Microbiology for Public Health: The Role of Medical Laboratories

1
Microbiology for Public HealthThe Role of
Medical Laboratories

• Judy Isaac-Renton MD
• Director BCCDC Laboratory Services, PHSA
  Laboratories
• BCSLS, April 2008

2
Objectives

1. To describe the different microbiology
   disciplines
2. To outline Core Functions of public health labs,
   outlining some Why, What and Whos
3. To list provincial, national and international
   public health partners
4. To describe how all microbiology labs collaborate
   in the public health network
5. To let you know what BCCDC and what BCCDC
   Laboratory Services does (your provincial public
   health reference microbiology labs)

3
Network Example 1 Reference

• Late Friday afternoon
• Physician (Respirologist) from IHA
• On Call Medical Microbiologist
• 58 yr old female in ICU, ventilated
• Fever, CXR findings, risk factors

4
Network Example 1 Reference

• Later Friday afternoon, team convened
• CAP? (Bacteriology Program staff)
• Viral? (Virology Program staff)
• Hantavirus? (ZEP Program staff, NML)
• 24/7 specialized expertise
• Create knowledge/information (labs impact gt80
  medical decisions)

Hanta?
LD?
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Network Example 2 Public Health

• Testing in front-line microbiology labs,
  hospitals and community labs
• 143 cases of disease due to E. coli O157
• 42 persons hospitalized bloody diarrhea
• Children on dialysis No deaths
• Public health galvanized, intervenes
• Isolates from front-line microbiology labs, to
  provincial public health labs (BCCDC)

E. coli
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Network Example 2 Public Health
Environmental Health Officer Sleuthing
E. coli
PFGE
All Labs Testing BCCDC Labs Sleuthing
Epidemiologists Analysing
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Network Example 2 Public Health

• Front-line labs do patient testing (patient
  focused)
• Public health ref labs (e.g., BCCDC labs) do
  reference clinical and environmental microbiology
  testing (focus on specialty tests, link
  environmental with clinical and population
  health)
• Both create information, Quality Assure it,
  interpret it, connect with health care workers
• Information shared with public health workers in
  HA, Epi, CPHLN PulseNet

WWW
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Network Example 2 Public Health

• Provincial public health labs, member of Canadian
  Public Health Network (CPHLN)
• Link to National Micro Labs and PulseNet
• To USA CDC Labs and PulseNet
• To Labs world-wide and PulseNets
• For both patients and populations
• Interventions with prevention, a focus
• Legislated framework

WWW
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Microbiology Disciplines Include (From Largest
Microbes to Smallest)

• Parasitology worms are large
• Mycology fungi are also large

Giant tapeworm
Aspergillus
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Microbiology Disciplines Include

• Bacteriology bacteria are smaller (light
  microscope)
• Virology smallest (seen using an electron
  microscope, not a light microscope)

Virus
Bacillus
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Microbiology - Other

• Some, such as prions, break all the rules
• Communicable diseases (CDs) are the main focus of
  PH reference labs
• All CDs are caused by infectious agents but not
  all infections are considered CDs

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Core Functions forPublic Health
MicrobiologyLaboratories Networks

• Ten Core Functions for public health laboratory
  system
• CPHLN considers these a minimum requirement for
  optimal service on behalf of our communities

http//www.cphln.ca/CPHLN/src/public_publications.
php
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Core Functions

• Communicable disease surveillance, prevention and
  control
• Outbreak and emergency response to communicable
  diseases
• Environmental health and food safety
• Reference testing, specialized screening and
  diagnostic testing
• Biosafety, containment, and biohazard response
• Integrated communicable disease data management
• Public health policy development and evaluation
• Laboratory Quality Assurance
• Training and education of health care workers
• Public health related research and development

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Surveillance Outbreak Response Core Function

• Systematic data collection interpretation of
  clinical and lab info
• Multidisciplinary team needed
• Labs in community, hospitals, public health
  all report to local public health
• Public health analyses and responds

HUS
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Surveillance Outbreak Response Core Function

