1. Laboratory training course: Proper selection, handling and shipping of samples for diagnosis of influenza and other respiratory viruses

2. SESSIÓN 4: SELECTION, HANDLING AND CORRECT SHIPPING OF SAMPLES

3. http://www.livescience.com/16382-viruses-raw-sewage.html Know criteria for selection and characterization of samples Review the guidelines for sending samples to WHO CC Review basic concepts of packing and shipping samples Know the requiered documentation for sending samples Objectives

4. What Information is Important about Influenza Viruses? Emergence of novel subtypes Mutations among circulating viruses Increasing incidence/emergence of antiviral resistance among circulating viruses Comparison of circulating viruses to viruses in current seasonal vaccine

5. How can we resolve these questions? To answer these questions it is necessary to have different laboratory tests and tools for identification. Some are available at the NICs and others are performed the WHO CC, among which are the following: Inmunofluorescence Viral Isolation (MDCK and Embryonated Eggs) Titration of HA and IHA (Antigenic Characterization) Microneutralization Typing and subtyping by qRT-PCR Pyrosequencing and Sequencing Bioinformatics analyzes

6. National Influenza Centers http://www.who.int/influenza/gisn_laboratory/national_influenza_centres/t erms_of_reference_for_national_influenza_centres.pdf

7. WHY, WHERE AND FOR WHAT SEND SAMPLES?

8. Because of the capacity of transmission and evolution of influenza viruses, it is necessary to complement monitoring by more detailed characterization of circulating viruses Why?

9. Regional Labs to NICs NICs to WHO CC WHO CC shares information and viruses with the Global Influenza Surveillance Network ) Where?

10. Selection of strains for vaccine formulation Antiviral Resistance Novel Virus Mutation detection WHO-CC For What?

11. CRITERIA FOR SELECTION OF SAMPLES

12. Samples for the WHO-CC ObjectiveHow to Select Samples When to Send Samples Funding Source to Ship Samples Detect novel subtypeAny unsubtypeable influenza A virus Immediately  WHO Global Shipping Project, PAHO, CDC, Country Resources Detect anti-viral resistance Cases receiving anti- viral therapy, immunosuppressed cases Routine  (2-4 times each year)  Number of samples is according to epidemiological presentation  Number of samples is between 15 to 20 Detect mutationsRandom Contribute to vaccine composition Random  Based upon influenza season and by August and January 15

13. Random Selection All circulating virus types/subtypes Different age groups Varying geographic regions Ambulatory and hospitalized cases Deaths Outbreaks Recipients of antiviral therapy

14. - 5 to 10 representative samples of unusual outbreaks (e.g. outside the expected seasonal) - Any sample corresponding to unusual cases with inconclusive results Sending at any time Other criteria

15. Additional Principles in Selecting Samples to Submit Type of sample to send  isolates preferred, also send clinical material Time period to select from  recent viruses (1-3 months old)

16. Objective 1: Detect Novel Subtype Which samples to send: any influenza A virus which is unable to be subtyped When to send: immediately Public health significance –Emergence of novel subtype with pandemic potential –Introduction of H5 or H7 in the Americas Region

17. Objective 2: Detect Anti-viral Resistance Which samples to send –Prioritize Cases receiving anti-viral therapy Cases who are immunosuppressed –Part of random selection of 15-20 samples When to send –Routinely (2-4 times each year) Public health significance –Emergence of anti-viral resistant strain –Fewer options for treatment/chemoprophylaxis

18. Objective 3: Detect Mutations Which samples to send –Part of random selection of 15-20 samples When to send –Routinely (2-4 times each year) Public health significance –Poor vaccine match

19. Objective 4: Contribute to Vaccine Composition Development Which samples to send –Part of random selection of 15-20 samples When to send –Routinely (2-4 times each year) –Before strain selection meeting (February, September) Public health significance –Data needed to determine which three/four strains to include in the seasonal influenza vaccine

20. Seasonal Influenza Vaccine Trivalent or quadrivalent vaccine –Influenza A (H1) –Influenza A (H3) –Influenza B (Yamagata and/or Victoria) Southern Hemisphere and Northern Hemisphere composition –Southern Hemisphere composition determined in September –Northern Hemisphere composition determined in February –Recommendations match ~66% of the time

21. When to Send for Routine Submission JANFEBMARAPRMAYJUNJULAUGSEPTOCTNOVDEC NH INFLUENZA SEASON SH INFLUENZA SEASON NH STRAIN SELECTION MEETING SH STRAIN SELECTION MEETING  TROPICAL COUNTRIES INFLUENZA SEASON

