NCSLPH 2013 GUIDE TO RABIES PACKAGING AND SHIPPING NC State Laboratory of Public Health

Proper Packaging and Shipping Ensures: Optimal sample integrity Protection of personnel against exposure to unknown biological substances during packaging, transporting, and testing of the sample Accurate test results with rapid test turn- around time Compliance with Department of Transportation (DOT) Regulations NCSLPH 2013

NCSLPH 2013 Supplies Needed Absorbent materials (A) Primary container (leak proof zip-lock bags) (B) Secondary container (leak proof zip-lock bags)(C) Cushioning material Insulated container with lid (at least 2” thick if no outer container used) (D) Sturdy outer mailing container (optional) (E) Biohazard label UN3373 Biological Substance Category B Label Requisition form (DHHS #1614)(F) Tape Ice Packs Mailing Label A BC D E F

NCSLPH 2013 Primary Container Place sample in primary container Primary container must be leak proof/ watertight Zip-lock bags are preferred Make sure animals are treated for fleas, ticks, maggots, or other insects before packaging

NCSLPH 2013 Primary Container (cont.) Add absorbent material to primary container Absorbent material must be sufficient to absorb any liquids in the primary container Butcher’s meat packaging absorbent pad or equivalent is acceptable material

NCSLPH 2013 Primary Container (cont.) The sample should be visible through the primary container so that the condition of the sample can be viewed before removing it from the container Wrap samples only when sharp objects such as bones or teeth are protruding Live bats, fleas, maggots, ticks, etc. may not be detected if sample is wrapped in multiple layers Bats should never be wrapped

NCSLPH 2013 Primary Container (cont.) Zip the primary container closed Primary container must be leak proof; if unsure, use duct tape to secure Biohazard and dark bags should not be used as a primary or secondary container

NCSLPH 2013 Secondary Container Place the sealed primary container inside a secondary leak proof container Seal secondary container To ensure the secondary container is leak proof, use duct tape to seal

NCSLPH 2013 Biohazard Labels Place biohazard labels on the secondary container ONLY Biohazard labels should NEVER be placed on the outer container Container with biohazard label on the outside will cost more to ship

NCSLPH 2013 Insulated Container The tertiary container MUST be insulated Container should be at least 1” thick; if the tertiary container is used as the outer container, it must be at least 2” thick Prepare the insulated container by placing newspaper or some other form of cushioning inside Newspaper should be folded and not balled up

NCSLPH 2013 Add Sample After cushioning has been added, add sample to the container More than one sample can be shipped in one container If multiple samples are shipped together, each sample must have it’s own primary and secondary container with a matching requisition form Unique identification must be included on both the sample and the form

NCSLPH 2013 Coolants Add enough coolants to ensure the sample(s) will be kept cold during shipment During summer months, additional coolants should be added Failure to adequately maintain cool temperatures during shipping is a major cause of samples being unsatisfactory for testing Bats should have extra cushioning around them to prevent being crushed by coolants

NCSLPH 2013 Requisition Form Completely fill out DHHS #1614 (available at Use ONE form per sample; multiple samples should not be included on one form, even if the samples have exposed the same person If a low risk sample has been approved for testing, indicate this on the form Ensure the contact person (Section 2) can be reached at a working number so that results can be reported during normal working hours and on weekends/holidays

NCSLPH 2013 Requisition Form (cont.) Place requisition form in a zip-lock bag to prevent contamination from blood or any other liquid that may be associated with the sample If the form has blood or any other liquid on it, it should be copied and the copy placed in the zip-lock bag

NCSLPH 2013 Outer Mailing Container An outer mailing container is not needed if the tertiary container is at least 2” thick The outer container must have a UN3373, Biological Substance Category B label on the outside

NCSLPH 2013 Seal the mailing container Shipping Labels Place a rabies shipping label on the outer container These labels are available through the NCSLPH mailroom (919)

Weekend/Holiday Shipping Guidelines NCSLPH does not perform routine rabies testing on weekends/holidays; however, weekend testing is available for samples meeting established criteria Contact the Communicable Disease Branch to obtain approval for weekend/holiday testing at (919) Samples which are approved for weekend/holiday testing will be tested only if the submitter is available to receive test results on the weekend Notify the authorizing official of the method of shipment Notify the laboratory once a sample has been approved for weekend/holiday testing at (919) Approved samples for weekend testing should be packaged according to standard procedure for shipping rabies samples Mark the outside of the shipping container “Weekend/Holiday Testing” NCSLPH 2013

Weekend/Holiday Shipping Guidelines When using the state courier service, check with the state courier at (919) to confirm pick-up and delivery time to the State Laboratory It is the responsibility of the submitter to ensure the sample is delivered to the laboratory no later 12:00 noon (preferably by 10:00 am) on Saturdays for weekend testing Although using the state courier is the preferred method, samples may also be shipped using FedEx When using FedEx, ensure that ‘Priority Overnight’ and ‘Saturday Delivery’ are checked on the Air bill Shipments via FedEx or UPS will be accepted by State Capital Police at the State Laboratory at any time (24/7/365) The Rabies laboratory will notify State Capital Police to expect the sample NCSLPH 2013

