Wisconsin Laboratory Response Network WLRN Update: 20045 Review

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Wisconsin Laboratory Response Network (WLRN)
Update2004-5 Review 2005-6 Preview

• Carol Kirk
• Laboratory Network Coordinator
• Wisconsin State Laboratory of Hygiene
• cjk_at_mail.slh.wisc.edu
• August 24, 2005

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2004-2005 Accomplishmentsin Emergency Laboratory
Response

• Convened 6 regional meetings of Wisconsin.
• Completed site visits of 59 clinical
  laboratories.
• Completed a second laboratory response exercise.
• Continued
• Laboratory messaging system
• Audioconferences
• Through HRSA, provided funding for biosafety
  cabinets.
• Activated the Laboratory Technical Advisory Group
  (LabTAG).

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2004-2005 Accomplishmentsin Emergency Laboratory
Response

• Distributed shippers to 91 local health
  department repository sites.
• Developed distributed Packaging Shipping
  Training Manual.
• Updated Bioterrorism Response Guide for Clinical
  Laboratories (currently at the printer).
• Planned 2005-6 Laboratory Proficiency Exercises.
• Developed WLRN Bench Guide for Bioterrorism
  Agents (currently at the printer).
• Began developing plans and criteria for Sentinel
  Laboratory Award.

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2004-2005 Accomplishmentsin Emergency Laboratory
Response

• Increased testing capability capacity for
  bioterrorism, chemical terrorism outbreak
  response.
• Maintained testing support, consultation, and
  specimen collection kit for Wisconsins eight
  regional HazMat teams.

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Wisconsin Laboratory Response Network (WLRN)
2004-5 in Review

• Todays Highlighted Topics
• Regional Meetings
• Laboratory Site Visits
• BT Laboratory Response Exercise

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Wisconsin Laboratory Response Network (WLRN)
2004-5 Review

• In the Spotlight
• 2005 Regional Meetings

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Regional Meetings of the Wisconsin Laboratory
Response Network

• Purpose
• Provide information about the Laboratory Response
  Network.
• Enhance understanding and relationships between
  clinical laboratories and public health.
• Provide an outbreak scenario exercise.

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Regional Meetings of the Wisconsin Laboratory
Response Network

• Logistics HRSA Regions
• 6 meetings
• Turtle Lake
• Wausau
• Green Bay
• LaCrosse
• Madison
• Pewaukee
• May 3 May 12, 2005

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Regional Meetings of the Wisconsin Laboratory
Response Network

• Target audience
• Laboratory managers, supervisors and bench
  technologists in clinical laboratories
• Infection Control Practitioners
• Emergency Department staff
• Local Public Health Departments Laboratories
• Public Health Consortia representatives

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Regional Meetings of the Wisconsin Laboratory
Response Network
Attendance 2005 2004 Total 202 221 Lab
oratory Personnel 137 135 Clinical
Laboratories 88 90 Public Health/Consortia 62 8
4
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Regional Meetings of the Wisconsin Laboratory
Response Network

• Agenda
• Bioterrorism State National Perspective
• WLRN Update
• Introduction to Laboratory Technical Advisory
  Group (LabTAG)
• HAN Introduction to the Command Call Feature
• Our Role in an Outbreak panel presentations
• Emergency Response Scenario
• Open Discussion

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Regional Meetings of the Wisconsin Laboratory
Response Network - Feedback

• What did you like about the meeting?
• Recurring Themes
• Information Updates
• Networking Communication
• Information-sharing Across Disciplines
• Informality
• Candid Discussions
• Scenario!!!

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Regional Meetings of the Wisconsin Laboratory
Response Network - Feedback

• What topics would you suggest for next year?
• More scenarios
• Case Reviews How System Worked
• New Information Updates
• Practical Applications
• Laboratory Methods
• Biosafety Levels
• Packaging Shipping
• Communication/coordination between partners

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Regional Meetings of the Wisconsin Laboratory
Response Network - Feedback

• What do you think are the highest priority
  activities in support of emergency laboratory
  response?
• Of 80 responses, 40 dealt with communication
• Other Comments about Regional Meetings
• More microphones
• Larger print
• Invite local health along on site visits
• Need to document and follow up on issues
  uncovered in discussions.

