Florida Bureau of Public Health Laboratories 2012 Annual Report

2012: Annual Report Bureau of Public Health Laboratories

one test at a timeContributing to a healthier Florida,

The Fellowship Experience: A Journeyinto the Bureau of Public HealthLaboratories, 2

Politics & Public Health, 4

New HIV Diagnostic Algorithm, 5

Florida Pubic Health–Prepared forEmergencies, 7

Newborn Screening Program Adds NewLife-Saving Test, 9

2012 BPHL Timeline, 12

Multi-drug Resistant Tuberculosis—Not Just a Disease in ForeignCountries, 14

Raccoons, Bats and Cats. . .Oh, My!, 16

Ensuring the Quality of EnvironmentalLaboratory Testing, 18

Work Published in National ScientificJournals and Publications in 2012, 20

National Meetings & Presentations, 20

Committees, 20

Service Milestones, 21

Awards, 21

CONTENTS 2012: ANNUAL REPORT • BUREAU OF PUBLIC HEALTH LABORATORIES

We are committed to the FloridaDepartment of Health mission,

“to protect,promote andimprovethe healthof all people in Florida throughintegrated state, county andcommunity efforts.”

The Florida Department of Health,Bureau of Public Health Laboratoriesunderwent several changes:

nThe Bureau name changed fromthe Bureau of Laboratories to the“Bureau of Public HealthLaboratories” (BPHL).nThere were leadership changesfollowing the retirement of theJacksonville and Tampa LaboratoryDirectors and the departure of theBureau Chief.nThe Bureau moved under theDivision of Emergency Preparednessand Community Support.

Despite the changes, it wasbusiness as usual as the BPHL staffcontinued to strive to fulfill theBureau’s mission to “contribute to ahealthier Florida by providingdiagnostic screening, monitoring,reference, research and emergencypublic health laboratory services.”The BPHL had several successes in2012 including:

nThe implementation of a lifesavingtest in the Newborn ScreeningLaboratory.nThe implementation of a new HIVDiagnostic testing algorithm—hefirst major change in HIV screeningsince the BPHL began HIV testing23 years ago! nThe response to public healthevents including providing well watertesting for those impacted byTropical Storm Debby andcoordinating submission of samplesrelated to the multi-state fungalmeningitis outbreak to the Centersfor Disease Control and Prevention(CDC) and reporting results back toproviders.

In 2012, the BPHL continued tofoster the important relationshipswith our federal, state and countypartners as evidenced by thecollaborative efforts before andduring the Republican NationalConvention. Additionally, the BPHLhas an ongoing partnership with theFlorida Department of Health,Bureau of Epidemiology to providetesting for outbreaks and diseasesurveillance and strong connectionswith CDC and the Association ofPublic Health Laboratories (APHL).

In this report, you will learnabout these and other noteworthyBPHL accomplishments, all whichwould not be possible without theefforts of our talented and dedicatedstaff. As we move into 2013collaboration will be key, especiallywith challenges created bydecreases in funding and workforceshortages. We are committed to theFlorida Department of Healthmission, “to protect, promote andimprove the health of all people inFlorida through integrated state,county and community efforts.”

Victor JohnsonDirector, Division of EmergencyPreparedness and Community Support

Susanne CroweInterim Chief, Public Health Laboratories

From top to bottom:Tampa Laboratory

and the Jacksonville Laboratory

Greetings! We are verypleased to present theinaugural Bureauof Public HealthLaboratories 2012:Annual Report. . .andwhat an exciting andeventful year 2012 hasbeen!

2012: ANNUAL REPORT • BUREAU OF PUBLIC HEALTH LABORATORIES 1

New Name, New Structure, New Challenges, New Opportunities.

Mission Accomplished!

Upon being awarded a one-year training fellowship in emerging infectious diseases (EID) through theAssociation of Public Health Laboratories (APHL) and the Centers for Disease Control and Prevention(CDC), I was pleased to be accepted as a fellow at the Florida Department of Health, Bureau of PublicHealth Laboratories’ (BPHL) Tampa laboratory.

The Fellowship Experience:

A Journey into theBureau of PublicHealth Laboratories

AAcceptance into the APHL/CDC EID Fellowship program is extremelycompetitive, and I was very excited about the opportunity to work in a statepublic health laboratory. I began my fellowship in August of 2012 with muchenthusiasm and many expectations for the coming year.

I set a goal to obtain a well-rounded education during my fellowship byrotating through every department at the BPHL Tampa laboratory. I rotatedthrough the arbovirology, virology, serology and microbiology departments. Iwas also able to experience working in a Biosafety Level-3 laboratory. Therotation schedule was ambitious, but it was important for me to learn as muchas possible about the operations of a State Public Health Laboratory.

My first rotation was in the arbovirology department. The arbovirologylaboratory tests blood from ‘sentinel chickens’ for a type of virus called an

Kayleigh Jennings isolating an agarose plug ofbacterial DNA. These plugs are then treatedwith enzymes that cut the DNA into differentsized pieces. This method allows us togenerate a specific DNA fingerprint of thebacterium being studied.

By Kayleigh Jennings

2 2012: ANNUAL REPORT • BUREAU OF PUBLIC HEALTH LABORATORIES

‘arbovirus’ that is carried bymosquitoes. West Nile Virus, EasternEquine Encephalitis Virus and St.Louis Encephalitis Virus are allexamples of arboviruses that arecarried by mosquitoes; when thesemosquitoes bite humans, they cantransmit the virus to humans causinginfection, sometimes leading to

serious conditionslike encephalitis. Aspart of Florida’sarbovirussurveillanceprogram, thesentinel chickenslive in flocks,located throughoutthe state. Sincemosquitoes bitechickens, publichealth workers canmonitor whatdiseases are beingcarried inmosquitoes bytesting thechickens’ blood forantibodies toarboviruses.Detecting antibodiesin chickens is anearly warning signfor the humanpopulation. When

the chickens test positive forantibodies to an arbovirus, publichealth workers can take action toprotect the public such as sprayingfor mosquitoes and notifying the

public to avoid mosquitoes. I learneda lot from the hardworking team inarbovirology, and I am thankfulbeyond words for the “behind thescenes” work they do to keep thepublic health front safe.

