Public Health Wales Microbiology Cardiff Quality Status: Controlled for Wales Centre for Mycobacteria
Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria User Manual Document and Version: WCMQMS 035.5 Author: M Ruddy Authorised by: P James Date authorised: 8 May 2012 Publication/ Distribution: NHS Wales (Intranet) Public (Internet) Review Date: 8 May 2014 Purpose and Summary of Document: To provide information on the Wales Centre for Mycobacteria (WCM), services offered by the WCM and guidance on requesting these services. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 1 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Document amendments Document amendments by completing the following table. Date Section Page Version Description No No No 15/12/09 2 2 Removal “collation/assistance” insertion “Cellular interferon…” Insert „in conjunction with NPHS Microbiology Swansea‟ 15/12/09 4 2 Replace Alan Paull with Paula Brookes 15/12/09 4 2 Removed Paul Ellis and Debbie Charles 15/12/09 6.2.2 (ii) 2 Insert reference to Mtb complex being speciated by phenotypic methods and NTMs as necessary 15/12/09 6.2.5 2 Change NMRL London to NPHS Swansea Insert „£40‟ 15/12/09 Appendix 2 Replaced HPA NMRL forms with F NPHS Wales forms 15/12/09 6.2.1 2 9am Tuesday changed to midday tuesday 15/12/09 6.2.1 2 Addition of Negative results for these specimens do not exclude M. tb complex infection 15/12/09 6.2.2 (i) 2 Molecular identification changed to „identification by Geneprobe‟ 15/12/09 6.2.2 (ii) 2 „for these few isolates.‟ added 15/12/09 6.2.4 2 17regions (loci) changed to 15 15/12/09 2 15/12/09 2 15/12/09 Title page 2 15/12/09 3.0 2 all the M. tuberculosis complex strains for molecular typing identification and sensitivity testing of Mycobacterium tuberculosis complex isolates Removal of “world TB day” and change document number (also in footer) Removal “HAYS” 15/12/09 6.2.1 2 Removal of text: “the Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 2 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication sensitivity …. Individual basis” 15/12/09 6.2.3 2 15/12/09 6.2.4 2 15/12/09 6.2.5 2 02/02/12 All 02/02/12 02/02/12 02/02/12 02/02/12 02/02/12 02/02/12 04/02/12 08/05/12 08/05/12 All 3 Removal “Dr Ian Campbell” insertion “lead Consultant….” Insertion of “extra MIRU loci or..” Insertion of “the original ELIpsot assay..” “..an enhanced version has been developed…” Delete section “until Oct 2007..kits to them” Insert “WCM has introduced QFT-G…” Delete “to cover ….are discarded/lost” Delete “NMRL” insert “NPHS Swansea” Delete “£35” insert “£40” Delete “introduction of….. accommodate this” Update to new format. Change MOTT to NTM. Change MRU to NMRL. Addition of images. Addition support to R&D 2 3 4 3 6.2.4 3 6.2.5 3 7 3 Additions to WCM staff members Details of change from 15 loci to 24 loci. Updates to CDC & NICE guidance 2010/11 Additions to references 1 and 6 3 Addition of images Metadata 4 Published to correct category. No change to text. Addition of test turnaround times. Format change to QuantiFERON® form 6 8 5 Appendix F 32 5 Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 3 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Contents 1 INTRODUCTION ...................................................................... 5 2 SUMMARY OF SERVICES (JULY 2011) ..................................... 6 3 ADDRESS: ............................................................................... 6 4 WCM STAFF MEMBERS: ........................................................... 6 5 WCM CONTACT DETAILS ......................................................... 7 5.1 Contact Numbers: ................................................................. 7 5.2 Communications Algorithm: ................................................... 8 6 SERVICES AVAILABLE: ............................................................ 8 6.1 Turnaround times for Wales Centre for Mycobacteria ................. 8 6.2 Primary Cultures for mycobacteria: ......................................... 9 6.3 Reference services: .............................................................. 10 6.3.1 Direct molecular detection of MTBC on primary specimens .............................................................................. 10 6.3.2 Identification of mycobacteria: .................................. 11 6.3.3 Sensitivity testing: ..................................................... 12 6.3.4 Typing of Mycobacterium tuberculosis isolates: ......... 13 6.3.5 Gamma- Interferon assays: ....................................... 17 7 SELECTED REFERENCES: ....................................................... 