to a laboratory capable of
performing the necessary tests

reliable equipment is used and tests
performed correctly

timely feedback is provided to the
appropriate authorities

the integrity of the surveillance system is
monitored on an ongoing basis
Preparedness: Some measures needed

1. Bio-safety Level 3 Laboratory (P3 Lab)

2. Training
3. International Linkages
4. Resources
5. Guidelines for Collection and
Transportation of Specimens
 The Outbreak Control Team

Membership

Leadership
Co-ordinate further investigation and
response

Responsibilities

Lines of communication

Communication and decision making
process
Report to and advise higher authorities
 Virology Unit, IDRC, IMR

- In 2002 initiated focus surveillance for:

 HFMD
 Influenza
 Dengue

- 16 March 2003, designated National

Reference Laboratory for SARS

- 2004 designated as the National Reference

Laboratory for Avian Influenza
 SARS OUTBREAK
Laboratory Facilities:
(i) BSL3 facilities and BSL3 work
practices:
samples processing and virus
isolation

(ii) BSL2 facilities with stringent BSL3

work practices:
PCR, IFA and EM
 Virology Laboratory, IMR

Setting up of the operations room

Teams by function

Retraining

All staff buy-in

Morale building

Guidelines
 Guidelines

Specimen collection

Specimen transport

Containment

Documentation

Information flow
 Specimens collection

The following should be considered for
collection of specimen for culture:
 Timing
 Appropriate site
 Proper collection
 Proper transportation
 Alert the laboratory of disease
suspected especially agents that
requires special culture media
Flow Chart For Specimen Receipt At IMR Specimen
Reception Counter
Clinical Specimen

Use PPE

Transfer Specimen to biohazard cabinet

Other specimen, process in

If Class 3 or 4 Pathogen
usual manner
DO NOT OPEN

Leave specimen in biohazard cabinet

Contact Virology Unit

Flow Chart for Specimen Receipt At Virology Unit Specimen
Reception Counter/Guard House

Clinical Specimen

Inform Officer and Technician in-charge

Use PPE

Place Specimen in Containment Box

Transfer Specimen to P3 Laboratory

 Laboratory Tests Investigation (1)

Cell culture

Nucleic acid testing

Processing
Specimen P3

Electron microscopy

Immunoflourescence
 Laboratory Tests Investigation (2)

use validated test methods

standard operating procedures

false positive/false negative results

verify test results
 Verification process

Laboratory results Head of Virology

Director General
Of Health

Deputy –Director General of Health

Minister of Health

CDC
 Problems Encountered

Inappropriate Specimen:
 Only swabs received (not suitable for EM)
 Only serum/blood received
Transportation of Specimen:
 Unsealed box/not labeled
 Not packed separately from other specimens for routine
tests.
 Staples used
Request Form:
 Request form packed together with sample
 Blank/incomplete request form
 Virology Unit, IDRC, IMR (4)

- Prepared for future pathogen level 3

outbreak investigation

- P3 laboratory adequately equipped

- Staff confident and prepared to cope

with future outbreaks.
PPE
Process Specimen in the
BSL-3 Cabinet

Autoclave Biohazard Collect Specimen From Pass-

Bag/Waste through Box
 Conclusion

Both the public health authority and the lab have a

role in ensuring optimum lab services:

Public health: to educate the health-care

providers on the importance of lab testing and to
make sure that the lab resources are accessible

Lab: to develop and maintain testing resources, SOP

& QAP, and to analyze data and provide feedback to
the public health authorities
 Lessons learnt

Be prepared for eventualities -training

Contingency plans- evaluate capabilities

Optimize resources : team work

Leadership role

Hands on

Keep cool and level headed