Improving anthrax outbreak response team work in Almaty oblast
Bio-Threat Agents: Environmental Sampling · Investigative Sampling Strategy Anthrax Outbreak ......
Transcript of Bio-Threat Agents: Environmental Sampling · Investigative Sampling Strategy Anthrax Outbreak ......
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Bio-Threat Agents:Environmental Sampling
Kenneth F. Martinez, MSEE, CIHNational Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
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Classification
Obligate parasites (must have a living host)virusesbacteriarickettsia
Facultative saprophytes (will utilize dead organic material)
fungibacteria
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Size Ranges of Microorganisms
FungalSpore
Escherichia coli
PolioVirus
RabiesVirus
1 µm
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Mechanisms for Microbial DispersalLinear Distances
Very Short Medium Long
Motility Sewage Wind
Gliding Motion Ground Water Animal Vectors
Eroding Soil Water Currents
Inanimate Objects
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Health Concerns
Infections
Immunologic Reactions
Toxic Effects
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Infectious Disease
PathogenicityVirulenceRelationship between virulence (V), numbers of pathogens or dosage (D), and resistant state of the host (RS)
ColonizationInvasiveness
Infectious Disease =V * DRS
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Infectious DiseaseTerminology
Portal of entryExposure vs. infectionClinical vs. subclinical or asymptomatic infectionCarrier stateOpportunistic infectionHuman pathogen vs. virulenceImmunosuppression
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Infectious DiseasePathways
RespiratoryOral (via ingestion)ContactPenetrationVectors (via insect bite)
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Investigative Components
Physician
EnvironmentalCharacterization
Epidemiology
Sampling
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Investigative ComponentsEnvironmental Characterization
Opportunity toCharacterize the exposure environmentSearch for the contaminant sourceEstablish a sampling plan (if needed)
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OccupantBiocontaminant
Pathway
Environment
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Investigative Components
Physician consultationEpidemiologyEnvironmental CharacterizationBioaerosol sampling
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Environmental Sample Types
Bulk
AirSurface
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Sampling Bioaerosols
Where to Sample?
1 2 3
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Sampling Bioaerosols
Where to Sample?Sampler Selection
Mycotoxins
Fungi
Bacteria
Endotoxins
Spores
Protozoans
?
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Culturable Air SamplesPros
ID speciesconsensus reference standard
Consunderestimate total concentrationnutrient media is selectivesmall sample windowlabor intensivecomplicated data interpretation
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Non-culturable Air SamplesPros
easy to implementmeasures total loadsamples collected full-shiftcollection of PBZ
Consnonspecific (viable and nonviable)results can be obscured by debris
For countsNOT for PCR and immuno assays
requires qualified analytical lab
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Bioaerosol SamplersBACTERIA AND FUNGI
Andersen cascade impactorsSASBiotestSlit-to-agarAll glass impingerSKC BiosamplerFilter cassettes
SPORESSpore trapFilter cassetteZefon Air-O-Cell
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Bioaerosol SamplersAndersen Two-stage Cascade Impactor
Petri Dish
Air Flow
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Air Flow
ParticleImpactorInlet
Timer
RotatingBase Petri Dish
DriveMotor
Bioaerosol SamplersSlit-to-agar Sampler
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Bioaerosol SamplersBiotest Reuter Centrifugal Sampler
AgarStrip
Air Flow
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Bioaerosol SamplersFilter Cassette
Air Flow
Back-upPad
Filter
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Sampling Bioaerosols
Where to Sample?Sampler SelectionSampling Techniques
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Sampling Techniques
Sampler CalibrationSampler DisinfectionSampling Time?Quality ControlNutrient Media
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Sample Analysis
Incubation of sample plates
22 - 56°C
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Sample Analysis
Incubation of sample platesViable microorganism and fungal spore counts
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Bioaerosol Concentration Calculation
Conc = CntQ • ts
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Sample Analysis
Incubation of sample platesViable microorganism and fungal spore countsEnumeration of taxa
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Recognition
Evaluation
Control
IH Governing Principles
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Bacillus anthracis
BacteriumAerobicNon-motileGram positive
1 to 5 µm endosporesRespirableResistant to environmental extremesElectrostatic (?)
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Where It All Began . . .
