Cough to Cure: Activities of the Tuberculosis Laboratory II

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Cough to CureActivities of the Tuberculosis
Laboratory

• Lourens Robberts, PhD
• Clinical Microbiologist, ProvLab
• Assistant Professor
• School of Public Health Sciences
• University of Alberta
• lourens.robberts_at_albertahealthservices.ca

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ACKNOWLEDGEMENTS

• Tuberculosis Laboratory Program
• Greg Tyrrell (MOC)
• Steven Drews (Calgary)
• Marguerite Lovgren (manager)
• Cary Shandro (technologist)
• Bacterial Typing Unit
• Linda Chui
• Administration
• Deb Green
• Rae Roulston

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Edmonton Tuberculosis / Level III Laboratory staff
Brenda Martha Rosslyn Donna
Birg Cindy Tracy Urzula
Christine Darla Toni Cary
Baeudin Gable Antoniuk Fillion
Friedenstab Fraser Elliott Rudy
Talarico McGowan Harms Shandro
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Activities of the Tuberculosis laboratory
Tuberculosis Laboratory Service Levels Level
I Prepare and examine smears Level
II Isolation, identification and DST MTB
complex Level III Isolation, identification and
DST of all mycobacteria
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Activities of the Tuberculosis laboratory
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ProvLab TB Service Remit
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ProvLab TB Service Remit
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The Testing Process Begins and Ends with the
Patient NC Elder et al. 2008
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The Testing Process Begins and Ends with the
Patient NC Elder et al. 2008
Authors Analytical Analytical Analytical
Authors Pre Intra Post
Ross, et al. 1991 45.5 7.3 47.2
Plebani, et al. 1997 68.2 13.3 18.5
Astion, et al. 2003 71.0 18.0 11.0
Carraro, et al. 2007 61.9 15.0 23.1
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The Testing Process Begins and Ends with the
Patient NC Elder et al. 2008
Stroobants et al, 2003
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The Testing Process Begins and Ends with the
Patient NC Elder et al. 2008
Pre-pre-analytical
Post-post-analytical
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Pre-pre-analytical Specimen collection
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Pre-pre-analytical Specimen transport
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Pre-pre-analytical Specimen transport
Delivery time gt 7 days 2008 989 / 20,816 4.75
Specimen sensitivity 1 2 3 82 92 100
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Pre-analytical Specimen processing
2 NaOH digestion and decontamination
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Pre-analytical Specimen processing
2 NaOH digestion and decontamination
Optimal lt10
Mycobacterial species identified, 2009 (n 1,918)
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Pre-analytical Specimen inoculation
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Pre-analytical Specimen inoculation
Solid Media
Liquid Media
NYS Dep. Health, 2009 n 77
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Analytical Sputum smear microscopy
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Analytical Sputum smear microscopy
n 116
NYS Dep. Health, 2009
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Analytical Sputum smear microscopy
n 902
n 860
n 440
ProvLab 0 Incorrect
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Analytical Sputum smear microscopy
STAT (direct) vs. concentrated sputum microscopy
Direct Sensitivity 0.47 (0.41 0.50)
(n502) Specificity 0.99 (0.98
1.00) Concentrate Sensitivity 0.50 (0.43
0.54) Specificity 0.99 (0.98 1.00)
ProvLab 2000 - 2009
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Analytical PCR amplification detection

• Nucleic acid amplification and detection in real
  time
• Sensitive and specific for M. tuberculosis
  complex
• Artus M. tuberculosis LC PCR assay (Qiagen,
  Germany)
• Analytical sensitivity 1.6 copies/µl

• ProvLab Experience Introduced in 2004.Performed
  on all initial smear-positive specimens
• PCR vs. culture (n 248)
• Sensitivity 0.94 (0.91 0.95) PPV 0.98 (0.95
  0.99)
• Specificity 0.97 (0.93 0.99) NPV 0.90 (0.86
  0.92)
• ? 0.89 (0.82 0.92)

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Analytical PCR amplification detection
PT pass rate 100 PHAC CTLTN, 2008
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Analytical PCR amplification detection
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Analytical Isolate identification

• 16S rRNA Probes
• MTBC
• MAC
• M. gordonae
• M. kansasii

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Analytical Isolate identification
Pigmentation
Growth temperature
Iron uptake
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Analytical Isolate identification
Niacin Production
Catalase Production
TCH resistance
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Analytical Isolate identification
NYS Dep. Health, 2009 n 77
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Analytical Isolate identification
2009 n 2,196 440 labs
2008 n 4,461 431 labs
2007 n 4,681 477 labs
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Analytical Drug susceptibility testing
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Analytical Drug susceptibility testing
1 Agar Proportion Method (MOP) Reference method
employed for confirmation of resistance
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Analytical Drug susceptibility testing
CDC, 2009
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Analytical Drug susceptibility testing
PHAC CTLTN, 2009
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Analytical Drug Susceptibility Testing
PHAC CTLTN DST PT events PHAC CTLTN DST PT events PHAC CTLTN DST PT events
2008 2008
Incorrect laboratories (n 9)
INH 2 2
RIF 0
EMB 4 3
PZA 4 2
2009 2009
Incorrect laboratories (n 9)
INH 0
RIF 0
EMB 2 1
PZA 5 3
ProvLab errors 0
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Analytical Drug susceptibility testing
CDC, 2009
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Analytical Molecular epidemiological
investigations
Restriction Fragment Length Polymorphism (RFLP)
with IS6110 hybridization
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Analytical Molecular epidemiological
investigations
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Analytical Molecular epidemiological
investigations
PHAC CTLTN, 2008
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Analytical Molecular epidemiological
investigations
PHAC CTLTN, 2008
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(No Transcript)
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Biosafety Level III Laboratory
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Biosafety Level III Laboratory
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Biosafety Level III Laboratory
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Biosafety Level III Laboratory