Legionnaires’ Disease Laboratory Response Plan: Are you ready? - … · 2017-06-13 · Hi...
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National Center for Immunization & Respiratory Diseases Legionnaires’ Disease Laboratory Response Plan: Are you ready? Anna Llewellyn, PhD Laboratory Leadership Service Fellow Pneumonia Response and Surveillance Laboratory OID/NCIRD/DBD/RDB Association of Public Health Laboratories 2017 Annual Meeting Providence, Rhode Island Monday, June 12 th , 2017
Legionnaires’ Disease Laboratory Response Plan: Are you ready? - … · 2017-06-13 · Hi everyone. I’m excited to be here today to share with you CDC’s new Legionnaires’
National Center for Immunization & Respiratory Diseases
Legionnaires’ Disease Laboratory Response Plan: Are you ready?
Anna Llewellyn, PhDLaboratory Leadership Service FellowPneumonia Response and Surveillance LaboratoryOID/NCIRD/DBD/RDB
Association of Public Health Laboratories 2017 Annual MeetingProvidence, Rhode IslandMonday, June 12th, 2017
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Hi everyone. I’m excited to be here today to share with you CDC’s new Legionnaires’ Disease Laboratory Response Plan toolkit. Last year I presented a poster on our ideas for this toolkit and distributed a beta version of the plan. I received a lot of great feedback from many PHLs that helped inform the final product. This is just a first version of this toolkit and we hope to hear suggestions for improvement from PHLs in the coming months.
Before I go one, I encourage anyone in the audience with a laptop, ipad, or similar device to go to the CDC Legionella website and download this kit right now so that you can look through it with me as I go through the rest of my slides. Here is the direct URL or you can google Legionella and CDC, click on the “For Laboratories” tab on the sidebar and then click on the Laboratory Response Plan Toolkit icon.
As we’ve heard, LD responses are complex and often can involved large numbers of environmental samples. Additionally, LD responses are frequently highly visible, both politically and in the media.
Potential for LD outbreaks across US
4.5-fold ↑ LD incidence Legionella prevalent in US
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So how likely is a LD outbreak to occur in the region that your lab serves? From 2000-2015, the rate of reported incidence of legionelllosis increased four and a half fold. This increase is likely due to multiple factors, including increased awareness of and testing for LD. In addition, a study soon to be published by our laboratory found detectable levels of Legionella in cooling towers from regions spanning the continental US. Out of 196 cooling towers tested, 84% were positive for Legionella DNA (shown on the map in green triangles) and half of the PCR-positive samples were culture positive. Together, these data highlight the real potential for LD outbreaks to occur throughout every region served by a US PHL.
LD laboratory responses can be complicated
Limited clinical specimens – UAT
Legionella is fastidious– Limited growth media availability
As my colleagues have demonstrated, LD lab responses can be complicated. Often clinical specimens, and therefore clinical isolates, are limited as most patients are diagnosed via a urinary antigen test. In addition Legionella bacteria are fastidious and require specialized media that can be challenging to make in-house and often has limited commercial availability during prime LD season. Finally, environmental samples can be challenging to collect and often require multiple processing steps… and A LOT of BCYE plates.
What is a LD Laboratory (LDL) Response Plan?
Identify, document, strengthen
– Current capacity
– Response Team
– In-house Testing Plan
– Referral Testing Plan
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So what is a LD Lab Response Plan? It is intended to help state and local PHLs establish a LD game plan BEFORE a potential response. The LDL Response Plan focuses on identifying, documenting, and strengthening the main aspects of LDL Response: First, there is a checklist to help identify your lab’s current capacity for the performing the main components of a LD lab response, Second, there is section to help define PHDept’s LD Response Team: who in PH Dept (from epi, environmental health, comms) will you be working and what will the flow of communication be and what will the expectations be among the groups in the Response Team? Next, there is an in-depth LD In-house testing plan: capacity, tests, responsibilities, TATs, and other considerations. Finally, there is a LD Referral testing plan: establish which lab you may refer tests to, details about expectations related samples/specimens, tests, TATs and more.
Which labs can benefit from an LDL Response Plan?
Some LD testing capacity LD Response Team In-house Testing Plan Referral Laboratory Plan
No LD testing capacity LD Response Team Referral Laboratory Plan
Full LD testing capacity LD Response Team In-house Testing Plan
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So which labs can benefit from completing a LDL Response Plan? Labs with SOME LD testing capacity can benefit from completing the LD Response Team, In-house Testing, and Referral Lab components of the Response Plan. Labs with NO LD testing capacity can benefit from completing the Response Team and Referral Lab components, and labs will FULL LD testing capacity can benefit from completing the Response Team and In-house Testing components.