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Regional Meetings of the Wisconsin Laboratory
Response Network - Preview

• Continue annual meetings 6 or 7 locations
• Maintain informal, discussion-oriented format as
  much as possible
• Always include scenario
• Include more practical applications content

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Wisconsin Laboratory Response Network (WLRN)
2004-5 Review

• In the Spotlight
• 2005 Site Visits

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Laboratory Site Visits An Overview

• Julie Tans-Kersten
• TB Laboratory Program Coordinator
• Wisconsin State Laboratory of Hygiene
• tanskejl_at_mail.slh.wisc.edu

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WLRN Laboratories 2004-5 Site Visits
Bayfield
Douglas
Ashland
Iron
Vilas
Sawyer
Washburn
Burnett
Price
Oneida
Florence
Forest
Barron
Rusk
Marinette
Polk
Lincoln
Taylor
Oconto
Langlade
Chippewa
St. Croix
Dunn
Menominee
Marathon
Clark
Pierce
Shawano
Eau Claire
Door
Pepin
Waupaca
Wood
Portage
Buffalo
Kewaunee
Outagamie
Trempealeau
Jackson
Brown
Manitowoc
Waushara
Winnebago
Juneau
Adams
Monroe
LRN Reference Laboratories
Calumet
LaCrosse
Marquette
Fond du Lac
Sheboygan
Sentinel Laboratories (Site Visit 2005)
Vernon
Green Lake
Sauk
Columbia
Dodge
Richland
Ozaukee
Washington
Crawford
Sentinel Laboratories (Site Visit 2004)
Dane
Milwaukee
Jefferson
Waukesha
Iowa
Grant
Sentinel Laboratories (Site Visit pending)
Green
Walworth
Racine
LaFayette
Rock
Kenosha
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Laboratory Site Visits Background

• This spring summer
• Visited 59 laboratories throughout Wisconsin
• Will visit 5 remaining laboratories within next
  month (including 2 tomorrow)
• Visited 68 laboratories last year
• Total 132 labs visited

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Laboratory Site Visits Background

• Purpose of site visits
• Review emergency laboratory response activities
• Provide opportunity for one-on-one discussions
• Provide WSLH staff with perspective on clinical
  laboratory operations and facilities, capacity
  for emergency response

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Laboratory Site Visits Background

• Format of site visits
• Presented summary of emergency laboratory
  response activities
• Discussed laboratory preparedness
• Completed questionnaire/checklist
• Toured laboratories

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Laboratory Site Visits Highlights

• Most Bioterrorism Response Guide for Clinical
  Laboratories blue binders accessible to staff
  during all hours of operation.
• Saw priority Agents of Bioterrorism Level A
  (Sentinel) Laboratory Guide poster on display in
  most laboratories.

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Laboratory Site Visits Concerns

• Approximately 30 of laboratories not represented
  on Facility Emergency Planning Committees
• Laboratories that are represented are often
  represented through infection control
• Approximately half (48) of laboratories had not
  participated in any emergency response exercise
• For those laboratories that did participate, the
  exercise often ended without engaging laboratory.
  Exercise rarely involved a bioterrorism event.

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Laboratory Site Visits Concerns

• Laboratories are unsure of procedures for
  shipping infectious substances.
• WSLH recently sent out a Packaging and Shipping
  Training Manual which incorporates the most
  recent shipping regulations.
• 58 of laboratories have some staff registered on
  the Health Alert Network.

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Laboratory Site Visits Suggestions for the
Integrated Laboratory Response Plan

• Add lists of reportable diseases select agents.
• Add separate section for chem. terrorism agents.
• Provide guidance on handling/disposal of select
  agents.
• More information on chain of custody.
• Provide detailed protocols for packing and
  shipping infectious agents.
• Add information on shipping containers where to
  get them.

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Laboratory Site Visits Suggestions for the
Integrated Laboratory Response Plan

• Provide a question answer section or competency
  assessment for staff.
• Post on WSLH website for easier access.
• Template of a laboratory plan
• Provide specifics on specimen handling safety

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Laboratory Site Visits Support Needed from the
WSLH

• Biosafety cabinet for laboratory
• Funds requested and approved (38 labs).
• Packaging and shipping training shippers
• Shipping manual sent out (will post on HAN)
• Shippers distributed to over 90 local health
  departments listing posted on the HAN.
• Update WSLH website with links, bioterrorism
  information
• Continue training/education information flow,
  post educational materials on website