20 8 APPENDIX A ......................................................................... 23 9 APPENDIX B ......................................................................... 24 10 APPENDIX C.......................................................................... 25 11 APPENDIX D: NTM (NON TUBERCULOSIS MYCOBACTERIA) .. 26 12 APPENDIX E: MICROBIOLOGICALMYCOBACTERIAL ENQUIRIES: ............................................................................................. 28 13 APPENDIX F: WCM EXAMPLE FORMS..................................... 29 Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 4 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Wales Centre for Mycobacteria (WCM) Llandough Hospital ~1933 (courtesy Cardiff University) 1 Introduction The WCM functions as the National Reference Laboratory for mycobacteria for Wales and also as the regional mycobacterium reference unit for the South West of England, along with providing a service to various other users in England, the Channel Islands, Isle of Man, Ireland and veterinary practices. A mycobacterial reference laboratory has been located in Cardiff since at least the early 1950s. From 1959 the laboratory was managed by the Public Health Laboratory and was the UK reference unit until 1996 when it became part of the PHLS network of regional reference laboratories. The PHLS network was dissolved in April 2003 and since then the management of the unit has transferred to the National Public Health Service Wales now Public Health Wales. The other regional mycobacterial laboratories and the UK National Mycobacterium Reference Laboratory (NMRL), London are now managed by the Health Protection Agency in England, however we continue to work closely within this network and provide services to the South West of England as well as Wales. There are three principal mechanisms for reporting on the work of the laboratory: through the Public Health Wales Microbiology Laboratory network as part of Microbiology Cardiff through the Public Health Wales Respiratory Disease Programme via the Public Health Wales TB Programme Group and Public Health Wales CDSC Wales through established UK mycobacterial structures to the Department of Health (e.g. via the HPA, with the HPA NMRL in London as the lead UK mycobacterial reference centre and the HPA Centre for Infection, Respiratory Division Colindale) Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 5 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 2 Quality Status: Controlled for Internet Publication Summary of Services (July 2011) Processing of primary specimens for mycobacterial culture Direct molecular detection of Mycobacterium tuberculosis complex available on primary specimens. Detection of mycobacteria from clinical specimens (direct microscopic and molecular methods) Isolation of mycobacteria (liquid and solid culture; plus culture storage) Identification of Mycobacteria sp. (both initial rapid molecular and conventional phenotypic identification) Primary sensitivity testing Molecular strain typing and epidemiological surveillance of M. tuberculosis (support to Public Health outbreak and control management) using VNTR / MIRU technology Cellular interferon gamma release assays (CIGRA) in conjunction with Public Health Wales Microbiology Swansea Clinical advice for case and outbreak investigation and management. Technical laboratory advice. Support to Research and Development into mycobacterial disease in Wales. 3 Address: Wales Centre for Mycobacteria Microbiology Cardiff Public Health Wales Llandough Hospital, Penlan Road, Penarth CF64 2XX DX Address: 4 Telephone Number: 029 2071 6408 Secretary: 029 2071 5298 Wales Centre for Mycobacteria Cardiff Public Health Wales (Llandough) DX 6070400 Penarth 90 CF WCM Staff Members: Dr. Michael Ruddy Consultant Microbiologist, medical lead for WCM Paula Brookes Technical Head of Bacteriology Department Rhian Williams Technical Lead WCM Gwyneth Samuel BMS 2 Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 6 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Kay Parry BMS 2 Dr. Sally Corden Lead Clinical Scientist, Head of Wales Molecular Centre UHW Dr. Lewis White Lead Clinical Scientist, mycology / Mycobacteriology / Wales Molecular Centre UHW Michael Perry Clinical Scientist, bacteriology / Wales Molecular Centre UHW Rotational posts (shared with Food Water & Environmental Laboratory Public Health Wales Cardiff): David Tucker BMS 1 Lynda El-Araby BMS 1 Colin Mills MLA Plus rotational posts with Public Health Wales Microbiology Cardiff 5 WCM Contact Details 5.1 Contact Numbers: Technical enquiries TB laboratory (Llandough) 029 2071 6408 Molecular enquiries Molecular Laboratory (UHW) 