Another favorite on my rotationschedule was the microbiologydepartment. There I found my soulmate…PulseNet! PulseNet is anational program to track bacteriathat can be transmitted in food suchas Salmonella, E. coli and Listeria.Laboratories that participate in theprogram perform standardizedmolecular fingerprinting proceduresby a method called pulsed-field gelelectrophoresis (PFGE). The PFGE‘fingerprints’ are entered into anational database and public healthworkers can use this information toidentify and investigate foodborneoutbreaks, within and across states.I really enjoyed learning all of themethods involved in Salmonellaoutbreak surveillance and I was eventrained and certified by the CDC tojoin PulseNet!

I obtained a vast amount ofknowledge from my fellowshipexperience, yet what impacted memost was discovering that theindividuals in the public health fieldare among the hardest working,caring and most helpful people I haveever met. The BPHL-Tampa laboratorystaff are not here for the salary, theyare here because they love helpingpeople and making a difference. Ihave never felt so welcomed orrespected as I have felt at theDepartment of Health. As I prepareto finish my fellowship and move on, Itake with me the valuable lesson thatpublic health is for thick-skinned,unbelievably dedicated, caringindividuals. Simply put, this has beenthe greatest opportunity in my career!

Another favorite on my rotation schedule was the microbiologydepartment. There I found my soul mate. . .PulseNet! PulseNet isa national program to track bacteria that can be transmitted infood such as Salmonella, E. coli and Listeria.

Kayleigh Jennings

EID Fellow, 2012–2013


Prior to the convention, BPHL-Tampa planned for a year to beprepared for any event that couldnegatively impact public health andsafety during the RNC event. Allbiological outbreaks, natural andintentional, were considered. Thisincluded norovirus and non-seasonalinfluenza outbreaks, food and watercontamination (all of which canresult in large numbers of sickpeople), chemical threats, andsuspicious threat samples—the socalled “suspicious powders” that aresometimes sent in letters andpackages. Preparations includedincreased outreach and training withfirst responders for samplecollection for white powderincidents; increased training forchemical threats recognition for thehealth and medical community; fullscale exercises allowing participantsto practice for a coordinatedresponse to an intentional exposureevent; and participation in anexercise to evaluate the laboratory’sresponse if affected by a hurricane.Staff was cross-trained to provide

support to prepare for a surge in thenumber of samples for testing inone area. Also, a plan was put inplace to divert non-critical samplesand samples that are not fromcredible threats to the Jacksonvilleand Miami laboratories so thatBHPL-Tampa could concentrate ononly the essentials.

The laboratory’s environmentalair analysis program was put onheightened alert and readied forextra testing. As a precautionarymeasure, this program substantiallyincreased their surveillance ofenvironmental air samples.Additional personnel from othernational laboratories were broughton board to help out with the extraduties. Shifts continued around theclock during the RNC with a 24/7operation. During the period ofAugust 24–August 30, the programtested a total of 562 samples, all ofwhich were negative.

During the RNC, BPHL-Tampaworked closely with the DOH inHillsborough and Pinellas Countiesepidemiology programs, which wereextra vigilant with their surveillanceactivities during the RNC. Inparticular, epidemiologists paidclose attention to reports of patientswith unusual rash, food-relatedillnesses, bloody diarrhea, orunexplained severe infectiousillness/death in an otherwisehealthy person.

Fortunately, the conventionproceeded without biologicaloutbreaks or chemical threats of anykind. We stayed calm and carried on!


Politics & Public HealthIn 1939, the British Government coined the phrase “Keep Calm andCarry On” to raise the morale of the British people with respect to theimpending war with Germany. This same phrase was used by theBureau of Public Health Laboratories (BPHL) Tampa Laboratoryduring the week of the Republican National Convention (RNC), whichconvened from August 27 to August 30, 2012, in Tampa.

A HIV-1/HIV-2 Ag/Ab Immunoassay*

A+ A-

Repeat A in duplicate + Negative for HIV-1 andHIV-2 Ab and HIV-1 p.24 ag**

A(--)

A1 (++ or +-)

B HIV-1/HIV-2 Ab Differentiation Immunoassay

B HIV-1 (+)HIV-2 (-)

Positive forHIV-1 Ab #

BHIV-1 (-) HIV-2 (+)

BHIV-1 (+) HIV-2 (+)

BHIV-1 (-)/HIV-2 (-)

or inconclusive

Positive forHIV-2 Ab ‡

Positive forHIV-2 Ab §‡

C Individual HIV-1 NAT

C+

Positive forHIV-1 RNA #¶

C-

Negative forHIV-1 RNA #

* A could be an lgM sensitive antibody immunoassay if the Ag/Ab combination immunoassay is not available. † Repeating A+ is assay dependent. ‡ Refer to care and follow-up testing. § HIV positive—further testing required to rule out dual infection. ¶ Acute HIV-1 infection. # Consider HIV-2 DNA testing if clinically indicated. ** If early acute infection is suspected, NAT can be performed.

* A could b an lgM senuld be a lgM sennsitive antibantibody immunoassoassay ifoassay ifA b co the Ag/Ab combinatioon immunob immunoassayassay is not availablelable. † Repeatinng peatin A+ is asss assay ddependent. ‡ Refer o care and fo‡ Refer to and follow-uupw-u-up testing.

ositive—furthe § HIV po e—further testinng resting requrequired to rule out dual tion. infect ¶ Acuute HIV-1 infection.Acut # onside # Coonsider H# Con der HIV-2 DNA testing if f clinically indicated.ed.

f ear ** If early acute infef infection is suspfection is suspeected, NAT can be performe p ormed.

As part of the new testing algorithm,the BPHL implemented an FDA-approved laboratory-based HIV-1/HIV-2screening assay. This assay, commonlyknown as a “4th generation HIV-1/HIV-2 antigen/antibody comboimmunoassay,” is a qualitativeimmunoassay that can simultaneouslydetect HIV-1 p24 antigen, antibodies toHIV-1 (Groups M and O) and HIV-2 inhuman serum or plasma. This is a verysensitive assay and is intended as an

aid in the diagnosis of HIV-1 and/orHIV-2 infection, including acute orprimary HIV-1 infection. An acute HIV-1infection occurs when a person isinfected with the HIV-1 virus, but theydo not have enough antibodies for alaboratory test to detect it. Studiessuggest that the rate of HIVtransmission during the acute infectionstage is 26 times higher than duringestablished HIV infection. Mathematicalmodels indicate that acute HIVinfection, despite its short duration,can account for 10%–50% of all newHIV infections. This 4th generationantigen/ antibody screening test isable to detect HIV antigen as early as15–22 days after the person isinfected.