22. When to Send for Routine Submission- Southern Hemisphere JANFEBMARAPRMAYJUNJULAUGSEPTOCTNOVDEC SH INFLUENZA SEASON NH STRAIN SELECTION MEETING SH STRAIN SELECTION MEETING  Off- season Early- season Mid- season Late- season

23. When to Send for Routine Submission- Tropical Countries JANFEBMARAPRMAYJUNJULAUGSEPTOCTNOVDEC NH STRAIN SELECTION MEETING SH STRAIN SELECTION MEETING  Off- season Late- season Early- season Mid- season

24. Santa Cruz, Bolivia

25. Chile

26. Sep Feb OctAgo JulJun Nov Dic Ene Mar Abr May Selection and sending Meeting for the formulation of the vaccine SH NH When to Send for Routine Submission

27. Muestras enviadas a los CC OMS para caracterización adicional por fecha recibida y por país, 2014 Source: WHO CC data. Note: Each color represents one country. NH SH Samples sent to WHO CC for additional characterization by date received and by country, 2014

28. Samples sent to WHO CC for additional characterization by Region and month received, 2014 Source: WHO CC data.

29. SENDING SAMPLES

30. Transport of Dangerous Goods International Regulations UN Committee of Experts on the Transport of Dangerous Goods (UNCETDG) Transport of dangerous goods

31. International Regulations The International Air Transport Association (IATA) Air Regulations concerning the International Carriage of Dangerous Goods by Rail (RID) Rail The European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR) Road The International Maritime Dangerous Goods Code published by the International Maritime Organization (IMO) Sea

32. Difficulting finding transport Exposure to infectious substances Conse- quences Panic incident Shipment detained by customs Civil or criminal lawsuits Errors and delays in delivery Consequences of improper packaging

33. Sender responsibilities Complete documentation Coordinate with carrier and receiver Ensure Responsibility of the sender Label Packaging Clasification of the substance

34. -Categorization -appropriate packaging -appropriate labeling -Documentation Required -Format Air Shipping -Statement of dangerous goods (A) -Certificate Training Good to know…

35. Categorization

36. Class 2: Gases Class 3: Flammable liquids Class 6: Toxic and infectious substances Division 6.1: Toxic substances Division 6.2: Infectious substances Class 9: various dangerous goods and articles, including environmental substances Classes of Dangerous Goods

37. 1.Infectious substances (Category A) 2.Biological substances (Category B) 3.Biological products 4.Genetically modified organisms 5.Clinical or Medical wastes 6.Live and infected animals 7.Human samples/animal samples exemptions 8.Other exemptions Substances class 6 Class 6: Toxic and Infectious substances Division 6.2: Infectious substances

38. CATEGORY A Any infectious substance that could generated disability, life threatening or fatal disease in healthy humans or animals Proper shipping name: UN 2814 "INFECTIOUS SUBSTANCE, AFFECTING HUMANS" UN 2900 "INFECTIOUS SUBSTANCE, AFFECTING ANIMALS ONLY" CATEGORY B Any biological substance that does not meet the criteria for Category A. Proper shipping name : UN 3373: "BIOLOGICAL SUBSTANCE, CATEGORY B" A 3291: "CLINICAL WASTE, UNSPECIFIED" Categorization (Division 6.2)

39. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Flow for the classification of infectious substances

40. Category A (Infectious Substances) Category B (Biological Substances) Exemptions: 1.Samples without infectious components or with low probability of causing disease in humans or animals 2.Substances with non-pathogen agents for humans or animals 3.Neutralized or inactivated substances Categorization (division 6.2)

41. Category A (Infectious Substances) Highly pathogenic avian influenza virus (viral culture) Category B (Biological Substances) Highly pathogenic avian influenza virus (patient sample) Exemptions: 1.Samples without infectious components or with low probability of causing disease in humans or animals 2.Substances with non-pathogen agents for humans or animals 3.Neutralized or inactivated substances Categorization (division 6.2)

42. Some infectious goods included in category A

43. Packaging

44. Use three layers of packaging The first container must be resistant to seepage Use absorbent material in each container Packaging Primary container Secondary containerOuter container http://upload.wikimedia.org/wikipedia/commons/2/28/Tripe_embalaje.png

45. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Packaging Category A

46. All Category A infectious substances must comply with the instructions for packaging the United Nations (UN), P620. This guarantees the packaging has passed stringent stress tests (pressure, stacking, punching, etc.) The outer container must indicate the sign of the United Nations, ensuring quality packaging to officials http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.1 2_eng.pdf?ua=1 Packaging Category A

