LABORATORY USER MANUAL August 2001

q The Technical staff of the Laboratory division and the Public Health Intelligence unit for their technical guidance.

q The Administrative support staff of the Laboratory division for their preparation of the manuscript.

q The Laboratory Directors in our member countries who took the time to review and provide valuable feedback.

q The staff of the Information services department for their editorial and technical support for the preparation of the final product.

Preface

CAREC, as the disease monitoring and prevention agency of the Caribbean region, has as its vision

"CAREC, a Public Health Information Consulting Service, dedicated to being the best at providing information that people need to improve health and prevent disease in the Caribbean"

CAREC's laboratories function to provide reference laboratory services, training and support to research of public health importance within our member countries. Our staff are committed to providing the highest quality service to you, our member countries, and we have instituted and upgraded systems over the 25 years of our existence to ensure that the quality of our services is assured at all times.

We hope that this guide will provide the necessary information to facilitate access to our services.

- Reference and referral services in Microbiology, Virology, Immunology and Medical Entomology for all 21 CAREC Member Countries (CMCs)

- Support for Public Health Programmes in CMCs by strengthening technical and laboratory management skills in public and private laboratories through training and advisory services

- Advocacy for policy development in support of improved quality of laboratory services in CMCs

- Selected research in the areas of microbiology, immunology and vector management, aimed at developing appropriate technology to guide effective laboratory diagnosis in CMCs.

The Scientific Advisory Council (SAC) which guides the operations of the Centre recognised in 1997, the following primary roles of the Centre:

Major Programme Areas

The operational areas based on the laboratory disciplines utilized in support of surveillance and control activities are supported by a laboratory management system which includes key aspects of quality assurance, laboratory safety and information systems.

VIROLOGY

Support for surveillance and control of viruses of public health importance is provided to CMCs. These include laboratory identification of vector borne diseases e.g. dengue and yellow fever, as well as diarrhoeal diseases e.g. rotavirus. Support is also provided for surveillance of vaccine-preventable diseases (e.g. measles, rubella, and poliomyelitis) as part of the EPI programme in the Caribbean. Reference services for confirmatory testing of HIV, Hepatitis and HTLV are ongoing activities.

This laboratory provides services in support of research studies conducted at the Medical Research Foundation of Trinidad and Tobago. This foundation collaborates with several external agencies in the United States. The research conducted by the foundation is primarily on the population of Trinidad and Tobago for retroviruses namely HIV and HTLV.

PARASITOLOGY

Studies are done on the changing patterns of human parasitism in CMCs. In addition, appropriate methods for diagnosis of these parasites are developed, and training for technologists in applying these methodologies is conducted. Diseases of public health importance supported by this section include those caused by blood parasites such as malaria, filaria and Chagas and intestinal parasites including a variety of helminthes and protozoan.

MEDICAL ENTOMOLOGY

This area provides support for the control of vector borne diseases (e.g. dengue, yellow fever, and malaria) in CMCs. Studies are done on the biology and behaviour of blood-sucking arthropod vectors of disease in the Caribbean. Relevant methods for the management of these pests are developed and demonstrated to CMC vector management authorities. Insecticide resistance testing is conducted on mosquitoes and larvae from various CMCs and resistance patterns fed back to member countries. More recent initiatives include conduct and evaluation of community based interventions for control of Aedes aegypti.

BACTERIOLOGY

The role of this unit is to provide reference and referral services in support of:

IMMUNOLOGY

In response to emerging member country needs, this unit provides reference services for the investigation of immunologically-based diseases e.g. connective tissue diseases, SLE, as well as for the monitoring of the progression of diseases such as HIV/AIDS through provision of immunophenotyping services.

Cost recovery for laboratory services has been piloted in this area through provision of tissue typing services for organ transplants.

MOLECULAR BIOLOGY

Molecular biological work was re-initiated at CAREC in June 1997 and focused on serotype identification of the dengue virus. Work has also started on introduction of HIV-PCR for support of Mother to child transmission (MTCT) programme in the region.

Future areas of expansion include possible research projects in areas of HIV and Leptospirosis.

SUPPORT SERVICES/SAFETY

The role of the Support Services/Safety pod is to enhance the management of the technical and administrative components of the laboratory operations and to provide leadership, support, advice and training in the area of safety.

- Laboratory Safety Training – Laboratory design and layout in accordance with safety specifications.

- Assistance and training in transportation of Dangerous Goods by air (International Air Transport Association – Dangerous Goods Regulations).

- Decontamination of infectious laboratory waste and contaminated laboratory coats.

Customer Service/Information

This unit is the first point of contact within the laboratory to receive client queries via the telephone. This area is also the first point of contact for all patient specimens and it is also the last point of contact before all laboratory results are disseminated. This unit acts as the direct communication link with all customers in an effort to receive feedback on laboratory operations. This unit is also heavily involved in the monitoring of internal quality indicators in support of efforts to continually increase the quality of service to our external customers.