• Why?
• CDs, one important PH function
• Ongoing watchfulness
• Microbes impact quickly and widely
• Microbes know no borders, change quickly
• New patterns, novel pathogens, new tests
• Alert for early diagnosis, intervention and
  prevention

C. gattii
SARS, Walkerton, Pan Flu....
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Surveillance Outbreak Response Core Function

• What?
• Reportable Communicable Diseases (RCDs) from
  clinicians and labs (BC legislation)
• Unusual observations (BC legislation)
• Sentinel systems (respiratory, environmental)
• Who?
• All microbiology labs to public health in HA
• BCCDC Epid works on inter-jurisdictional issues
• PH labs works with HA PH, Epi and CPHLN

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Bioterrorism Emergency Response Core Function

• Why?
• Bioterrorism world-wide (purposeful release of
  infections agents)
• Special events and natural events
• Planning, capacity and response
• Expertise, leaders and facilities

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Environmental Microbiology Core Function

• Why?
• Specialized public health practice of
  microbiology (very different than clinical)
• Surveillance (upstream) and outbreak response
• Bioterrorism (global food chain)
• Natural emergencies (Fraser Freshet)
• Planning, capacity and response
• Expertise, leaders and facilities

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Environmental Microbiology Core Function

• Who?
• Private and public labs PHO approved for DW
• Public health audits
• Investigation of water-borne outbreaks
• BCCDC leaders in Quality Assurance (EWQA)

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Environmental Microbiology Core Function

• Who?
• Networks with CFIA, Health Canada
• Investigation of foodborne outbreaks from
  schools, restaurants, facilities etc
• Food poisoning investigations
• Public health food surveillance testing

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Integrated Data Management Core Function

• Who?
• Linking clinical and environmental testing
• Lots of Information Management changes (in BC,
  its PHIP, PLIS)
• Impacts of this change
• Networks key

WWW
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Research Training Core Function

• Faculty and staff carry out public health
  research and training
• New knowledge about communicable diseases (CDs)
• When novel pathogens appear, critical skills
  (capacity)
• Need to keep abreast of rapidly advancing
  technologies
• Many educational/training activities

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How Do PH Labs Core Functions Relate to Our
Labs Work?

• Communicable disease surveillance, prevention and
  control
• Outbreak and emergency response to communicable
  diseases
• Environmental health and food safety
• Reference testing, specialized screening and
  diagnostic testing
• Biosafety, biocontainment, ER
• Integrated communicable disease data management
• Public health policy development and evaluation
• Laboratory Quality Assurance
• Training and education of health care and public
  health workers
• Public health related research and development.

Other Core Functions
?
Some Core Functions
Day-to-Day Work
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Partners in Public Health

• Local Medical Health Officers, CD Nurses,
  Environmental Health Officers
• Epidemiology, STIC, TBC, EH
• All health care workers
• Provincial Health Officer
• Ministry of Health

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Partners in Public Health Lab Network?

• Community and hospital microbiology labs front
  line partners
• PH Labs reference and specialty labs
• Share basics
• Focus, hence roles, differ but work on
  Communicable Diseases together
• Satellite public health labs

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National Public Health Lab Network
International (WHO, CampyNet etc)
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BCCDC
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Overview of BCCDC

• British Columbias Centre of Excellence for the
  prevention, detection and control of communicable
  diseases (CDs)
• Affiliated with University of British Columbia
• Partners with the provinces public health
  workers in all Health Authorities as well as with
  MOH
• Provides support and tools to respond to
  emergencies, outbreaks and unusual events related
  to communicable diseases (CDs)

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BCCDC Divisions

• Environmental Health
• Epidemiology
• Hepatitis Services
• Laboratory Services
• STI/AIDS Control
• TB Control
• Vaccine Pharmacy

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BCCDC Laboratory Services,PHSA Laboratories

• Programs
• Bacteriology Mycology
• Biosafety Biocontainment
• Central Processing Receiving
• Environmental Microbiology
• Parasitology
• Quality
• TB/Mycobacteriology
• Translational Research
• Virology
• Zoonotic Emerging Pathogens