Reasons for Unsatisfactory Results NCSLPH 2013 The laboratory must be able to identify both a complete cross-section of the brainstem and the cerebellum or hippocampus before reporting a negative result If these parts are unidentifiable due to decomposition or trauma or if they are missing, the sample may be reported as “Unsatisfactory” Case management of “Unsatisfactory” samples requires that the case be handled as if the sample had tested “Positive”

Reasons for Unsatisfactory Results Decomposition (Due to improper shipment or natural causes) Samples in which the necessary sections of the brain are deemed unidentifiable Definitive results can not be reported due to interference with test interpretation NCSLPH 2013

Reasons for Unsatisfactory Results Brain Destroyed/ Trauma (When animal was killed) Sample must contain a complete cross-section of the brainstem and cerebellum or hippocampus for testing in order to report definitive test results Gunshots, Blunt Force, Hit by Car, etc. can damage brain tissue beyond recognition Brain condition is evaluated on a case by case basis at necropsy NCSLPH 2013

Reasons for Unsatisfactory Results Incomplete Cross-Section of the Brain Stem Applies only to facilities submitting extracted brain material for rabies testing Please contact the laboratory for questions regarding removal of brain material for submission to the NCSLPH NCSLPH 2013

Common Reasons for Rabies Samples Being Reported as “Test Not Performed” Dry Cavity No brain material for testing NCSLPH 2013

Common Reasons for Rabies Samples Being Reported as “Test Not Performed” Multiple Bats in an Occupied Dwelling 4 or more bats in a single dwelling will not be tested without prior approval If multiple bats are found in a dwelling, there is no guarantee that all bats were captured since it is highly likely that more are present Testing only the captured bats will not provide information about other unrecognized, un- captured bats that may have exposed a person Low positivity rates in bats make testing only captured bats unreliable for patient management decisions Contact the Communicable Disease Branch for questions and guidance NCSLPH 2013

Common Reasons for Rabies Samples Being Reported as “Test Not Performed” Low Risk Animals (require prior approval from CD Branch before testing) NCSLPH 2013

NCSLPH 2013 What’s Wrong With The Following Pictures?

Outer Mailing Container is not 2” thick The container broke and the sample rolled out of the container. Also, the sample was not packaged in leak proof primary or secondary containers with absorbent material (notice all the blood). The NCSLPH mailroom was not happy. NCSLPH 2013

Non-insulated container, no primary or secondary container, no coolants, no cushioning Wrong, wrong, wrong! NCSLPH 2013

Biohazard label and “Diagnostic Specimen” written on outer container NCSLPH 2013

NCSLPH 2013 Sample not treated for maggots

NCSLPH 2013 Requisition form taped on outer container Requisitions placed on the outside of the container may be damaged or accidently removed and lost from the package during shipment.

NCSLPH 2013 Sample not visible through primary container

NCSLPH 2013 Non-insulated container and no cushioning

NCSLPH 2013 Bat taped to bottom of container, no coolants, no cushioning

NCSLPH 2013 Sample wrapped in multiple layers, not visible through the primary container Multiple layers make the sample difficult to unwrap and time consuming.

NCSLPH 2013 Non-insulated container Sample may decompose during shipping if not insulated properly.

NCSLPH 2013 Biohazard bags used as primary and secondary containers These are neither clear nor leak-proof.

NCSLPH 2013 Thank You! Thanks to all those who serve the citizens of NC in the prevention & control of rabies The NCSLPH receives over 4,000 samples for rabies testing every year and most of those samples are packaged properly Let’s continue to work together to keep everyone safe! For a printer-friendly version of this presentation, click here!here

Thank you for viewing the Guide to Rabies Packaging and Shipping! NCSLPH 2013 If you would like continuing education credit with a certificate of completion… Next there are two options… Guide To Rabies - Packaging and Shipping Classroom The classroom page has the quiz link and instructions on how to register. If you are not interested in taking the quiz for continuing education credit… Guide To Rabies - Packaging and Shipping Survey This brief survey will help NCSLPH better serve your future training needs.

NCSLPH 2013 Additional Information Centers for Disease Control & Prevention, Office of Health and Safety – US Dept. of Transportation – US Postal Service – International Air Transport Association (IATA) – US Dept. of Agriculture – US Dept. of Interior, US Fish & Wildlife Service –

NCSLPH 2013 Additional Information (cont.) Thermosafe (Boxes) - North Carolina State Laboratory of Public Health - Casing Scientific ( Labels) - For a printer-friendly version of this presentation, click here!here