The new HIV algorithm also includeschanges in the HIV confirmatory

New HIVDiagnosticAlgorithm


The Bureau of Public Health Laboratories (BPHL) implemented aninnovative HIV Diagnostic Algorithm on April 16, 2012. This markedthe first major change in HIV diagnostic testing in 23 years. Thenew algorithm was developed based on the work of experts at theCenters for Disease Control and Prevention (CDC) and members ofthe Association of Public Health Laboratories (APHL) HIV/HCV sub-committee. The new algorithm has been published by the Clinicaland Laboratory Standards Institute (CLSI). The JacksonvilleRetrovirology Section Chief was a member of the APHL sub-committee that worked on this new algorithm.

0

50

100

150

200

250

300

350

May–July=312

Jan.–Mar.=339

fewer than 2 workdaysmore than 2 workdays

Turn Around Time in Days to Report HIV-1 Positive Reults, Jan.–July 2012

Jan.–Mar., only 22% were reported in 2 or fewer days

compared to 96% in May–July

244

327

12

68Laboratory reporting TAT

Num

ber

of Posi

tive

Resu

lts

Rep

ort

ed

Ketty Ledan, BS, MS, Ph.D.Health Services manager

“As we continue our efforts toexpand HIV testing and linkageto care, we are extremelydelighted with the fast turn-around result obtained from thisnew fourth generation test. Theadvantages of this newtechnology prompted us toencourage our registeredcounseling and testing sites toswitch to ‘blood testing’whenever possible. Suchadvantages include thediagnosis of more recentinfection, helping make peopleaware of their HIV status,expediting linkage to care andreducing the spread of HIV in thecommunity by people unawareof their positive status.”

process. The HIV-1/HIV-2 rapid test replaced the Western Blot as the primarysupplemental assay in the confirmatory process. The rapid test provides betterspecificity than the Western Blot and can differentiate between HIV-1 and HIV-2infections which is important in terms of disease progression, treatment andfor epidemiological purposes.

By the end of 2012, four patients with HIV-1 acute infections wereidentified using the new HIV Diagnostic Algorithm. Importantly, all four patientswere referred to a healthcare provider within 14 days of specimen collection.Epidemiological data have suggested that antiretroviral therapy reduces therisk of HIV transmission in heterosexual couples by 92%–98%.

Besides identifying acute HIV infections, the use of this new algorithm hasshortened the BPHL HIV turn-around times (TAT) for reporting positive testresults. In a three-month comparison of positive results reporting, BPHLincreased to 96% the number of positive results reported in two days or less.

The decreased TAT resulted in a four-fold increase in the reporting ofpositive results during the defined time period compared to the earlier timeperiod. This greatly expedites the linkage to care for affected patients. Lastly,the new HIV Diagnostic Algorithm virtually eliminates indeterminate orinconclusive laboratory interpretations. The transition to the new HIVDiagnostic Algorithm was smooth due to the efforts of the Office of HIV/AIDSPrevention, Surveillance and IT staff that assisted the BPHL during the sixmonths preceding the transition date.


Besides identifying acute HIV infections, the use of thisnew algorithm has shortened the BPHL HIV turn-aroundtimes (TAT) for reporting positive test results. In athree-month comparison of positive results reporting,BPHL increased to 96% the number of positive resultsreported in two days or less.

Prepared for Emergencies


Florida Pubic Health–

Jim woke up very early Saturday morning. Hewas excited about the day ahead. This was theday the Big Moose Lodge hosted their annualfundraising carnival. There would be rides, games and a lot ofgreat food! Jim was looking forward to spending the day at the carnivalwith his wife and grandkids! Jim and his family were having a greattime at the carnival but suddenly, Jim started feeling nauseous. At firsthe thought he had ridden one too many rides, but soon one of hisgrandchildren was complaining that his stomach hurt too. Jim and hiswife headed to take their grandson to the first aid tent. The first aid tentwas packed with people and many were vomiting uncontrollably andsome began passing out. The paramedics were working frantically totry to keep people calm and comfortable and transporting the sickest tothe hospital. Soon, all of the local hospital emergency rooms were fullwith people from the carnival. A man rushed into the tent saying thathe heard from a friend that the local newspaper had received ananonymous letter from an anti-government group stating that they hadpoisoned the food at the carnival. Rumors began to spread and theparents’ worried look was etched upon their faces as they feared forthe worst.

Wonder what happened next? Well, this was not an actual event but rather adress rehearsal to test how well prepared local, state and federal agencies areto respond to emergency situations such as large scale biological or chemicalexposures. Preparedness exercises like this one provide the Bureau of PublicHealth Laboratories (BPHL) and Florida’s health and medical community partnerswith the means of attaining, practicing, validating, and improving capabilities.

Dr. Rick France acting as the exercisedirector coordinates events for the2012 BPHL statewide, multi-agencyexercise.

In 2012, the Florida Biological Defenseprogram staff performed 223 tests onenvironmental and clinical samples.

80% of the samples tested wereclinical and 20% wereenvironmental.

The CDC LaboratoryResponse Network(LRN) maintains aproficiency testingprogram and requiresparticipation by allSelect Agentlaboratories. Thisyear’s proficiencypanel includedCoxiella (Q Fever),Brucella (Brucellosis),Poxvirus species(Pox) and Yersiniapestis.

The Chemical Threat (CT)program staff can test formany chemical agents.Here are a few agents thatBPHL staff tested for in2012:

Ricin metabolites

Lead, cadmium and otherheavy metals

Arsenic metabolites

Cyanide in blood

Nitrogen and sulfurmustard metabolites

Nerve agent metabolites

Volatile organiccompounds

And other toxic elements

In 2012, the CT lab staffalso analyzed 243samples of hair and salivato test for exposure tosecond hand smoke. Thisstudy of non-smokers ispart of the FloridaBehavioral Risk FactorSurveillance System(BRFSS) survey.