The Laboratory Information system (LABIS) designed in-house to meet the special needs of CAREC’s laboratory, provides an efficient system for tracking of patient and laboratory surveillance data, as well as quality assurance indicators.

Training

Training in support of the strengthening of National Laboratory capabilities is provided to a variety of persons including medical technologists, vector control personnel and University students in the Faculties of Natural Sciences and Medicine.

These training initiatives are conducted locally at CAREC or at the requesting institutions in the CAREC member countries. The format for these training initiatives are quite varied based on the customers’ needs and may include, lecture sessions, on-the-bench training in specific technologies, continuing education for medical technologists and clinical practice sessions for medical technology students. All departments of the laboratory administer proficiency testing programmes on an annual basis. The purpose of CAREC’s proficiency testing programmes is to:

Quality Assurance

Quality Assurance (QA) training workshops are conducted for laboratory staff in CAREC Member Countries (CMCs), as part of a programme to improve the quality of laboratory services provided in the region.

The major objective of the programme is the building of strong laboratory foundations in our member countries through an intensive focus on:

A European Union funded CARIFORUM project entitled "Strengthening of Medical Laboratories in the Caribbean" will begin implementation at CAREC in the last quarter of 2001.

· Training of human resources to implement standards and improve laboratory management skills.

· Utilizing information technology to improve timeliness and quality of laboratory data and information.

The project will be implemented over a 4-year time period and will include all CARIFORUM countries.

LABORATORY OPERATIONS

The laboratories at CAREC are open from Monday to Friday, from 8:00 am to 4:30 pm except for Public holidays.

Month	Day	Holiday
January	01	New Year's Day
March	30	Spiritual Baptist/ Liberation Shouter Day
May	30	Indian Arrival Day
June	03	Corpus Christi
June	19	Labour Day
August	01	Emancipation Day
August	31	Independence Day
December	25	Christmas Day
December	26	Boxing Day

For emergency situations on weekdays and/or public holidays, please contact CAREC at 868-622-4261/2.

Laboratory Contact Persons

This section provides a comprehensive directory of contact persons within all the major units of the laboratory.

All specimens being referred to CAREC from overseas must be routed through the national laboratory in the respective country.

All National Laboratories have a role to play to ensure that shipments of samples are appropriately classified, packaged, labelled and appropriate notification sent. National Laboratory directors therefore need to ensure that their personnel are adequately trained to prepare packages in accordance with current IATA regulations.

The following is a list of other additional criteria, which must be met for all overseas shipments being forwarded to CAREC:

1. All patient samples to be routed to CAREC for testing purposes must be packaged in accordance with IATA regulations. (Reference WHO/EMC/97.3 – Guidelines for the Safe Transport of Infectious Substances and Diagnostic Specimens).

2. All samples for shipment to CAREC should be packaged and cleared at local airports, to ensure that they can arrive in Trinidad by Friday morning for the latest for any given week.

3. Prior to delivery at the local airport, of such packages, all requesting laboratories must notify the laboratory at CAREC, each time, of the pending arrival of the package. Failure to do so can result in significant delays in the receipt of packages in Trinidad.

4. All packages being shipped by air must also have attached onto them, a shipment declaration form (see attached). Failure to attach this document results in delays with Customs clearance at Piarco Trinidad.

5. For shipping instructions for specific laboratory investigations, please refer to the Laboratory Services section of this guide under the relevant laboratory discipline.

Included is a specimen shipment checklist that must be used each time, prior to dispatching packages by air to CAREC.

Ø Has the carrier been contacted to ensure that the shipment will arrive by the most direct route, avoiding arrival in Trinidad on the weekend?

Ø Are all primary receptacles watertight, leakproof and clearly labelled with the patient identification?

Ø Have all primary receptacles been placed into a ziploc bag with adequate absorbent material to absorb all fluid in case of breakage?

Ø Does the number of primary receptacles and the number of patient forms match?

Ø Have all the specimen vials been labelled with the patient id and date of collection?

Ø Have all the patient forms been completed with all of the following information?

Ø Have the patient forms, letters and other type of documents been taped to the outside of the secondary receptacle?

1. All specimens being sent for laboratory investigation must be clearly labelled with the patient identification or laboratory identification code as well as the date of collection. The specimen forwarded to CAREC must be of an adequate quantity and acceptable quality.

If there is an occurrence of an unlabelled or mislabelled specimen, the specimen would not be processed at CAREC.

If a specimen volume is insufficient or is deemed not to be of an acceptable quality for processing at CAREC, they will be returned to the National Laboratory.

2. All specimens being sent to CAREC for laboratory investigations must be accompanied with patient documentation and vice-versa. Information required by CAREC on each specimen is as follows:

In the absence of the above underlined items, the specimens will be stored until the information is provided.