029 2074 4175 Clinical enquiries Dr Michael Ruddy 029 2071 6408 Laboratory Access: The WCM Llandough laboratory is staffed 08.45 to 17.00 Monday to Friday. Out of hours clinical advice and urgent AFB microscopy can be arranged (if appropriate) via the relevant local NHS/Public Health Wales microbiology laboratory. (For Cardiff contact University Hospital of Wales switchboard 02920 747747) Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 7 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 5.2 Quality Status: Controlled for Internet Publication Communications Algorithm: Please see Appendix E 6 Services available: 6.1 Turnaround times for Wales Centre for Mycobacteria Test AFB microscopy and culture Geneprobe culture TB PCR Target Turnaround time 4-6 weeks test on positive 2 days 6 days QuantiFERON®-TB Gold InTube test (Cellestis, Australia) 7 days (QFT-G): Comments Positive microscopy phoned 24hrs. Positive culture results phoned. Positive geneprobe test for Mtb complex phoned. Once a week batch testing (Wednesday). Results available Thursday afternoon after 4pm. Results will be available by telephone after 7 days For details of specimen containers, sample processing times and reporting arrangements please refer to Public Health Wales Microbiology Cardiff User Handbook (CDQMS 035) Appendices 1-3. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 8 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 6.2 Quality Status: Controlled for Internet Publication Primary Cultures for mycobacteria: We accept the following specimens for primary mycobacterial culture: Sputum, Broncho-alveolar lavage, non-directed bronchial lavage Tissue specimens Pus Gastric aspirate Early morning urine Blood/bone marrow (please request the appropriate blood culture bottles before submitting) Fluids (pleural, CSF, joint etc) Microscopy is performed using both auramine and ZN stains. Culture is performed using liquid culture media via a MGIT (Mycobacterial Growth Indicator Tube) 960 system (Becton Dickinson) and backed up with solid culture media (Lowenstein-Jensen media). If we do not routinely perform your primary cultures, please discuss your particular requirements for primary culture with the laboratory. ZN stain auramine stain Mycobacterial Cultures Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 9 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication 6.3 Reference services: 6.3.1 Direct molecular detection of MTBC on primary specimens Initial detection of Mycobacterium species (either MTBC or NTM) on primary specimens is performed using the Seegene Anyplex MTB/NTM PCR assay. Any samples positive for MTBC are then checked for common rifampicin and isoniaizid resistance markers using the GenoType MTBDRplus system (Hain Lifescience). These systems are validated for use on smear positive respiratory specimens. However, we accept the following specimens for Direct TB PCR: Sputum Bronchio-alveolar lavage Tracheal aspirates Non-directed bronchial lavage CSF } Minimum specimen volume 500 L The value of negative results from smear negative respiratory and CSF specimens is limited. Negative results for these specimens do not exclude M. tb complex infection. Any other specimen types MUST be discussed with the laboratory and will in general be referred to the Consultant Microbiologist covering the service. PLEASE NOTE THERE IS A CHARGE FOR THIS SERVICE (Please refer to website or contact the WCM for latest charges). Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 10 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 6.3.2 Quality Status: Controlled for Internet Publication Identification of mycobacteria: Isolates may be referred to us either from liquid culture systems (please see appendix A for details of how to prepare a specimen for sending to us) or on an L-J slope. Molecular Identification: i) M. tb complex & M. avium complex (Geneprobe): Following culture or receipt of a referred mycobacterial isolate our first line of identification is the application of a DNA probe (Geneprobe). This allows identification of M.tb complex and M.avium complex. The results are telephoned to the referring laboratory. The target turnaround time for reporting identification by Geneprobe is 2 working days from receipt of a culture. ii) Non tuberculosis mycobacteria (NTM) (HAIN): For the identification of non tuberculosis mycobacteria (NTM) the GenoType Mycobacterium CM kit (Hain Lifescience) is used. This improves the turnaround time to identification compared with phenotypic methods. This kit permits the identification of the following mycobacterial species: M. avium