LDL Response Plan Checklist
Current testing capacity– Legionella isolation– Isolate characterization– Molecular typing
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There are 3 main components required for a complete LD investigation. Your lab may do additional testing that can be captured in the In-house testing plan, but these are the main components required for a complete LD laboratory investigation. The checklist at the beginning of the response plan is intended to help capture what testing your lab currently performs. As an example, PHL X is able to perform Legionella isolation from clinical specimen and environmental samples as well as isolate characterization with a PCR that can detect L. pneumophila and L pneumophila serogroup 1, but testing to confirm other spp and serogroups would need to be referred to an outside lab, as would molecular typing performed to compare the relatedness of clinical and environmental isolates.
LDL Response Team
Laboratory
Epidemiology
Environmental Health
Communications
Contact Information
Response Considerations
Signatures
Public Health Department
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Once you have documented your lab’s capacity, The Response Team section can help identify or strengthen the team your lab might work with within your PHDepartment’s epi, env health, and communications divisions. There is a section for recording primary and secondary contact information, a section with questions to help organize communications and define expectations during a potential response, as well a section for signatures to document the understanding among the Response Team members.
The In-house testing section of the Response Plan has an overview table to gather testing information related to protocols, staff members, and TATs. There is specimen requirements and shipping section that can be completed and distributed to external facilities that may be providing you with specimens. And finally, a table of considerations related to in-house testing documentation, workforce capacity, culture/media issues, and post-response activities
LDL Referral Laboratory Plan
Contact information Overview
– Materials to be shipped– Tests requested– Cost– Turn-around-time
Specimen/Samples
Contact Information
Referral Overview
Referral Requirements
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The Referral lab section of the Response Plan is intended to help labs establish relationships with referral labs ahead of time with complete contact information, an overview of materials to be shipped, tests that may be requested, and anticipated costs and TATs. There is also a section to document the specimen requirements and shipping specifics as defined by the referral lab. Sometimes when you’re in the middle on an outbreak, issues with figuring out the timely and correct shipping of specimens and isolates can slow down the whole investigation, so gathering this kind of information ahead of time can streamline your response.
Example LDL Response Scenario
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The toolkit also includes and example LD lab response scenario. This is intended just as an illustration of a response and is not meant to be a recommendation for workflow. Just as every lab is different, so is every response.
Example LDL Response Scenario
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In the example response, there is a summary of a fictional investigation that is accompanied by a timeline that illustrates average times involved in different aspects of a LD lab response.
Example LDL Response Workflow
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In addition, there is a workflow graphic of the example scenario. We have found this to be a useful tool for illustrating to non-laboratorians the complexity and volume of work involved in a LD response.
Appendices: Example Workflow Documents
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Also included in the toolkit are example workflow documents
Appendix A: Customizable LDLRP
One size editable to most!– Word document– Add/delete/duplicate
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The first appendix is just an word document that allows you to edit the Response Plan tables to suit your own needs. We have tried to make the document as flexible as possible so the it can be editable to suit most any PHL’s needs.
Next is an example of worksheet for documenting the culture of environmental samples
Appendix C: Clinical Specimen Culture Worksheet
Specimen data
Daily culture checks– 3 dilutions
Track colony picks
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We also have an example of a worksheet for tracking specimen culture
Appendix D: Colony Testing Worksheet
Track colony tests
12 colonies per page
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And finally there is an example worksheet for tracking results of colony testing.
Appendix E: Specimen Shipping Guidelines
Share with outside labs:– Minimum requirements– Preparation– Storage before shipping– Shipping conditions– Testing available
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The last example document we included in the kit is CDC’s own specimen shipping and handling document as an example of a document that can be shared with labs who may be sending your lab specimens.
Acknowledgements
Pneumonia Response and Surveillance Laboratory (NCIRD/DBD/RDB)– Jonas Winchell, PhD– Brian Raphael, PhD– Claressa Lucas, PhD– Ellen Brown– Natalia Kozak-Muiznieks, PhD– Jeff Mercante, PhD
LDLRP Beta-testers– Michigan PHL– New Mexico PHL– New York City PHL– South Dakota PHL– Washington PHL
Laboratory Leadership Service– Xin Liu, PhD
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I’d like to thank everyone in the Pneumonia Response and Surveillance Lab for their incredible support of this project, the PHLabs that beta-tested last year’s draft and finally I’d like to thank the Laboratory Leadership Service for an incredible two years.
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