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Laboratory Site Visits Support Needed from the
WSLH

• Hands-on experience with bacterial agents
  (through a workshop or BT exercise)
• Lab Messaging System provide periodic updates on
  suspicious activities and unusual events
• Help bring laboratory needs to attention of
  hospital administration

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Laboratory Site Visits Where Do We Go From Here?
Start over! Aim to visit each laboratory at
least once every 3 years.
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Wisconsin Laboratory Response Network (WLRN)
2004-5 Review

• In the Spotlight
• Emergency Laboratory Response Exercise

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Emergency Laboratory Response Exercise

• Background
• Participation voluntary
• 21 Sentinel Laboratories
• Randomly selected by HRSA region
• Purpose
• Identify gaps in the emergency lab response
  system
• Assess communication, specimen transport and
  receipt.

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Emergency Laboratory Response Exercise

• Information Provided
• Background
• Blood cultures from a patient in your ICU are
  flagged positive after 24 hours incubation. The
  patient had a history of fever, cough, headache
  and vomiting. When admitted to the ICU, she had
  developed sudden fever, dyspnea and shock. Chest
  radiograph showed a widened mediastinum
  consistent with lymphadenopathy.
• The following stain and culture characteristics
  are noted by a technologist

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Emergency Laboratory Response Exercise
Information Provided ? Microscopic
characteristics

• Gram stain of the blood culture bottle
• Large gram-positive rods (1-1.5 by 3-5 microns)
  in long chains.
• Gram stain from SBA plate
• Large gm() rods (1 to 1.5 by 3 to 5 microns)
  singly and short chains, no spores.

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Emergency Laboratory Response Exercise

• Information Provided
• ? Colony characteristics
• ? Nonhemolytic on 5 sheep blood agar (SBA)
• ? Rapidly-growing (visible within 6 hours) at
  350C
• ? Non-pigmented, flat or slightly convex with
  irregular
• edges, ground glass appearance.
• ? Colonies have a sticky consistency when
  manipulated
• with a loop.
• ? Key characteristics from culture
  ? Gram-positive rods
• ? Nonhemolytic
• ? Catalase positive
• ? Non-motile

Sheep Blood Agar plate 18 24 hr growth
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Emergency Laboratory Response Exercise

• The technologist concludes that he/she is unable
  to rule out
• Bacillus anthracis.
• - From this point proceed as indicated in the
  Integrated Laboratory Response Plan.

• ? Contact the State Lab, call 24/7 Pager number
• ? Advised to send isolate to WSLH
• ?

Wisconsin State Laboratory of Hygiene
Communicable Diseases Rapid Response
Dunham Express
6.2 Infectious Substance Shipper
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Emergency Laboratory Response Exercise
Of 21 participants each year - most notified
WSLH of intended referral - all referred sample
to WSLH.
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Emergency Laboratory Response Exercise
Of 21 participants each year - most used
Dunham Express for transport to WSLH
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Emergency Laboratory Response Exercise
Time from 24/7 notification to receipt of
sample 2004 15 notified 24/7 2005 20
notified 24/7
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Emergency Laboratory Response Exercise
Number of participants that used class 6.2
shipper for commercial or USPS transport. (Total
18 each year)
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Emergency Laboratory Response Exercise

• Other Facts
• 9 labs used a shipper from a local health
  department (LHD) shipper repository
• 7 of the 8 said the system worked 1 had
  difficulty 1 was refused.
• Concerns about after-hours access.
• 1 was not the WERS shipper and was not a class
  6.2 shipper
• Only 4 of the LHD repository sites have contacted
  WSLH for a replacement shipper
• WSLH will follow up with the local health
  departments

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Emergency Laboratory Response Exercise

• Other Facts (continued)
• Only 9 of 21 labs addressed the package to Rapid
  Response or Emergency Response at WSLH.
• Correct Address Label (per updated instructions)

Rapid Response BT/CT/Outbreak Wisconsin State
Laboratory of Hygiene- Communicable Diseases
465 Henry Mall Madison, WI 53706
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Emergency Laboratory Response Exercise

• Other Facts (continued)
• Some labs also used evidence tape and chain of
  custody form.
• Discussed at Regional Meetings and included in
  WERS kit, but not included in binder information.
• 1 included chain of custody form only
• 3 used evidence tape only
• 1 included chain of custody form and evidence
  tape.