The ‘Big Moose Lodge Carnival’ event waspart of a 2012 preparedness exercise inwhich over 20 federal, state and localagencies and fourteen hospitals across thestate participated. The Centers for DiseaseControl & Prevention (CDC) and the FederalBureau of Investigation (FBI) participated atthe federal level. The Florida PoisonInformation Center and several Department ofHealth programs along with the FloridaDepartment of Law Enforcement and FloridaDepartment of Agriculture and ConsumerServices participated at the state level. Elevencounty health departments and hospitalsparticipated locally. The exercise evaluatedimportant aspects of responding toemergencies including information sharing;public health laboratory testing; public health surveillance and epidemiologicalinvestigations. Most important of all was achieving a collaborative attitude with allof the participating agencies. In this case, the poison used was ricin, which is botha biological and a chemical agent.

The BPHL Chemical Threat (CT) Program has designed, planned and participatedin preparedness exercises since 2006. The BPHL CT Program has consistentlypromoted a robust program for developing innovative training classes and exercisesthat assess roles of hospitals, emergency medical services, emergencymanagement, county health departments, and law enforcement. In recognition oftheir community preparedness efforts, the BPHL CT Program received theOutstanding Outreach to Poison Control Centers or Hospitals award presented bythe CDC and the Association of Public Health Laboratories (APHL) at the 2012National Laboratory Response Network (LRN) Meeting.

Photos from top to bottom:

Reden Salonga and Dr. JasonPalcic unwrap patient specimensthat have been shipped to theBPHL laboratory to test forchemical agents as part of theexercise.

Melissa Geiger prepares patientspecimens for testing as theyarrive from the regional hospitalsas part of the exercise.

Patient specimens are auto-pipetted in preparation for testingfor chemical agents as part of theexercise.


From top to bottom:Patricia Onasanya is punching 1/8-inch discs from

dried blood spots collected from newborns.

A closer look of the dried blood spots beingpunched with automated punchers.

Baby Aaliyah was born inFlorida on October 20, 2012—ahappy healthy baby girl! What Aaliyah’s parents did notknow was that although she appeared to be normal andhealthy, Aaliyah’s immune system was not functioningcorrectly. Aaliyah was lacking vital, functioning T-lymphocytes (T-cells) that facilitate the correctfunctioning of B-lymphocytes (B-cells). These T- and B-cells are major players in our immune systems that helpfight off infectious diseases. When T and B lymphocytesdo not work properly, the body is vulnerable to attackfrom every little germ. This disorder is called “SevereCombined Immunodeficiency” (SCID).

Because babies are born with antibodies from their mother, babies thathave SCID usually appear healthy for the first few months of life. How ever,after a few months, babies with SCID will begin to get infections. Doctors willeventually suspect the baby has an immune disorder, but because SCID is sorare (estimated at 1 in 40,000 to 100,000 live births) it is often way downthe list of possible diagnoses. Sadly, without early treatment, babies bornwith SCID may not live past age 2. Therefore, screening babies for SCIDwhen they are 24-48 hours old is game-changing.

NewbornScreeningProgramAdds NewLife-Saving

Test

36Florida Department of

Health tests for 36disorders as part of the

Newborn ScreeningProgram.

2,369,358BPHL staff performed

263,000 panels in 2012which is 2,369,358

individual tests!

209 & 62In 2012 the lab identified

209 infants with sicklecell disease and 62

infants with congenitalhypo-thyroidism which aretwo of the most commondisorders seen in Florida.

1In 2012 SCID testing wasimplemented and 1 infant

was detected by thescreening process.

So how did Aaliyah’s doctors learn that she had SCID so soon after herbirth? When Aaliyah was just one day old, a simple needle prick was made inthe heel of her foot. This prick provided a few tiny drops of blood which wereplaced on a special filter paper. The blood spots were dried on the paper andsent to the Florida Bureau of Public Health Laboratories (BPHL) in Jacksonvillewhere 35 different screening tests were performed on the blood sample. Theresults for these screening tests were reported back to the doctor within 48hours. In addition to a hearing test, these screening tests make up theNewborn Screening Panel that is performed on all babies born in the state ofFlorida. In 2011, there were approximately 215,000 babies born in Floridawhich represents about 5.5% of the total births in the US.

In the BPHL Newborn Screening Laboratory, all of the screening tests doneon baby Aaliyah’s blood sample came back normal except for one. Thescreening test for SCID, which had been implemented just a short 20 daysbefore Aaliyah was born, was positive! As with all screening tests that arepositive, the laboratory staff repeated the test and again it was positive. Thehospital and the Department of Health’s Children’s Medical Services NewbornScreening Program follow-up team were notified of Aaliyah’s positive SCIDresult and immediately leapt into action.

If the BPHL had not performed the screening test for SCID, Aaliyah couldhave been several months old and seriously ill before the doctors discoveredshe had SCID. But today Aaliyah is happy and healthy. Her parents continue tofollow the advice the doctors have given them and have protected Aaliyah frominfectious germs. She is living at home with her parents in isolation. In thefuture Aaliyah will need a bone marrow transplant which will increase herchances of a long, healthy life.

The implementation of statewide testing for SCID was no small feat. Itinvolved hard work and commitment from many groups including the FloridaGenetics and Newborn Screening Advisory Council, PerkinElmer, Children’sMedical Services Follow-up Program, the Bureau of Public Health LaboratoriesNewborn Screening Laboratory and referral centers at the University of Florida,University of South Florida and the University of Miami. There is a costassociated with performing this test on all babies. But ultimately, this test cansave a life which is priceless. Just ask baby Aaliyah’s parents.


Baby Aaliyah was fortunate. By the time she wasone week old, her parents had been notified of herpositive SCID screening test result and were able tomeet with experts to get the appropriate counselingregarding their daughter’s condition.

In July 2011 the Florida Genetic and Newborn ScreeningAdvisory Council unanimously voted to add SCID to our screening

panel.

In August 2011, Legislative Budget Request (LBR)was submitted to implement SCID screening for allnewborns in Florida.