3. It is the responsibility of all laboratory providers to ensure that the legibility of patient information on all investigation forms is adequate.

The absence of adequate legibility hinders our ability to process laboratory requests. Any instances of illegibility will be forwarded up with a letter seeking clarification, (addressed to the National Laboratory). The requests will not be processed until the clarification has been resolved.

4. The type of specimen container to be utilised varies with the laboratory investigation requested. Please refer to the respective test guidelines for selection of the appropriate specimen containers.

If there is an occurrence of an inappropriate container or specimen type for the test requested, the specimen would not be processed at CAREC.

5. Screening test data must support all specimens being referred for confirmatory testing.

In the absence of screening test information, testing would be delayed until such information is provided.

Laboratory Investigation Form

Filariasis Wuchereria bancrofti Thick and thin blood film Identification (acute stage)

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Gastroenteritis Entamoeba histolytica Stool in 10% formalin and PVA Detection of organisms

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Pneumocystis Pneumocystis carinii BAL, Induced sputum Detection of organisms

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Cryptosporidiosis Cryptosporidium parvum 10 litre sample of water Detection of organisms

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Leishmaniasis Cutaneous leishmania Scrapings from the base of the lesion Please call CAREC before

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Helminthiasis Enterobius vermicularis Stool in 10% formalin Detection of organisms

Specimens for Entomology

The following table lists information relevant to the collection and testing of specimens for Entomology investigations.

Note: All specimens sent to the Entomology unit should have the following accompanying information.

Mosquito identification Specimen collected Specimen should be sent in a preservative - either

ether, CO₂ or

rapidly frozen in a

domestic refrigerator

Virus Isolation Live adult mosquitoes[3]^, [4] Individual vials should contain a pool of 20

· Dengue fever · Aedes aegypti adults. Vials should be lined with wax paper and

· Yellow fever · Haemagogus spp; stored in a -70⁰C freezer until ready for shipment.

Sabethes spp.

· Eguine encephalitis · Culex nigripalpus; For foreign laboratories: For shipping, the vials

Culex quinquefasciatus must be transported to CAREC in a container

· Bancroftian filiariasis · Culex quinquefasciatus packed with dry ice.

For local laboratories: Live adult mosquitoes

should be brought directly to CAREC in ice

coolers within 24 hours of collection.

Insecticide resistance Aedes aegypti mosquito eggs On removal from ovitraps, papers containing

eggs should be allowed to dry gradually. Fold

papers in two with the side containing eggs on

the inside.

Shipping: Wrap papers in tissue or paper towels,

Package in envelope and forward to Entomology.

Specimens for Bacteriology

The following table lists information relevant to the collection and testing of specimens for Bacteriology investigations.

Note: All serum specimens should be maintained at -20⁰C to 4⁰C. All serum-containing receptacles being forwarded to CAREC for testing must not exceed the dimensions of 1.5 cm in diameter and 4.7 cm in height.

Disease/Test Suspected bacteria Specimen recommended Test performed/Notes

Foodborne illness Salmonella Isolate on nutrient agar slant Identification, confirmation,

Shigella Same as above Serotyping

Campylobacter Isolate in Cary Blair

Medium

Vibrio cholera Isolate on nutrient agar slant

Escherichia coli 0157:H7 Same as above

Staphylococcus Same as above Staph. and E. coli isolates

for toxin testing will be

forwarded to another

reference laboratory.

Escherichia coli Same as above

(toxin testing)

Outbreak investigation Salmonella Unpreserved stool Receipt must be within 1

(Identification or isolation) hour of collection and stored

at room temperature.

Shigella Unpreserved stool If transport time exceeds 2

Escherichia coli Unpreserved stool hours, a portion of the

Campylobacter Unpreserved stool specimen must be placed in

Vibrio cholera Unpreserved stool Cary Blair medium and sent

at 4⁰C.

Suspected bacteria Specimen recommended Test performed/Notes

Vi antibody titre Salmonella typhi Serum or clotted blood Only available for outbreak

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Antimicrobial susceptibility Neisseria gonorrhoeae Isolate on chocolate agar Store at room temperature[5]

Table of Contents

Mission Statements

CAREC's Mission Statement

CAREC's Laboratory Mission Statement

Acknowledgements

Preface

Areas of Technical Co-operation

Major Programme Areas

Laboratory Organogram

VIROLOGY

PARASITOLOGY

MEDICAL ENTOMOLOGY

BACTERIOLOGY

IMMUNOLOGY

MOLECULAR BIOLOGY

SUPPORT SERVICES/SAFETY

Customer Service/Information

Training

Quality Assurance

LABORATORY OPERATIONS

Laboratory Contact Persons

Shipment of Specimens to CAREC

CAREC Specimen Shipment Checklist

Specimen Collection/Identification

Laboratory Investigation Form

Laboratory Testing Services

Specimens for Entomology

Specimens for Bacteriology