FL- October 3, 2001
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Florida- AMI
Cases: 2 inhalation(1 death)
1 of >1000 nasal swabs +Exposure Assessment:
AMI worksite: widespread contaminationPostal facilities: low to no contamination
No opportunity to ID source
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NJ - Hamilton P&DC
Cases: 5 cutaneous; 2 inhalationNone of > 1,200 nasal swabs +
Exposure Assessment:Hamilton: widespreadcontaminationPostal facilities:little to nocontamination
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NYC- Multiple sites
Cases: 7 cutaneousNY Post, NBC, ABC,& CBS
None of > 2,500 nasal swabs +Exposure Assessment
Morgan P&DCResidences
Known letters to NY Post & NBC
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Washington, D.C.
Cases: 5 inhalation(2 deaths)
28 nasal swabs +Exposure Assessment
Brentwood P&DC: widespread contamination and mail facilities up and downstreamCapital Hill: contamination
Hart, Dirkson, Longworth, Supreme CourtDepartment of State annex: contamination
Others
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The “Letters”
1-2 grams of spores1 gram ≈ 1x1012
spores 2 grams ≈ 200 million doses
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Outliers
2 Inhalation casesNY health care workerCT elderly woman
Exposure AssessmentResidenceWork environment (NY)Subway (NY)
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Overall Scenario
AerosolSource
Characteristics
Aerosol Transport
Aerosol Lossesto Surfaces
SecondarySources
(Resuspension)
AerosolMeasurement
AerosolInhalation
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Aerosol Size Range
10-3
10-1
103
10
Particle Diameter (µm)0.001 0.01 0.1 1 10
Con
cent
ratio
n (#
/cm
3 / D
ln d
)
Viruses
Bacteria
Lab
FieldMycobacteriaMeasurements
Spores
Mechanical Generation
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Aerosol Particle Behavior
SettlingImpactionCharge effectsRelease from surfacesAgglomeration/ De-agglomeration
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Particle Settling in Air
Time to settle 5 feet by unit density spheres
41 hours 12 hours8.2 minutes
0.5 µm 1 µm 10 µm 100 µm
5.8 seconds
3 µm
1.5 hours
Aerodynamic diameter: diameter of unit density sphere that settles at the same velocity as particle in question
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Particle Settling in a Closed RoomStagnant air
Conc.
Time
Turbulent air
Conc.
Time
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Particle TransportVentilation system
Most losses by settlingComplex flow systemsTurbulence productionDoors, people, fans. ventilation
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Preparation to Sampling
TrainingSafety
http://www.bt.cdc.gov/DocumentsApp/Anthrax/Protective/Protective.asp
Record Keeping/DocumentationSampling Strategy
Define the goalConsult with buildingengineer/HVAC
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Purpose of Environmental SamplingMust be hypothesis driven!
Determine presence of Bacillus anthracis sporesDetermine extent and degree of contaminationSupport medical treatment and clean-up decisionsProvide guidance on re-occupancy
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Investigative Sampling StrategyAnthrax Outbreak
Follow the mailHigh traffic areasVentilation systemAreas that collect dust
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Consider…
DisseminationAirFomites
SurfacesPorous versus non-porous
Validated sampling protocolsMethods of analysis
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What Was Sampled?Anthrax Outbreak Investigation
Furniture (equipment)FloorsVentilation system
FiltersReturn air grills
VehiclesClothing
Source: EPA photos during Capitol Hill Clean-up
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Environmental Sampling Issues
Collection efficiencyRecovery efficiencyLimit of detectionConfirmatory testingShipping
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Environmental Sample Types
Bulk
AirSurface
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Environmental Sampling Protocols
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Predominant Sampling
SurfaceSwabsWipes
VacuumFilter “sock”37-mm filter cassette
Bulk
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Field Validation of Environmental Surface Samples
Dr. Wayne Sanderson, CDC/NIOSH
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ObjectivesCompare levels of Ba in side-by-side surface wipe, swab, and vacuum samples to compare relative efficiencies in collecting sporesCompare results of culture analysis with PCR analysis for the presence of Ba spores in extracts of surface samplesConduct additional surface sampling to more better characterize distribution of Ba spores throughout facilityEvaluate effectiveness of clean-up efforts to remove spores from contaminated surfaces
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MethodsDry swab, wet swab, wipe, and HEPA vacuum samples collected adjacent in areas suspected to be contaminated with Ba sporesSamples collected in randomized fashionWipe and swab samples processed on-site
CDC laboratory in AtlantaOn-site by PCR
HEPA vacuum samples analyzed by a contract laboratoryResults standardized to CFU/in2
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Template
WIPE
SWAB
Dry swab Wet swab
HEPA
WIPE
SWAB
Dry swab Wet swab
HEPA
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Surface Sampling StudyConclusions
Good agreement between wipe and HEPA vacuum samples on non-porous surfacesPoor agreement between swabs and HEPA & wipe samples
Wet swabs did not detect > 33% of timeDry swabs did not detect > 66% of time
Dry swabs should not be used to sample for B. anthracis environmental contamination
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Surface Sampling StudyConclusions
Wet swabsSample crevices, inside machinery, difficult locations
WipesLight dust loading
HEPA vacuumHeavy dust loadingMay cover larger surface area
*Complete study published in Emerg Infect Dis 2002 Oct 8 (10).