In June 2012, contract wasapproved for PerkinElmer to performSCID screening on-site for Florida.

More than 2000 samples, including 18 from known SCIDcases, were tested to validate the test method and establish

reporting limits.

On October 1, 2012, Florida statewide SCID screening wasimplemented.


SCID TestImplementation

Timeline

Learn more about SCID: www.scidangelsforlife.com/

Melinda Copiaco and Vibha Mittal loadingsamples to the new automated analyzers. The

instrumentation produces more accurate resultsand reduces total analysis time.

After 20 days, a baby was confirmed with anunknown SCID variant.

Weekly conference calls conducted with Children’s MedicalServices (CMS) follow-up group and immunologists from UF,USF, UM to develop criteria for reporting and follow-up of babieswith abnormal screening test results.

May 21, 2010, the U. S. Secretary of Health andHuman Services approved the addition of SevereCombined Immunodeficiency (SCID) to the core panel ofnewborn screening disorders as part of therecommendation to adopt the national RecommendedUniform Screening Panel (RUSP).


Florida Department of HealthGenetics and Newborn ScreeningAdvisory Council met to discuss avariety of topics including thepotential addition of testing forSevere CombinedImmunodeficiency Disease (SCID)and Critical Congenital HeartDisease (CHD). In January 2012 the testing panelincluded 35 disorders.

The 2012 Florida Biological Chemical Agent FullScale Exercise was conducted over 5 days. Theexercise involved local, state and federalagencies. The scenario was based on intentionalfood-poisoning with exposure to a biologicaltoxin, ricin, which is also considered a chemicalagent. Testing of the agent was performed atBPHL as part of the exercise.

The parasite Spirometrawas identified in apatient who had beenboar hunting and hadconsumed undercookedboar meat. This parasiteis a tapeworm that isfound in animals. Humanscan become infected bydrinking contaminated

water, eating undercooked meat from an infectedanimal or if broken skin comes into contact withinfectious parasite larvae.

BPHL started testing private well watersamples from counties affected by TropicalStorm Debby. The lab tested a total of 418samples from Suwannee, Clay, Nassau, andGilchrist counties over a period of 2 months.

The Mycobacteriology laboratory begantesting specimens as part of the effortto screen and test potentially exposedpersons in the TB cluster investigationof the homeless population inJacksonville.

The BPHLEnvironmentalChemistry sectionstarted work on ajoint project withthe BPHL ChemicalThreat section toperform theanalysis to test forarsenic in urineand water samples.

The project is being funded by theEnvironmental Public Health Tracking(EPHT) program through a CDC grant.

patresEpi

JANUARY

JULY AUGUST SEPTEMBER O

FEBRUARY MARCH

2012 BPHL T


Brucella suis was isolated in samplessubmitted from two separate Florida hospitalsin different regions of the state. One case wasrelated to a potentiallaboratory exposure.Brucella suis is themost commonlyreported laboratoryacquired bacterialinfection.

The bacterium Capnocytophaga canimorsus was identified froma patient. This bacteria is commonly found in cats and dogs, butrarely causes human infection. The patient had to have bothhands, both feet and part of his lip removed due to gangrenecaused by a severe infection with this organism.

The bacteriumVibrio cholerae,non-O1 serotype,was identifiedfrom a patient inthe panhandle.Vibrio choleraecauses choleraand is transmittedby contaminated food or water. Cholera isrelatively uncommon in the U.S. Thepatient had traveled to Haiti where the O1serogroup has been associated withepidemic cholera cases in Haiti since the2010 earthquake.

In response to themultistate outbreak offungal meningitisassociated withepidural paininjections, theJacksonville andPensacola labsreceived and shippedover 40 samples from

tients to the CDC for testing. The lab reportedsults from CDC back to the Bureau ofidemiology and the County Health Departments.

A foodborne outbreak in Lake City was identified followingtesting of patients and a chicken/ricedinner. Stool samples from severalpatients and the chicken samplestested positive for Salmonella Javiana.Fifteen patient isolates and two foodisolates had matching “fingerprint”patterns by Pulse Field GelElectrophoresis (PFGE).

Several Norovirus outbreaksoccurred including two whichwere confirmed by thesurveillance program, CaliciNet,as Norovirus Type GII.4 SydneyAUS. This is a new norovirusvariant that was first identifiedin Sydney, Australia and has nowbeen identified in the U.S. Theseare the first confirmed cases inFlorida.

OCTOBER NOVEMBER DECEMBER

APRIL MAY JUNE

TIMELINE

After her doctor told her he wanted to test her forTB, Anna started wondering how she could possiblyhave contracted it. Then she remembered that lastyear when her father was ill, she had returned to herhome country for several weeks to take care of him.Her father was in an open hospital ward along withmany other sick patients and Anna rememberedhearing several patients coughing. An enclosed spaceis an ideal setting for the TB germ to spread, as it istransmitted through the air when TB-infected patientscough.

Anna was directed to her local hospital to have“sputum” specimens collected. Sputum samples areneeded since the organism that causes TB,

Mycobacterium tuberculosis, is found deep in thelungs. All of her sputum specimens were negative bythe initial test for acid fast bacteria, or “AFB.” Inaddition to the sputum specimens, they performed atuberculin skin test (TST or “PPD”) which looks for areaction on the skin indicating possible exposure tothe TB organism. Anna’s skin test was positive, butsince many people vaccinated against TB (with BCGvaccine) often have a positive skin test reaction, Annareceived a chest X-ray.

The X-ray clearly showed there was somethinggoing on in Anna’s lungs. Normal X-rays should reveallungs that are completely clear; however, Anna’s X-rayrevealed a “lesion” in one of her lungs. Based on

Multi-drug ResistantTuberculosis


—Not Just a Diseasein Foreign Countries

It started with a dry cough, weight loss and a general feelingof tiredness. So when Anna* went for her annual physicalexam, she thought she had better mention it to her doctor.The doctor knew that anyone with these symptoms couldpossibly have tuberculosis (TB). But when Anna told himshe was originally from a former Soviet country in Eastern

Europe, her doctor knew the risk was even greater. In Anna’shome country there has been a resurgence of TB since thecollapse of the Soviet Union. In fact, her country has one of thehighest rates of TB in Europe and the number of cases isincreasing at an alarming rate.

