1. Laboratory Response to the 2009 H1N1 Event Texas Department of State Health Services Laboratory Services Section Grace Kubin, Ph.D. Vanessa Telles, MPH Emergency Preparedness Branch

3. Outline  Anatomy of a response – Surge!  How big and how bad  Surveillance mode – What does that mean?  Specimen collection, packaging and shipment

4. Laboratory Response Network (LRN) Flu Pilot = Statewide Surge  LRN laboratories around Texas participated in flu pilot project for 2008-2009 season  Split specimens – LRN performed PCR testing for seasonal influenza and remaining specimen sent to DSHS Austin laboratory for culture

5. Laboratory Response Network (LRN) Flu Pilot = Statewide Surge

6. Regular Flu Season  Approximately 22 specimens tested per day  2 technical staff performing PCR  Between 1000 to 1500 specimens received the entire season (between the months of October through May)

7. H1N1 Response: Calling all specimens Received between 1000 to 1500 specimens per day early in the event

8. Ramping Up in 9 days:  Staffing: Increased from 2 to 25 trained laboratory staff Contracted 15 temporary laboratory employees 66 non-technical laboratory staff to support the response

9. Ramping Up: Equipment  Equipment 4 ABI 7500 FAST instruments  1 upgraded instrument in virology area  1 instrument in Biothreat area  2 on loan from manufacturer 1 Luminex instrument on loan

10. Ramping Up: Specimen Throughput  One ABI instrument: 2 trained staff 22 specimens per day (regular 8 hour day)  4 ABI instruments: 20 trained staff 252 specimens per shift  One “shift” 14.5 hours

11. Ramping Up: Specimen Throughput  One Luminex instrument: 6 trained staff 90-360 specimens per shift  One “shift” 10-14 hours

12. Samples Received during H1N1  DSHS Austin Total: 13,500 specimens (running tally through July 8th)  Texas Total: Over 38,000 specimens (running tally through July 8th)

14. Overall H1N1Results For all specimens tested at DSHS:  Percent Positive for H1N1: 21.1%  Percent Negative for Flu A: 74.9%

15. The Purpose of H1N1 Surveillance  to detect the distribution and spread of the virus  to detect new variants of the virus  and to assist in outbreak investigations

16. Surveillance Specimen Criteria Draft only – not yet approved  Patients hospitalized for 48 hours or greater and the following symptoms: Fever > 37.8ºC (100ºF) and cough and/or sore throat plus one or both of the following conditions: severe illness with lower respiratory tract infections or pneumonia OR certain atypical presentation in children, adults > 64 years of age, and immunocompromised individuals  Patients who have died with influenza-like illness and have no other known cause of death (ante mortem specimens only)  Pregnant patients with influenza-like illness

17. Surveillance Specimen Criteria Draft only – not yet approved  Individuals with influenza-like illness who are part of a critical public health investigation as identified by the DSHS Health Service Region (HSR), DSHS Infectious Disease Control Unit (IDCU) or local health department and communicated by the HSR or IDCU to the state laboratory.  Providers who are participants in the DSHS viral culture/PCR surveillance system as designated by the DSHS Infectious Disease Control Unit (IDCU); only enrolled providers will be allowed to submit specimens.

18. Surveillance Specimen Criteria Draft only – not yet approved  Specimens not meeting one of these criteria should be submitted to a reference laboratory.  Reference laboratories performing H1N1 testing: Quest Diagnostics Texas Children’s Hospital (Houston) List of laboratories will be posted to the DSHS website

19. Proper Specimen Collection: Swabs  Swabs accepted for testing: Sterile, polyester fiber tipped swabs with a plastic shaft  Either Dacron or Rayon swabs  Swabs not accepted for testing: No cotton tipped or wooden shaft swabs No swabs that contain calcium alginate Genprobe testing swabs are unacceptable

20. Acceptable Specimens  Nasopharyngeal swabs  Nasopharyngeal aspirates  Nasal swabs  Throat swabs  Dual nasopharyngeal / throat swabs

21. Proper Specimen Collection: Media  Do not use expired media Be sure to check expiration date  Store properly according to package insert  Place swabbed specimens in media

22. Specimen Handling  Transport specimens to the laboratory as soon as possible  Preferably ship the same day of collection  If collected on a Friday, a holiday, or the weekend, store at -70°C and ship on Monday or the following business day

23. Shipping  If specimens will be shipped the same day of collection Store specimens at 4°C Ship using cold packs  If specimens will be stored for > 2 days after the date of collection Store specimens at -70°C Ship on dry ice

24. Overview: Why will my sample be rejected?  Use the wrong swab for collection  Use expired media  Stored at wrong temperature  Specimen received at ambient temperature  Sample spilled; broken collection tube  Incomplete information on submission form or tube

25. Questions? Grace Kubin Grace.Kubin@DSHS.state.tx.us