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Air Sampling
CulturableCascade impactorsImpingersFiltration
Non-culturable (PCR or immuno assay)ImpingersFiltration
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Air Samples Collected for AnthraxInitial Response
Hart Building37-mm filter cassettesAndersen cascade impactors
AMI BuildingAndersen cascade impactorsSlit-to-agar cascade impactors
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Air Samples Collected for AnthraxRemediation
Daschle SuiteMail Facilities
USPS PD&CState Department and WH mail annex
AMI Building
Cascade impactorsAndersens, SAS
37-mm filter cassettesDFU
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Field Validation of EnvironmentalAir Samples
Robert McCleery, CDC/NIOSH
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Evaluation Methods
Wipe sampling Air sampling
Andersen single-stage cascade impactor using tryptic soy agar (TSA) with 5% sheep bloodFilter cassette sampling
Mixed-cellulose ester (MCE) filters, 37-mm, 0.8 µm pore size, 2 LpmPolytetrafluorethylene (PTFE) filtersGelatin filters, 37-mm, 3 µm, 2 LpmDry filter unit (DFU) with polyester felt filter, 17/8 inch, 1 µm, ~ 400 Lpm
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Wipe Sampling
Composite samples used sterile polyester/rayon pads moistened with sterile waterFive samples collected around jogger, feeder, and readerComposite samples collected of all bins in a column
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Air Sampling
Prior and subsequent to DBCS operationContainment built around machine
Volume = 1785 cu. ft. (70’ x 15’ x 7’)Six sample locations around machineA “test deck” was run through the machine during the 45 minute operation time
6,521 “test deck” sheets run through
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Sample Locations
1 2
3 4 5
6
Bins
Feed
er Reader
Enclosure
Enclosure
Jogger
= Dry Filter Unit (DFU)
≈70’
≈15’
Sample locations 1 through 6 contained MCE, PTFE, and GEL filters; while Andersen samples were located at 1-5.
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Air Sampling13 Andersen samples at each location
10 collected in succession every ten minutes over an approximate 2–hour period in each location1 sample collected every 2–hour session over a 6–hour period
Filter cassettes2 MCE and PTFE samples each location
1 2–hour session and 1 8–hour session6 GEL samples each location
2 1-hour samples per 2-hour session and 4 2-hour samples per 8-hour session
DFU1 2-hour, 1 2-hour modified, and 1 8-hour
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n/a67% (10 of 15)n/a27% (4 of 15)360 min
n/a98% (49 of 50)n/a16% (8 of 50)120 min
And
*100% (1 of 1)100% (1 of 1)0% (0 of 1)480 min
*100% (2 of 2)100% (2 of 2)0% (0 of 2)120 min
DFU
47% (8 of 17)29% (7 of 24)0% (0 of 24)0% (0 of 24)480 min
100% (6 of 6)50% (6 of 12)8% (1 of 12)0% (0 of 12)120 min
Gel
100% (3 of 3)50% (3 of 6)17% (1 of 6)0% (0 of 6)480 min
100% (3 of 3)50% (3 of 6)0% (0 of 6)0% (0 of 6)120 min
PTFE
100% (5 of 5)17% (1 of 6)0% (0 of 6)0% (0 of 6)480 min
100% (3 of 3)50% (3 of 6)17% (1 of 6)0% (0 of 6)120 min
MCE
% Positive% Positive% Positive% Positive
Subsequent to DBCS Operation (remaining pellet)
Subsequent toDBCS Operation (10% of pellet)
Prior toDBCS Operation(remaining pellet)
Prior toDBCS Operation(10% of pellet)
TimePeriod
Sample Media
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DiscussionPrior to machine operation…
Wipe samples collected at ~ Bin 100 to the end of machine indicated confluent growthWipe samples indicate that DBCS machine was still highly contaminated with B. anthracissporesPositive Andersen samples did not seem to be in any particular order or indicate some event during the 8-hour sampling period that would have generated spores to be collected
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DiscussionDuring & subsequent to machine operation…
Wipe samples collected ~ Bin 100 to the end of the machine indicated confluent growthAndersen initial analysis indicates declining number of colonies per sample as time passed during 8-hour session
One sample was negative during the first two hours of samplingIndicates DBCS machine aerosolized a large amount of spores when in operation
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Discussion cont…During & subsequent to machine operation…
Approximately a to ½ of the MCE, PTFE, and GEL samples were positive
MCE and PTFE positive samples did not seem to be consistently located at any one particular sampling location or timeGEL filters seemed to be more consistently positive at Stations 3 and 4Positive GEL samples were collected in the first four hours of the 8-hour sampling period