Staff in the TB laboratorystand next to a new piece of

instrumentation which isused for a molecular test

for TB and will reduceworkload for staff andstandardize our current

procedure.

*Patient name changed

Anna’s symptoms, the X-ray, and herrisk factors, her doctor decided thatshe probably had TB; however, he stillneeded definite laboratoryconfirmation. A specimen from theactual lesion on her lung wasobtained by a “fine needle aspirate”and immediately sent to the Bureauof Public Health Laboratories (BPHL)in Jacksonville for analysis.

BPHL laboratory technologistsdetected mycobacteria on the AFBsmear. Next, they inoculated thespecimen onto culture media to growthe organism so that additional testscould be performed. Simultaneously,they also performed a rapidmolecular test directly on thespecimen. This very specific andsensitive test is able to detect themycobacteria that cause TB within afew hours. In Anna’s case, the rapidtest was positive and the doctor wasalerted immediately. The followingday Anna was given four differentdrugs to start fighting her TBinfection.

But this does not complete all thetesting required to confirm thepresence of the TB organism; it ismerely the start! When the rapid testis positive, another molecular test isautomatically performed to look atwhether there are any markers forresistance to two of the mostcommonly used “first-line drugs,”rifampin and isoniazid.

This test takes a few days to runbut is much quicker than waiting forthe mycobacteria to grow on theculture. The test came back withfrightening results: Anna’s TB wasresistant to the first-line drugs, acondition known as multi-drugresistant tuberculosis (MDR-TB).

Within five days of receiving thespecimen the BPHL lab had a)identified mycobacteria in thespecimen, b) confirmed it as beingMycobacterium tuberculosis, thecausative agent of TB, and c)detected resistance to two of themost important drugs for treatment,rifampin and isoniazid. An immediate

call to the doctor meant that Anna’sdrugs could be changed, becausetwo of the four drugs she was takingwere not going to be effective. It wasmore than four weeks later, after thecultures grew out, that the organismwas determined to be resistant toseveral drugs, indicating that herdrug regimen needed to be carefullymonitored.

Although an MDR-TB diagnosis isserious, it is a treatable disease e.Anna will need a total of 19 monthsof drug therapy to completely cureher TB. The good news is thateveryone worked together to ensurethe right steps were taken at theright time. From the hospital, to theTB Physicians’ Network, to the FloridaDepartment of Health TB ControlSection, to the Bureau of PublicHealth Laboratory’s MycobacteriologySection, good communication waskey. Timely and accurate diagnosisand drug susceptibility testing for TBwas an essential component in thiseffort and meant that Anna’s doctorwas able to administer the correctmedication as soon as possible.Florida is one of the few states in thecountry that performs molecularscreening for drug resistance on allfirst-time patients that are positivefor TB. The conventional method is toculture the organism and then testagainst various drugs but this takesseveral weeks. The molecular testmeant that the doctor knew the TBwas resistant to two drugs very earlyon. This not only contributed to agood outcome for the patient, it alsodecreased the risk of spread of herdrug-resistant strain of TB to otherpeople.

Chest CT of TB patientshowing right upper lung

mass with cavitation.

Learn more about tuberculosis: www.cdc.gov/tb/publications/factsheets/statistics/TBTrends.htm

The state of Florida reportsthe 4th highest number oftuberculosis cases amongU.S. states.The BPHL mycobacteriologysection performsapproximately 30,000 TBtests a year.In 2012 the state reportedsix new MDR-TB cases.The mycobacteriologysection performs tests toidentify a wide range ofdisease causingmycobacteria in addition toTB.



While the majority of incidents leading to therequest for rabies testing do not involve dramaticanimal attacks or exotic pets, these examplesunderscore the ongoing need for timely and accuratelaboratory reporting that allows clinicians and otherpublic health partner agencies to carry out their ownrelated responsibilities.

Rabies is a viral zoonotic disease with worldwidedistribution. Though less common in the United States,the particularly lethal nature of this neurologic infectionmakes diagnosis and monitoring of rabies a priority ofthe Centers for Disease Control and Prevention (CDC)as well as the Florida Department of Health. Newsheadlines such as “Rabid Raccoon Attack PromptsNew Rabies Alert In Suwannee County” and “Expertswarn Brevard: Rabies out there, be wary of wildanimals” demonstrate the level of media awareness

and attention focused toward prevention of thisdisease in both humans and animals throughoutFlorida.BPHL performs all of the rabies testing for the state ofFlorida. In 2012, the BPHL tested 2,168 domestic andwild animals for rabies. Most requests for rabiestesting followed an exposure of humans and domesticanimals to the rabies virus via bites and scratchesfrom suspect

Raccoons, Bats and Cats. . .

Oh,My!

A man was helping his neighbor repair a car

and startled a fox that was hiding beneath it.

In broad daylight the usually timid and nocturnalcreature chased and attacked the man, biting himmultiple times. The incident was investigated bythe local county health department, post-exposureprophylaxis to the bite victim was initiated andthe animal’s brain was forwarded to the Bureau ofPublic Health Laboratories (BPHL) where it testedpositive for the rabies virus. In light of thepositive test results, treatment of the victim forrabies exposure was continued and a publichealth warning was issued for the local areawhere the attack occurred. In another incidentduring 2012, a pet monkey, housedoutdoors, viciously attacked and bit itsowner. The monkey’s aggressivebehavior and potential exposure to wildlife(raccoons, bats, etc.) led authorities to suspectrabies. This animal, also forwarded to BPHL,tested negative for rabies averting the need forfurther treatment of the victim.

animals. Following recent historical trends, the majority of positive results occurredamong the wildlife rabies vector species, most notably raccoons, foxes and bats.Distribution of the virus is statewide.

Dogs and cats account for the majority of animals tested. Generally regarded aspets, these animals often have close contact with wildlife and people;both are factors leading to an increased risk of rabies transmission tohumans. Cats also make up a significant proportion of the “positives”since a significant population of feral cats can be found statewide.