ssp., M. chelonae/M. immunogenum, M. Abscessus/M. immunogenum, M. Fortuitum/M. mageritense, M. gordonae, M. intracellulare, M. scrofulaceum, M. interjectum, M. kansasii, M. Malmoense/M. haemophilum/M. palustre, M. peregrinum/M. alvei/M. septicum, M. marinum/M. ulcerans, M. tuberculosis and M. xenopi. However not all isolates can be satisfactorily identified by molecular methods and phenotypic systems will continue for these few isolates. Please note: using the GenoType Mycobacterium CM kit it is not possible to differentiate species that are paired together Automated geneprobe for ID of Mycobacterial species “HAIN GenoType” HAIN GenoType Mycobacterium Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 11 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Phenotypic identification: Phenotypic tests are set up on all positive cultures of M. tuberculosis complex for speciation. Phenotypic tests are also set up on NTMs when molecular results are unavailable or require confirmation. We currently use solid media phenotypic methods to identify the mycobacteria. 6.3.3 Sensitivity testing: Mycobacterium tuberculosis complex: Sensitivity testing is carried out on all first isolates of Mycobacterium tuberculosis and M.tb complex. (Routine repeat sensitivity testing is only performed on subsequent isolates from samples > three months post the original isolate). 1st line: 2nd line: Isoniazid, Ethambutol, Rifampicin, Pyrazinamide Clarithromycin, Ciprofloxacin, Streptomycin Currently sensitivity testing is carried out on solid media (using the “Absolute Concentration Method” measuring MIC on solid agar). To improve turnaround times liquid culture drug sensitivity testing systems are being validated, however solid media confirmation of resistance occurs in all instances. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 12 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication If an isolate is found to be multi-drug resistant (i.e. 2 or more of 1st line isolates testing resistant) the isolate will be referred to the HPA NMRL, London for 3rd line testing (including capreomycin, amikacin, kanamycin, moxifloxacin, ofloxacin, prothionamide) Mycobacteria other than tuberculosis (NTM): Drug sensitivity testing for NTM is not well standardised. The poor correlation between in-vitro testing and in-vivo outcomes and the possible colonisation/contamination from widespread environmental sources, necessitate caution in general testing, particularly if isolated from only a single sample. (See Appendix D). Sensitivity testing will be routinely performed for: M kansasii (if multiple respiratory isolates): -Rifampin, Ethambutol, Ciprofloxacin, Clarithromycin M marinum (any skin/soft tissue isolate): -Rifampin, Ethambutol, Ciprofloxacin, Clarithromycin MAIC (sterile sites eg blood/bone marrow): -Clarithromycin Rapid growing mycobacteria (M. fortuitum, M. chelonae, M. abscessus, M. peregrinum) (for respiratory isolates if underlying lung damage eg cystic fibrosis; for sterile sites eg blood/tissue if line associated or disseminated disease): -Clarithromycin, Ciproflxacin, Amikacin, Gentamicin, Tobramycin, Kanamycin, Cefoxitin, Imipenem, Sulphonamide, Trimethoprim, Piperacillin, Doxycycline, Linezolid, Augmentin If sensitivity testing is required outside these parameters the case should be discussed with the WCM Consultant Microbiologist. Further advice on clinical management of NTM can be obtained from the lead Consultant Chest Physician for mycobacterial disease, Llandough Hospital and the Infectious Diseases unit at University Hospital Wales. 6.3.4 Typing of Mycobacterium tuberculosis isolates: Since April 2005 all strains of Mycobacterium tuberculosis submitted to the Wales Centre for Mycobacteria have been prospectively typed using the UK wide standardised VNTR / MIRU method (Frothingham and MeekerO‟Connell, 1998 and Supply et al., 2001) agreed by the HPA DAME group. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 13 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication This molecular typing method initially involved analysis of 15 regions (loci) of the TB genome using PCR amplification looking for repeat gene sequences. The amplification products are further analysed using a Beckman-Coulter sequencer. As two of the ETR loci overlap with the two of 12 MIRU loci a final 17-digit number was reported as a 5-plus 12 digit code incorporating the 5 digit “ETR” code followed by a 12 digit “VNTRMIRU” code. for each M. tuberculosis strain. The number generated reflects the number of gene sequence repeats at each locus. Since April 2011 in line with UK HPA DAME group recommendations 9 extra loci have been added. The 24 loci now reported (5 “ETR” + 10 original UK VNTRMIRU + 9 extra MIRU) help minimise false clustering and enable international standardisation. Previous 15 loci reports can be compared to the new 24 loci and if indicated further loci on previous isolates can be assessed as all DNA is kept indefinitely. When isolates of Mycobacterium sp. are submitted identification and sensitivity testing is performed with submission of all the M. tuberculosis complex strains for molecular typing. Our M. tuberculosis reports now include confirmation of the strain identification, the results of sensitivity testing and a 24-digit typing code. As the WCM database of TB typing results builds up, BioNumerics software will be used to build up a dendrogram showing the relationship of all TB isolates. It is intended that these dendrograms will be routinely available to Health Protection Teams in due course. On occasions the typing results will throw up similar isolates, which will be highlighted to the relevant microbiologists / Health Protection Teams for further investigation of any epidemiological links. The strain type results will also be entered into a UK wide database to further enhance TB control. Investigation of possible outbreaks of TB: It remains important, however, that if you suspect an outbreak of TB or a cross-infection incident in your laboratory that you inform us which patient strains are implicated so that we can prioritise the typing of these isolates as an “outbreak / cross-infection” investigation. The typing service will run alongside the routine identification and sensitivity testing of Mycobacterium tuberculosis complex isolates. Turnaround times of final reports for identification and sensitivities are not affected by the addition of the typing service. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 14 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication VNTR (variable number tandem repeats) – The Principle TAAGGGCCA (X1) Strain 1: Strain 2: 2 TAAGGGCCA (X2) 4 3 1 3 ETR–A ETR-B TAAGGGCCA (X3) 8 3 1 4 ETR-C ETR-D 4 ETR-E Digital Code for Strains generated by ETR – VNTR Strain 1 1 3 2 2 3 Strain 2 3 3 2 3 3 Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 15 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Typical MIRU VNTR results 4 3 0 7 A .B 1 1 _ 0 5 0 7 0 5 1 4 A 8 4 3 0 7 b .B 1 2 _ 0 5 0 7 0 5 1 5 M I 70 000 35000 60 000 4","5 MIRU 30000 26","2 MIRU 2","2 MIRU 50 000 39","3 MIRU 25000 27","3 MIRU 20","2 MIRU 40 000 20000 24","2 MIRU 30 000 15000 16","3 MIRU 20 000 10","4 MIRU 10000 40","3 MIRU 31","5 MIRU 10 000 23","10 MIRU 5000 0 100 200 300 400 500 600 700 Size (nt) 0 Dye Signal Dye Signal 0 0 50 10 0 15 0 20 0 25 0 30 0 35 0 40 0 S ize (n t) 45 0 50 0 55 0 60 0 65 0 70 0 WCM 24 Loci TB Typing Report A B C D 31 2 10 16 20 23 24 26 27 39 40 Sample 42 19 21 23 24 31 36 40 41 4 55 63 47 01 71 90 52 56 1 8 5 2 1 5 2 4 3 2 6 2 2 3 1 3 2 10 6 3 2 3 6 4 1 2 4 2 2 3 5 2 6 4 2 5 1 5 3 3 4 3 4 2 4 2 3 3 - 8 3 4 2 2 3 5 2 5 4 2 5 1 7 3 3 3 4 4 2 4 2 3 2 5 - 4 8 4 4 4 5 2 4 2 2 6 2 2 3 1 3 2 11 2 3 2 3 2 7 1 5 4 2 2 3 5 2 6 3 2 5 1 7 3 3 3 4 4 2 4 2 3 3 - - 6 3 2 3 3 2 2 3 3 2 5 1 5 3 2 4 4 3 3 4 4 3 3 - 3 7 4 2 2 3 5 2 5 4 2 5 1 5 3 3 3 3 4 2 4 2 3 3 6 3 8 3 2 4 3 3 2 3 3 2 6 1 5 3 2 3 2 4 2 4 4 3 3 4 3 Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 16 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 6.3.5 Quality Status: Controlled for Internet Publication Gamma- Interferon assays: Background: Blood based commercial tests have been developed to aid the diagnosis of infection with Mycobacterium tuberculosis (based on the release of interferon-gamma from peripheral blood monocytes in patient blood samples, by specifically testing the response to exposure to antigens found in the Mycobacterium tuberculosis complex). They have several distinct benefits compared to traditional tuberculin skin testing (TST): The antigens used (e.g. ESAT-6, CFP-10, TB7.7(p4)) are absent from the vaccine-strain BCG and hence unlike TST these tests are not influenced by prior BCG vaccination. In addition to being absent from all BCG strains the antigens used are also absent from most mycobacteria other than tuberculosis (NTM) (with the exception of M. kansasii, M. marinum and M. szulgai) enabling the tests to help distinguish positive TST reactions due to exposure to NTM. Because interferon-gamma tests require single blood sampling, patients do not need to return for a second visit for test reading as is required for TST (where failure to return within 72 hours requires repeat testing). Current systems: Two main systems have been developed, one ELISA based measuring interferon-gamma release in whole blood on exposure to the antigens (QuantiFERON®-TB