DFU filters were positiveFor the 2-hour sampling period, the total air volume sampled ~¼ of the enclosure air volume
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Conclusion
All air sampling media capable of collecting B. anthracis spores
Andersen more consistent when concentrations varyAndersen more sensitive
Positive air samples collected before machine was operatedAble to detect the subtleties of the decay curve
Positive Andersen samples before the machine was operated suggest that even walking and light work in the enclosure may be sufficient to re-aerosolize anthrax spores
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Conclusions cont…
Other positive factors for using the Andersen sampler
Lower risk processing for the laboratoryQuicker turn-around timeLess laboratory bias resulting from reduced amount of sample processing
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Investigator PPE
“Level C”F-F PAPR w/ HEPA filtersCoated Tyvek® suit (w/hood)Disposable rubber bootsDouble gloves (nitrile, vinyl)
Higher levels of protection may be required
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Investigator PPE
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First Responder PPE
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Laboratory Response Network for Bioterrorism
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A Snapshot of the LRNOperational since Sept 1999 Now 120 Confirmatory Reference labs providing identification of biological threat agentsIncludes state and local public health, federal, military, international, veterinary, food and environmental testing facilities, as well as chemical laboratoriesA variety of partners that span the spectrum of BT preparedness and response
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Partnerships
Founding PartnersCDCAssociation of Public Health LaboratoriesThe Federal Bureau of InvestigationThe Department of Energy
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Extended LRN Partners in Biological Terrorism Preparedness and Response
American Association of Veterinary Laboratory DiagnosticiansAmerican Society for MicrobiologyEnvironmental Protection AgencyDepartment of AgricultureDepartment of DefenseFood and Drug AdministrationDepartment of Homeland SecurityCanada, UK, Australia
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LRN Operational SuppositionsSystem must be flexible in order to respond to both overt and covert events as well as integrate with law enforcement Frontline response begins at the local levelLeverage existing Public Health infrastructure and the strength of collaborative partnershipsInfrastructure investments should have dual useLaboratory-based biodetection must be rapid to support timely public health decision makingTesting algorithms and reagents must be standardized for interoperability and consequence management
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LRN Strategic Vision 2002
The LRN will be the strategic partnership framework for a coordinated system that integrates the operational strength of laboratory analytical capacity domestically and in conjunction with key global partners for preparedness and response to biological and chemical terrorism as well other urgent threats to public health and national security.
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Front Line Response Begins at the Local Level
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Time to Results
0
ViralCulture
Real-timePCR
TRFImmuno-
assay
DFA
BacterialCulture
TIME (hours)
1 2 3 24 48 72
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LRN MissionThe LRN and its partners will develop and maintain an
integrated national and international network of laboratories that can respond quickly to acts of biological or chemical terrorism and other public health emergencies.
Our Mission in ActionOur Mission in ActionBioterrorism PreparednessBioterrorism Preparedness
••Anthrax attacks of 2001Anthrax attacks of 2001•• BioWatchBioWatch
Public Health Emergency Response Public Health Emergency Response ••Severe Acute Respiratory SyndromeSevere Acute Respiratory Syndrome
•• MonkeypoxMonkeypox
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National Laboratories
National laboratories currently include those highly specialized facilities operated by the CDC and the US Army Medical Research Institute of Infectious Diseases (USAMRIID). These facilities are responsible for maintaining BSL-4 containment and uniquely trained and vaccinated staff. Capacity for performing bioforensics, handling highly infectious biological agents and detecting chimeras and recombinant engineering of organisms.