Though the proportion of positive tests is low, each exposurerepresents a true emergency since untreated rabies is virtuallyalways fatal to the victim. While the vast majority of suspect animalstest negative for rabies, the value of these results must not beoverlooked. Given the lack of reliable ante mortem test proceduresfor rabies, bite victims cannot be accurately tested for true exposureto or infection by rabies virus. Negative animal test results offer theonly viable diagnostic indicator that a bite victim has not beenexposed to the virus. Negative results help to guide treatment,reduce healthcare costs and prevent further discomfort to thevictim.

The BPHL values its role and responsibilities as a partner in theintegrated efforts of state, county and community agencies to thecontrol this potentially fatal disease. While domestic animalscontinue to fight with raccoons, feral cats continue to thrive, andchildren find fascination with dead bats, BPHL will remain available24/7 as the sole provider of rabies diagnostic testing withinFlorida.


Karen Chaires of the BPHL Jacksonville virology department displays acommon Florida species, the Northern Yellow bat (Lasiurus intermedius)prior to testing for rabies infection.

Though the proportion of positive tests is low, eachexposure represents a true emergency since untreated rabiesis virtually always fatal to the victim.


The legislature expanded the scope of theprogram in 1986 to cover domestic wastewatertesting conducted under the Clean Water Act aswell as certification for other types ofenvironmental testing. Early on, the Floridaprogram took an active role in establishing theNational Environmental Laboratory AccreditationConference (NELAC) and Program (NELAP),becoming one of the first of 13 AccreditationBodies in the U.S. recognized under the programin 1999. Today the Environmental LaboratoryCertification Program continues to be active in thedevelopment and adoption of national consensusaccreditation standards through the work of TheNELAC Institute (TNI). Applying these qualitystandards, the Environmental LaboratoryCertification Program certifies laboratories to usechemical and biological techniques in testing awide variety of matrices, including drinking water,non-potable water, solid and chemical materials,biological tissue, and air. Through periodicproficiency testing and on-site assessments,certified laboratories must demonstrate that theyhave the capability to produce high quality testingresults in the interests of protecting the healthand environment of Florida’s citizens.

Out-of-State Laboratory Certifications

Other

Research

Federal

State

Water and Wastewater

Commercial

Ensuring the Qualityof EnvironmentalLaboratory Testing

In-State Laboratory CertificationsOther

Reseacrh

Federal

University

County Health Department

State

Water and Wastewater

Commercial

The Environmental Laboratory

Certification Program was established in

1979 to ensure laboratory quality and

capacity to perform testing of drinking

water regulated under the Florida Safe

Drinking Water Act.


Samples by Customer Type

Juvenile Detention

Other

Hospital

Jail

Non-CHD Clinics

County Health Department

Samples in Thousands

Laboratory Samples

0 100 200 300 400 500 600

Virology

EnvironmentalBacteriology

Microbiology

TB

Sentinel Chickens

HIV

NewbornScreening

Serology

BPHL by the NumbersThe BPHL tested over 1,000,000 samplesin 2012 with the majority submitted bycounty health departments.

TRAINING TYPETOTAL

NUMBER OFPARTICIPANTS

County HealthDepartment Staff 23

EIS Program (DOH) 10

Emerging Infectious DiseaseFellows (APHL) 2

First Responder—Response toSuspicious Samples 701

High School Students 12

“HIV 101” HIV Training forHealthcare Personnel 200

Infectious Disease Fellows(Shands) 2

International Visitors/Residents10

Turkey, Ukraine,Mexico,

Costa Rica

Med Tech Students 5

Packaging and Shipping ofInfectious Agents 505

Sentinel Laboratory BiologicalDefense 83

Teleconferences/Webinars for DOHStaff (CEUs)

132Programs notparticipants

Undergraduate/Graduate/Medical Students

52UNF, FSCJ, USF, FIU,

UM

Note: Less than 1% of testing was submitted by Reference Laboratories;Physicians; Public Health Laboratories; Community Based Health Centers;School Based Wellness Centers; Prisons; Law Enforcement; and HazMat.

National Meetings& Presentations

In 2012, staff from theBureau of Public HealthLaboratories attendednational meetings andpresented their work by

giving talks or presenting posters.More than 20 staff attendednational/ international meetingsand over 10 presentations weregiven to these national andinternational audiences.

MEETINGS INCLUDED:

Forum on Laboratory Accreditation ofThe National EnvironmentalLaboratory Accreditation Conference(NELAC) Institute (TNI)

Public Health Preparedness Summit

American Society for Microbiology(ASM) General Meeting

Clinical Virology Symposium

Association of Public HealthLaboratories (APHL) Annual Meeting

International AIDS Conference

Interscience Conference onAntimicrobial Agents andChemotherapy (ICAAC)

Laboratory Response NetworkNational Meeting

Newborn Screening EmergencyPlanning Meeting

National Bio-monitoring Meeting

HIV Diagnostics Conference

REGIONAL & STATE

MEETINGS INCLUDED:

First Coast Infectious Disease/ClinicalMicrobiology Annual Conference

Florida Public Health AssociationAnnual Meeting


ASSOCIATION OF PUBLIC HEALTH LABORATORIES:

nInformatics CommitteenPublic Health Preparedness and Response CommitteenWorkforce Development CommitteenInfectious Diseases CommitteenHIV Sub-committee

AMERICAN SOCIETY FOR MICROBIOLOGY:

n Committee on Post-doctoral Education Programs

COMMITTEESBPHL staff provides important input on several committees.

Work Published inNational Scientific Journalsand Publications in 2012DePasquale JM, Freeman K, Amin MM, Park S, Rivers S, Hopkins R, CannonMJ, Dy B, Dollard SC: Efficient linking of birth certificate and newbornscreening databases for laboratory investigation of congenitalcytomegalovirus infection and preterm birth: Florida, 2008. Maternal ChildHealth J. 2012 16:486–94.

Samuel V, Benjamin C, Renwick O, Hilliard A, Arnwine S, Spike D, Zabala J,McConnell K, Salfinger M, Mitruka K, Gardner T, Johns E, Luo R, Beau deRochars M, Dantes R: Tuberculosis cluster associated with homelessness—Duval County, Florida, 2004–2012. Morbidity Mortality Weekly Report July 20,2012/Vol. 61(28):539–540

Somoskovi A, Parsons LM, Gutierrez C, Lee E, Salfinger M: Line probe andautomated real-time PCR TB assays warrant adherence to strict qualityassurance measures. Int J Tuberc Lung Dis 16:705–706 (2012).