47. Labeling Category A

48. Information on the outer container : Name and address of the sender Telephone number responsible for shipping Name and address of consignee Proper shipping number (UN 2814 or UN 2900) Temperature requirements (optional) If dry ice or liquid nitrogen is used: technical name, UN number and total amount. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.1 2_eng.pdf?ua=1 Labeling Category A

49. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Labeling Category A

50. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Labeled Category A

51. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Labeled Category A

52. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Packaging Category B

53. Each shipment must have the following information : Airway: name, phone number and address of the sender Phone of person responsible for emergency contact Name, telephone number and address of the recipient. Proper name, visible: (“BIOLOGICAL SUBSTANCE, CATEGORY B") Optional: Special requirements for temperature http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Labeled Category B

54. A packing list format or the address of the consignee, the number of packages to send, weight and detail of the content. Declaration or import/export permit (if required). Sending Format (air waybill) where the content is detailed http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.12_eng.pdf?ua=1 Air waybill: Documentation of Category B

55. Declaration of Dangerous Goods A packing list format or the address of the consignee, the number of packets to send, weight and detail of the content. Declaration or permit import/export (if required). Appropriate documents (waybill) for shipments by rail, road or sea. http://apps.who.int/iris/bitstream/10665/78075/1/WHO_HSE_GCR_2012.1 2_eng.pdf?ua=1 Declaration of Dangerous Goods These documents must be prepared and signed by the sender: Documentation of Category B

56. Declaration of Dangerous Goods X Documentation of Category B

57. Ensure cold chain. Include details of sending samples, identification number and epidemiological data Final recomendations…

58.  Blanton,L., Brammer,L., et al.(2011) Influenza. Manual for the surveillance of vaccine- preventable diseases. 5th Edition. Available online at: http://www.cdc.gov/vaccines/pubs/surv-manual/chpt06-influenza.pdf http://www.cdc.gov/vaccines/pubs/surv-manual/chpt06-influenza.pdf  World Health Organization (WHO). (2006) Collecting, preserving and shipping specimens for the diagnosis of avian influenza A(H5N1) virus infection. Guide for field operations. Available online at: http://www.who.int/csr/resources/publications/surveillance/CDS_EPR_ARO_2006_1.pdf?ua= 1  World Health Organization (WHO). (2004) Guidelines for the collection of clinical specimens during field investigation of outbreaks. Available online at: http://www.who.int/csr/resources/publications/surveillance/whocdscsredc2004.pdf http://www.who.int/csr/resources/publications/surveillance/whocdscsredc2004.pdf  World Health Organization (WHO).(2009) Instructions for storage and transport of suspected or confirmed human and animal specimens and virus isolates of pandemic (H1N1). Available online at: http://www.who.int/influenza/gisrs_laboratory/logistic_activities/transport_storage_specimens _isolates/en/ References

59.  World Health Organization (WHO). Laboratory biosafety manual, Biosafety guidelines. Third Edition (2004). Available online at: http://www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf?ua=1 http://www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf?ua=1  World Health Organization (WHO). Manual for the laboratory diagnosis and virological surveillance of influenza. Available online at: http://whqlibdoc.who.int/publications/2011/9789241548090_eng.pdf?ua=1 http://whqlibdoc.who.int/publications/2011/9789241548090_eng.pdf?ua=1  World Health Organization (WHO). Nasopharyngeal and Oropharyngeal Swabs. Available online at: http://www.youtube.com/watch?v=mfZYAMDpGNk  World Health Organization (WHO). Selection of clinical specimens for RT-PCR and virus isolation and of viruses for shipment from National Influenza Centres to WHO Collaborating Centres. Available online at: http://www.flu.mn/mgl/images/stories/Sudalgaa_shinjilgee/GISN2010/suppl.03.%20Selection%20on% 20clinical%20specimens%20for%20PCR,%20virus%20isolation%20and%20shipment%20for%20NIC s.pdf http://www.flu.mn/mgl/images/stories/Sudalgaa_shinjilgee/GISN2010/suppl.03.%20Selection%20on% 20clinical%20specimens%20for%20PCR,%20virus%20isolation%20and%20shipment%20for%20NIC s.pdf  World Health Organization (WHO). WHO information for molecular diagnosis of influenza virus in humans – update (2012). Available online at: http://www.who.int/influenza/gisrs_laboratory/molecular_diagnosis_influenza_virus_humans_update_2 01211.pdf http://www.who.int/influenza/gisrs_laboratory/molecular_diagnosis_influenza_virus_humans_update_2 01211.pdf  World Health Organization (WHO). Personel Protective Equipment (PPE). Available at: World Health Organization (WHO). References (2)

60. Thank you!