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Labs ramp up for Ebola patients, specimens

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Karen Lusky

Amid Ebola preparation, an EV-D68 outbreak

December 2014—Clinical laboratories have made impressive headway in their Ebola preparedness, though their plans are shaping up in different ways. That’s due, in part, to varying opinions about how to manage a dangerous and unpredictable virus.

“We are really learning as we go along with this,” says D. Jane Hata, PhD, D(ABMM), director of microbiology and serology at Mayo Clinic in Jacksonville, Fla. For years there has been talk of the possibility of an airplane passenger bringing Ebola into the U.S., she says. “But we are on the ground now and we’re all actively planning to deal with this.”

Above all, says Cleveland Clinic’s Gary W. Procop, MD, MS, institutions need a procedure to determine if a patient meets the Centers for Disease Control and Prevention’s criteria for a person under investigation (PUI) for Ebola. Two experienced physicians, one of whom should have infectious diseases training, should make that assessment, says Dr. Procop, an infectious disease pathologist and microbiologist and chair of the CAP’s Microbiology Resource Committee. (The CDC describes the PUI criteria at www.cdc.gov/vhf/ebola/hcp/case-definition.html.)

Dr. Procop

Dr. Procop

This type of approach, Dr. Procop says, weeds out the worried well, ensuring that only those truly at risk receive testing and care in a situation requiring heightened safety measures. “Once the person has been appropriately identified as a PUI, then the designated health care provider would obtain the appropriate specimens for necessary testing after, of course, they have donned their personal protective equipment.”

As for how labs are handling diagnostic testing for suspected Ebola patients, Kaiser Permanente’s Susan Novak, PhD, D(ABMM), says many are moving to point-of-care testing to mitigate exposure to Ebola in the laboratory setting.

“Clinical laboratories are at a disadvantage since we haven’t really worked with specimens positive for this virus before,” says Dr. Novak, director of microbiology at Kaiser Permanente Regional Reference Laboratories in Southern California. “So testing specimens in the open clinical laboratory environment has caused some concern within the microbiology community. Ebola isn’t known to be transmitted via aerosols, but most clinical laboratories are hesitant to place specimens on analyzers within the open lab space.”

Bourgeault

Bourgeault

A survey of the laboratories that are members of the Compass Group, which includes 28 health care systems and more than 350 hospitals, found that only four of 17 respondents say they will allow suspected or confirmed Ebola virus disease specimens into their labs, says Robert Bourgeault, MS, MLS(ASCP), director of laboratory operations at Baystate Health in Springfield, Mass., and a member of the board of directors of the Compass Group.

One of those four will restrict testing to a biosafety level 3 isolation room and use handheld point-of-care analyzers, Bourgeault tells CAP TODAY. Another respondent will start with laboratory-based testing and then move to point-of-care over time. “A third respondent plans to discourage sending specimens to the laboratory but will remain open to requests from clinicians on a case-by-case basis,” he says. Bourgeault presented all of the survey’s findings in a recent Compass Group webinar.

Dr. Campbell

Dr. Campbell

Sheldon Campbell, MD, PhD, associate professor of pathology at Yale University, is uneasy about the clinical impact of “stringent point-of-care only protocols,” which he agrees are being implemented widely. The problem, he says, “is that the Emory [point-of-care] laboratory was set up to manage a patient who came in with a diagnosis of Ebola and most of us aren’t going to be doing that. We are going to be managing the patient who has risk factors for Ebola and a fever, and a differential diagnosis includes a dozen things other than Ebola.” Malaria, for example. “In Liberia last year, there were 1.2 to 1.6 million cases of malaria, so that’s high on everybody’s list,” he says.

Dr. Hata

Dr. Hata

Mayo Clinic’s Dr. Hata agrees it’s a dilemma that’s generating much discussion. “I think everyone has to come up with a solution that works for their institution and the levels of containment they can realistically achieve at the patient site and in the laboratory.”

In Chicago’s northern suburbs, NorthShore University HealthSystem plans to perform all laboratory testing for potential Ebola patients in its biosafety level 3 microbiology laboratory. It will do blood cultures and a malaria smear, a basic metabolic group, and a peripheral smear for a white count and platelet assessment, says Richard B. Thomson Jr., PhD, D(ABMM), division head of clinical laboratories.

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