Patel P, Bennett B, Sullivan T, Parker M, Heffelfinger J, Sullivan P: Rapid HIVScreening—Missed Opportunities for HIV Diagnosis and Prevention. J ClinVirol 51:42–47 (2012).

Samuel V, Benjamin C, Renwick O, Hilliard A, Arnwine S, Spike D, Zabala J,McConnell K, Salfinger M, Mitruka K, Gardner T, Johns E, Luo R, Beau deRochars M, Dantes R: Tuberculosis cluster associated with homelessness—Duval County, Florida, 2004–2012. Morbidity Mortality Weekly Report July 20,2012/Vol. 61(28):539-540

Tatavarthy A, Sanderson R, Peak K, Scilabro G, Davenhill P, Cannons A, AmusoP: Molecular Typing and Resistance Analysis of Travel-Associated Salmonellaenterica Serotype Typhi. J Clin Microbiol 50:2631–8 (2012).

Marquardt G, Currier R, McHugh DM, Gavrilov D, Magera MJ, Matern D,Oglesbee D, Raymond K, Rinaldo P, Smith EH, Tortorelli S, Turgeon CT, Lorey F,Wilcken B, Wiley V, Greed LC, Lewis B, Boemer F, Schoos R, Marie S, VincentMF, Sica YC, Domingos MT, Al-Thihli K, Sinclair G, Al-Dirbashi OY, Chakraborty P,Dymerski M, Porter C, Manning A, Seashore MR, Quesada J, Reuben A,Chrastina P, Hornik P, Atef Mandour I, Atty Sharaf SA, Bodamer O, Dy B, Torres Jand 89 co-authors: Enhanced interpretation of newborn screening resultswithout analyte cutoff values. Genet Med 14:648–55 (2012).

THANK YOU FORYOUR SERVICE!

The Bureau of Public HealthLaboratories is staffed by ateam of highly qualified and

dedicated individuals. In 2012, severallong term staff retired and we thankthem for their many years of serviceprotecting the health of Florida’sresidents and visitors.

40Dr. Lillian Stark, Tampa

37Dr. Dean Willis, Jacksonville

37Dr. Phil Amuso, Tampa

34Annette White, Pensacola

33Hilda Moore, Jacksonville

24Aurora Garcia, Miami

24Susan Dean, Jacksonville

21Dr. Jack Perman, Tampa

21Beverly Butler, Pensacola

20Sarah Terry, Jacksonville

19Justina Rosario, Jacksonville

Forty years of dedication to the Bureauof Public Health Laboratories. Dr. LillianStark worked within the Florida Public HealthLaboratory System for 40 years. She began hercareer in Florida at the Epidemiology ResearchCenter (ERC) as a laboratory technician in viralserology in June 1972 and continued when ERCmerged with BPHL-Tampa in 1992. Over the years,she advanced through the ranks and at the timeof her retirement she was the Director of theVirology Section of BPHL-Tampa. In addition to herrole as the Director of the Virology section, Dr.Stark also served as the lead virologist for theentire BPHL and worked closely with the Bureauof Epidemiology. She is also an Adjunct Faculty at the University of South Florida,College of Public Health in the Department of Global Health.

Associate Bureau Chief Retires. Dr. Philip Amusoretired after 37 years in the Public Health Laboratory System.He initially worked at the Epidemiology Research Center inTampa then moved to the Tampa BPHL. Dr. Amuso becameLaboratory Director in 2000 and then BPHL Associate BureauChief. Dr. Amuso oversaw the bureau-wide staff responsiblefor laboratory safety, human resources, finances, informationtechnology, and preparedness. He was the BPHLpreparedness liaison for the Florida DOH and a Co-PrincipalInvestigator for a Department of Defense funded biological

defense contract along with the University of South Florida (USF). Dr. Amusoprovided invaluable contributions and received several state and national awards;the Award of Excellence as a Laboratory Director (2010), presented by U.S.Department of Homeland Security; and the Gold Standard for Public HealthLaboratory Excellence Award (2005), presented by APHL.

Farewell to the chief. In 2012, the BPHLalso said goodbye to the Bureau Chief, Dr.Max Salfinger. Dr. Salfinger joined BPHL inDecember 2006 and during his 5 ½ yearswith the Bureau provided great leadership,advocacy and direction to the laboratories.Dr. Salfinger has moved to National JewishHealth in Denver where he is the LaboratoryDirector of the Mycobacteriology andPharmacokinetics Laboratory.


Stark

Amuso

Salfinger

Laboratory Response Network On October 10, 2012,Florida Department of Health, Division of EmergencyPreparedness and Community Support, Bureau of Public HealthLaboratories Chemical Threat Preparedness Program receivedthe “Outstanding Outreach to Poison Control Centers or Hospitals”award. The Outstanding Outreach award is given to a group that hasbeen involved in sustained outreach to Poison Control Centers and/orHospitals, by pursuing training opportunities and striving to makeongoing improvements to training and exercise programs. Theseoutreach efforts help strengthen the public health infrastructure.

2012 ASTHO Vision Award—Achieving Excellencein Public Health Through Innovation Florida Departmentof Health received First Place for its MDR TB Screening Program.

Since July 2009, BPHL—Jacksonville has performed a molecularrapid test (Hain) automatically on all initial sputum AFB smear

and nucleic acid amplification test positive specimens (i.e., highlyinfectious patients). By conventional methods, drug susceptibilityresults are available within 4-to-8 weeks. The early detection ofmultidrug-resistant tuberculosis (MDR TB) cases allows for patients tobe placed on appropriate anti-TB therapy much sooner and results incost savings for the public health system in Florida.

awards

Bureau of Public HealthLaboratories—Miami(305) 324-2432

Bureau of Public HealthLaboratories—Tampa(813) 974-8000

FloridaHealth.gov

Bureau of Public HealthLaboratories—Pensacola(850) 595-8895

Bureau of Public HealthLaboratories—Jacksonville(904) 791-1500

Florida Bureau of Public Health Laboratories 2012 Annual Report

Documents

Transcript of Florida Bureau of Public Health Laboratories 2012 Annual Report