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Emergency Laboratory Response Exercise

• 2005 Participant Feedback (14 evaluations
  returned)
• Exercise was useful for your laboratory (14 of
  14)
• Liked the exercise format (14 of 14)
• Contributed to your overall knowledge for BT
  Response (14 of 14)
• Gained new knowledge to apply to your laboratory
  practice (14 of 14)
• Would participate in a future similar exercise
• (14 of 14)

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Emergency Laboratory Response Exercise

• 2005 Participant Feedback What did the
  participants like about the exercise?
• Opportunity to practice in-house protocols and
  find improvements
• Opportunity to actually go through the steps of
  reporting a BT event
• The unexpectedness sample came at the end of a
  busy day
• Seeing if you know what to do in the event of a
  real emergency.

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Emergency Laboratory Response Exercise

• 2005 Participant Feedback Other Comments
• Would be easier if there was more familiarity
  with procedures.
• Would like paper exercise for practice and
  competency exam for BT Binder
• Chain of custody instructions are not included in
  the WERS kits.
• Confusion about WSLH use of the term Integrated
  Laboratory Response Plan or ILRP
• WSLH will no longer use term ILRP.

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Conclusion

• This exercise provides a valuable, hands on
  experience and assessment of the system.
• WSLH will continue to provide similar exercises.
• Competency exam will be developed.
• WSLH will return 6.2 shippers.
• WSLH will provide individual feedback to
  participating labs.
• Thank you to all the participating laboratories!

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Wisconsin Laboratory Response Network (WLRN)
2005-6 Preview
What do we see happening in the next 12 months?
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Wisconsin Laboratory Response Network (WLRN)
2005-6 Preview

• Continuing Activities
• Regional laboratory meetings
• Laboratory site visits
• Laboratory Response Exercise
• Audioconferences
• Laboratory message system
• Updates to
• Wisconsin Emergency Response Guide for Clinical
  Laboratories
• Packaging Shipping Training Manual
• WSLH website HAN

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Wisconsin Laboratory Response Network (WLRN)
2005-6 Preview

• Continuing Activities
• Maintain shipper repository
• Test capability capacity development
• Clinical Laboratory Technical Advisory Group
• Additional Activities
• Proficiency exercise
• Establish criteria and procedure for Laboratory
  Award

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Wisconsin Laboratory Response Network (WLRN)
2005-6 Preview

• Todays Highlighted Topics
• Proficiency Exercise
• Sentinel Laboratory Award

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Proficiency Exercise

• Overview
• This is a voluntary educational exercise to
  improve laboratorians confidence in ruling out
  potential bioterrorism agents, with no reporting
  to regulatory authorities.
• An audioconference will be held on November 16,
  2005, discussing the agent(s), testing,
  biosafety, etc. The audioconference will be
  recorded.
• We plan to provide educational proficiency
  samples twice a year (spring and autumn), each
  followed by an audioconference.

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Proficiency Exercise

• Samples will be sent the week of September 6
  please report your results by September 20.
• Sample packages will be addressed to the
  Microbiology Laboratory Supervisor at
  laboratories that perform microbiology culture of
  limited or most specimen types.
• If you receive samples, but do not perform this
  testing, please note in comments section and
  return form.
• Dispose of the samples as infectious material.
• Samples will consist of duplicate culti-loops
  for each of two samples.

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Proficiency Exercise

• Overview
• We encourage laboratories to participate in this
  educational proficiency exercise.

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Sentinel Laboratory Award

• Formal presentation of award to laboratories that
  provide documentation of meeting award criteria.
• Will include notification of administration and
  local media.
• Award should represent continuing achievement
• May be developed as tiered award to represent
  levels of achievement
• Announcements will be mailed included in
  laboratory messages when details finalized.

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Sentinel Laboratory Award

• Award criteria in development, but expect to
  include
• Laboratory biosafety and risk assessment for
  bioterrorism agents
• Packaging and shipping of laboratory samples
• Emergency Laboratory Response Guide procedures
• Participation in an emergency response exercise
• Laboratory Emergency Preparedness
• Registration on the Health Alert Network (HAN)
• Proficiency in rule out of potential isolates
  of bioterrorism agents
• Communication with local public health agency

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Wisconsins Laboratory Response Network (WLRN

• Thank you
• to our laboratory partners and colleagues
• for your support, assistance, ideas,
  commitment.