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Bacteriology Mycology Program

• Program Head Linda Hoang
• Section Head Ana Pacaggnella
• Team 30 staff
• Research
• Emerging pathogens
• Healthcare acquired infections
• New and unusual bugs
• International medicine
• Bacterial BT agents

Linda Hoang, MD, DTMH, FRCPCProgram
Head Clinical Assistant ProfessorDept of Path
Lab MedicineUniversity of British Columbia
Email linda.hoang_at_bccdc.ca
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Bacteriology Mycology Program

• Reference tests for bacteria with new molecular
  assays (PCR, 16S)
• Identification and typing of isolates to detect,
  monitor and control outbreaks
• Linked electronically with all other public
  health labs to assess PFGE patterns
• Examine specimens for fungal systemic infections
  (deep mycoses)
• Diagnosis of sexually transmitted diseases such
  as Chlamydia trachomatis, GC, and other CDs by
  nucleic acid testing, PCR.

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Biosafety Biohazard Containment

• BCCDC Labs Biosafety Biohazard Containment
  Program (TDG, WHMIS, CL3, ERAP, BRAT..)
• Program Head Biosafety Officer Neil Chin
• Containment Level 3 Suites on 3 floors
• Bioterrorism Emergency Response Team for labs
• Links with Emergency management at HA, provincial
  and national levels (Bi-Ex Field exercise)

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Environmental Microbiology

• Program Head
• Judy Isaac-Renton
• Section Head Joe Fung
• Research
• Water Microbiology
• Norovirus DNASequencing
• Botulism
• Giardiasis
• Microbial Source Tracking

Judy Isaac-Renton, MD, DPH, FRCPCDirector, BCCDC
Laboratory Services Professor Dept Path Lab
Medicine, University of British Columbia Email
judy.isaac-renton_at_bccdc.ca
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Environmental Microbiology

• Detection of protozoan parasites (Giardia,
  Cryptosporidium),in water
• Developing PCR tests for specific pathogens
• Test drinking, pool, beach water samples
• Investigation of foodborne or waterborne
  outbreaks
• Leaders in Provincial Health Officer program
  (EWQA)
• Food poisoning investigations
• Norovirus RT-PCR and DNA sequencing

Photo courtesy University of Alberta, Public
Health
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TB Mycobacteriology Program

• Program Head Patrick Tang
• Section Heads Mabel Rodrigues
• Staff 20
• Research
• Molecular diagnostics
• Microarrays and bioinformatics
• Discovery of novel infectious agents

Patrick K.C. Tang, MD, PhD, FRCPCClinical
Assistant ProfessorDept Path Lab
MedicineUniversity of British Columbia Email
patrick.tang_at_bccdc.ca
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Mycobacteriology/TB Program

• Prepare smears (acid-fast stains, fluorescent)
  for diagnosis of TB
• Liquid culture (automated process) and solid
  culture on Lowenstein Jensen media
  -Identification of all Mycobacterium species
• Detect M.tb directly on smear positive sediments
  by molecular methodology
• Biochemical identification and drug sensitivities
  in CL3
• Fingerprinting by RFLP and PCR VTRU to evaluate
  clusters of infection

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Parasitology Program

• Examination of samples for parasites of medical
  importance
• Examination for intestinal parasites from SAF
  preserved stools (concentration, stained smears)
• Outbreak investigation and surveillance
• Examination for Blood/Tissue parasites such as
  malaria, Acanthamoeba and Leishmania
• Specialized procedures (cultures, Baermann)
• Tick identification
• Mosquito surveillance for West Nile virus
  monitoring

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Translational Research in Microbiology

• Development and adaptation of molecular
  diagnostic methods for use in all laboratories
• DNA sequence identification of all organisms
• Compilation of sequence databanks available to
  outside laboratories
• Rigorous program for monitoring Molecular Quality
  Control
• Education and training in new molecular methods
• Network for public health technology transfer