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Reference Labs
Reference laboratories -responsible for detection and confirmatory identification of biological threat agents in referred specimens and samples using rapid advanced technology and specialized assays, reagents and support services provided by the LRN. Made up of over 100 state and local public health, federal, military, veterinary, agriculture, environmental and food testing laboratories.
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Sentinel LaboratoriesSentinel laboratories provide routine rule-out and referral functions using conventional methods and commercially available and approved diagnostic tests. Although these laboratories may not be equipped to perform the same tests as LRN Reference laboratories, they can test clinical specimens and low risk environmental samples to determine if they should be shipped to confirmatory reference or national level laboratories for further testing.
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Laboratory Testing Required in Support of Response Involved Both Clinical Specimens and Non-Clinical Samples
Environmental samples for risk assessment Nasal swabs for epidemiological investigationsClinical specimens for detecting exposure and infection Culture isolates referred for confirmation.
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LRN Environmental Testing Load
0
10000
20000
30000
40000
50000
60000
10/19/2001 10/26/2001 11/2/2001 11/9/2001 11/16/2001 11/23/2001 11/30/2001
Sum of All ENV Samples Received
Sum of ENV Samples from CT, NY, NJ, FL, DC, MD, VA, & PA
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Proof of ConceptLRN Response to Oct-Dec 2001 Anthrax Events:
DoD inclusive (25%) 30,200 environmental workups performed
+ CDC inclusive (6%)7,500 environmental workups
+ PHL inclusive (69%)84,010 environmental workups
Total:
>121,710 environmental workupsBray et al, BPRP. Information based on electronic responses through the Laboratory Response Network for Bioterrorism and telephone inquiries. Updates occurring as entities refine data.
CDC6%
LRN Military25%
LRN PHL's inclusive
69%
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Role of LRN in BioWatchLRN expedited, in collaboration with Homeland Security, the assay development, personnel training and lab supply for high throughput real-time PCR testing in LRN/BioWatch lab facilities.Testing is sustained on a daily basis in support of environmental monitoring to detect an aerosol release.Designated labs support air sampling operations in cities as well as special event needs.Testing algorithm uses screening and verification panels for target nucleic acid sequences of priority biothreat agents.
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Role of LRN in BioWatchCDC (BPRP) staffed BioWatch labs with emergency federal hires.LRN working to facilitate integration of laboratory “confirmed PCR positive” result with subsequent response cascade in Public Health Response Plan for consequence management.LRN at CDC requested to facilitate performance review and determination of interoperability of assays used in DoDprograms.
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Smallpox
April 10, 2003 - LRN PCR to detect Variola major nucleic acid in clinical specimens provided to network
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SARS
May 30, 2003 - LRN PCR to Detect SARS CoronavirusRNA in Respiratory Specimens provided to network
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Extrapolation…
SARSBioWatchRicin
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Transport of Specimens
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Biological Agents
Infectious agents of humans, animals, and plantsToxins produced by microbesGenetic material
Potentially hazardous by itselfPotentially hazardous when introduced into a suitable vector
Purified/concentrated or in “other”materials
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Transportation/Transfer
TransportationAir, land, or seaGenerally commercial conveyance
TransferExchanging materials between facilities
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Protection from Exposure
Rigorous packagingSturdyPrevents leakage
Appropriate labelingDocumentation of hazardous contentsTraining of workers
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RegulationsInterstate transportation of biologic agents
Public Health Service: 42 CFR Part 72Hazardous materials regulations
Department of Transportation: 49 CFR Parts 171-178Ability to mail etiologic agents
United States Postal Service: 39 CFR Part 111, Codified in the Domestic Mail Manual 124.38: Etiologic Agent Preparations
Occupational exposure to blood borne pathogensOccupational Health and Safety Administration (OSHA): 29 CFR Part 1910.1030
Dangerous goods regulationsInternational Air Transport Association (IATA)
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Shipping Containers
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General Packaging RequirementsPackaging
Triple packagingPrimary receptacleWater tight secondary packagingDurable outer packaging
Certified to meet rigorous performance tests of DOT, USPS, PHS, and IATA
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General Packaging RequirementsLabels
To: and From:Shippers phone number displayed
Infectious substance labelIncludes class or division
Proper Shipping NameEx: Infectious substance affecting humans (Bacillus species), UN2814
Cargo aircraft label (when appropriate)
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General Packaging RequirementsDocumentation
ManifestIdentifies the contentsPlace outside water tight container
Chain of custody