Gold In-Tube test, Cellestis, Australia) (QFT-G) the other using the enzyme-linked immunospot principle involves counting of individual activated specific T-cells (ELISpot, T-Spot.TB assay, Oxford Immunotec, UK). Both methods have been shown to be sensitive and specific. Whilst it remains unclear whether one will prove more reliable in specific circumstances, there is some suggestion that the ELISpot assay may have greater sensitivity in young children and the immune-compromised. Logistically the original ELISpot assay was more challenging as blood needed to be processed within a few hours of sampling for optimal results, requiring a special courier service to transport from centres in Wales to the commercial laboratory in Oxford. An enhanced version (T-Spot.TB Xtend, Oxford Imunotec, UK) has been developed which can be performed at 24 hours allowing overnight transport (FDA approval September 2010, usage studies ongoing). The QFT-G samples can be initially incubated in the nearest local microbiology laboratory, prior to sending on to the testing laboratory by regular transport. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 17 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication National recommendations for usage: In the USA QFT-G had originally been recommended by the Center for Disease Control and Prevention (2005) for use in all circumstances in which TST is used, including as an aid for diagnosing both latent TB infection and TB disease. In 2010 this updated guidelines were produced (see reference). Within the UK the National Institute for Health and Clinical Excellence (2006) recommended that interferon-gamma testing should be considered to diagnose latent TB in patients with positive results on Mantoux testing (or in whom Mantoux testing may be less reliable, re the “Green Book” 2006) and for the six week follow up of close contacts of active TB with initial negative TST. Because the tests do not distinguish between latent infection and active disease their role in the diagnosis of active disease is more contentious, however NICE have stated they may have a utility in ruling out infection when investigating for active disease with negative cultures results (in the context of appropriate clinical/pathological/radiological investigations). In March 2010 NICE released updated guidance (CG117 Tuberculosis, 23 March 2011). The Department of Health commissioning “toolkit” for TB services (2007) concluded that there was no evidence interferon-gamma tests are cost effective in the diagnosis of active TB, however it did note their potential value in diagnosis in difficult cases (e.g. children and the immune compromised). Interferon-gamma tests have also been suggested as tools to assist in TB screening. NICE recommended they could be used instead of Mantoux for screening employees new to the NHS with no evidence of prior BCG vaccination. This has been included in the Department of Health recommendations on new healthcare worker occupational health clearance screens (2007). The potential utility of interferon-gamma testing for other screening programmes (e.g. asylum seekers, prison health) is being explored to assess if the cost benefit analysis compared to TST may be favourable. Additional screening with interferon-gamma testing has been suggested for certain patient groups prior to planned immunosuppressive therapy (e.g. anti TNF-α treatment). Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 18 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication IFNg release: rationale Andersen P et al, Lancet 2000 Current mechanisms for testing in Wales: 1) QuantiFERON®-TB Gold In-Tube test (Cellestis, Australia) (QFTG): The Wales Centre for Mycobacteria (WCM) introduced interferon-gamma testing via Public Health Wales Microbiology Swansea for laboratories in Wales, using the QFT-G system since November 2009. Stocks of kits (sampling tubes and instruction documentation) are kept at the WCM. Appropriate users in Wales (nominated TB physicians/TB nurses, consultant microbiologists, public health teams etc) requesting interferon-gamma testing should contact their local microbiology department or the WCM* for supplies of authorised kits which should then be returned via the local microbiology laboratory to Public Health Wales Microbiology Swansea as per the instructions kit (see attached sheets). It would be advised that patient sampling is only performed Monday to Wednesday (due to the distance involved the local laboratory would need to do the initial overnight incubation then arrange transport to Public Health Wales Microbiology Swansea to ensure samples arrive Monday to Friday for further processing, avoiding the weekend). Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 19 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication NB it is imperative that local teams discuss with their local microbiology laboratory in advance of testing to ensure appropriate transport and handling of samples. It is anticipated the turn around of results will be within seven working days. Unfortunately the £40 cost to the WCM needs to be re-charged to the requestor pending any future business case. *Wales Centre for Mycobacteria, Microbiology Cardiff, Llandough Hospital; Tel: 029 20716408 Email: [email protected] or [email protected] 2) ELISpot T-Spot.TB assay and TB Xtend (Oxford Immunotec, UK): This service is currently not available through NHS laboratories in Public Health Wales or the HPA but is accessible via the commercial company Oxford Immunotec. Enquiries should be made directly to: Oxford Immunotec Limited, 91 Milton Park, Abingdon, Oxon, OX14 4RY. Tel: 01235 442780 Fax: 01235 442781 Queries: For any queries concerning interferon-gamma testing in TB management (e.g. when and how to test) or for guidance with interpreting results please contact the Wales Centre for Mycobacteria: Wales Centre for Mycobacteria, Public Health Wales Microbiology Cardiff, Llandough Hospital, Penlan Road, Penarth CF64 2XX Tel: 02920 716408 Email: [email protected] or [email protected] 7 Selected references: Health Protection Agency (2006). Investigation of specimens for Mycobacterium species. National Standard Method BSOP 40 Issue 5. http://www.hpastandardmethods.org.uk/documents/bsop/pdf/bsop40dk.pdf. Public Health Wales Microbiology Services Standard Operating Procedure MSBSOP 040 Investigation of specimens for Mycobacterium species. NHS Wales intranet http://nww2.nphs.wales.nhs.uk:8080/QualityManagementDocs.nsf Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 20 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication For provisions for the transfer of infectious substances please refer to: “The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amendment) Regulations 2005” – ADR 2005. (Category A infectious substance – Packing Instruction PI 620 applies to UN Nos. 2814 & 2900; Category B infectious substance – Packing Instruction PI 650 applies to UN No. 3373) National Institute for Health and Clinical Excellence (2006). Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Clinical Guideline 33 developed by the National Collaborating Centre for Chronic Conditions. www.nice.org.uk/CG033. Replaced and updated by NICE update 2011 http://guidance.nice.org.uk/CG117 Control and prevention of tuberculosis in the United Kingdom: code of practice 2000. Joint Tuberculosis Committee of the British Thoracic Society. Thorax. 2000 Nov;55(11):887-901. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society. Thorax. 1998 Jul;53(7):536-48. Griffith DE et al. (2007) An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases. Am J Respir Crit Care Med. 175:367–416. http://www.thoracic.org/sections/publications/statements/pages/mtpi/ nontuberculous-mycobacterial-diseases.html Management of opportunist mycobacterial infections: Joint Tuberculosis Committee Guidelines 1999. Subcommittee of the Joint Tuberculosis Committee of the British Thoracic Society. Thorax. 2000 Mar;55(3):210-218. American Thoracic Society: Diagnosis and Treatment of Disease caused by Non tuberculous mycobacteria. Am. J Respir. Crit Care Med 156: S1 S25 1997. Barnard M, Albert H, Gerrit C, O‟Brien R, Bosman M. Rapid Molecular Screening for Multidrug-Resistant Tuberculosis in a High-Volume Public Health Laboratory in South Africa. Am. J Respir. Crit Care Med 177:787792; 2008 Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 21 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication P. Supply, S. lesjean, E. Evgueni, K. Kremer, D. van Soolingen and C. Locht. Automated high-throughput genotyping for study of global epidemiology of Mycobacterium tuberculosis based on mycobacterial interspersed repetitive units. Journal of Clinical Microbiology (2001), 39, 3563-3571. R. Frothingham and W.A. Meeker-O‟Connell. Genetic diversity in the Mycobacterium tuberculosis complex based on variable numbers of tandem DNA repeats. Microbiology (1998), 144, 1189-1196. Centers for Disease Control and Prevention. Updated Guidelines for Using interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection – United States 2010. MMWR 2010;59(No.RR5 1-25) Useful websites: www.iechydcyhoedduscymru.wales.nhs.uk /www.publichealthwales.org www.hpa.org.uk http://www.cdc.gov/ http://www.tbalert.org/ http://www.theunion.org/ http://www.who.int/en/ http://www.hain-lifescience.de/en/ http://www.cellestis.com/IRM/content/aust/home.html http://www.seegene.com/en Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 22 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 8 Quality Status: Controlled for Internet Publication Appendix A Preferred procedure for sampling MGIT 960 tubes for sending to WCM Remove MGIT tube from MGIT 960 without disturbing the sediment at the bottom of the tube. Film small quantity of sediment to confirm presence of Acid Fast bacilli Using a sterile pipette, remove approximately 1 ml sediment from the bottom of the tube and place in a small flat bottomed tube with an „O‟ ring in the lid. Ensure the top of the tube is secure and further secure with parafilm. Pack the vial according to the regulations governing transport of infectious material. In order to comply with the new regulations for transfer of mycobacteria you are required to notify us of cultures being forwarded. Our preferred option is that you contact us by E-mail using [email protected] Please do not send the patients name, only the initials, date of birth and your laboratory number. When the culture arrives we will then confirm receipt by returning the message. If no parcel arrives within two working days we will contact you. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 23 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 9 Quality Status: Controlled for Internet Publication Appendix B Packaging of Category III specimens for sending to WCM Specimens – clinical samples and/or microbiological cultures must be packed in a triple packaging system to 620 (602) standard as follows: The primary container must be watertight and leak-proof and may be glass, metal or plastic. Screw caps must be re-enforced with adhesive tape or parafilm. The container must be wrapped in sufficient absorbent material to absorb the contents of the container in the event of breakage or spillage. The primary container must be placed into a secondary container that is leak proof and watertight. Several wrapped primary containers may be placed in the secondary container (not exceeding 50 ml or 50g). Sufficient absorbent material must be placed between the specimens and the secondary container to prevent rattling and also to absorb any spillage or leakage. The secondary container must be placed in an outer package for shipment. Include the request forms with the secondary container and not inside the secondary container. Include the following details on the outer package: o Name and address of Sender o Name and address of receiver (see front of User Manual for WCM address) o Contents of Package o Package orientation label/ THIS SIDE UP if liquids are being sent NB Royal Mail “SafeBox” packaging system is 650 specification only and should not be used to transport Hazard Group 3 biological agents In order to comply with the new regulations for transfer of mycobacteria you are required to notify us of cultures being forwarded. Our preferred option is that you contact us by E-mail using [email protected] Please do not send the patients name, only the initials , date of birth and your laboratory number. When the culture arrives we will then confirm receipt by returning the message. If no parcel arrives within two working days we will contact you. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 24 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 10 Quality Status: Controlled for Internet Publication Appendix C Prices for external services: Please refer to the Public Health Wales website or contact the WCM for the latest updates on prices. Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 25 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 11 Quality Status: Controlled for Internet Publication Appendix D: NTM (Non Tuberculosis Mycobacteria) Mycobacterial sp. Clinical syndromes Pulmonary disease in damaged lungs M. avium M. intracellulare Lymphadenopathy in children Disseminated disease in immunocompromised. M. kansasii M. marinum M. ulcerans Pulmonary Disease in damaged lungs Extra-pulmonary disease Skin and soft tissue disease. “Fish tank granuloma” Indolent ulceration on legs Site of Isolation Respiratory Lymph node or aspirate Sterile sites (e.g. blood or bone marrow) Urine Respiratory Comment Significant if isolated from repeated specimens with appropriate clinical history. Treat according to BTS guidance 2000* Removal of node is best treatment otherwise follow BTS guidance 2000* Testing of clarithromycin susceptibility may be relevant in patients who have failed prior macrolide therapy. Significance doubtful from urine Significant if isolated from repeated specimens with appropriate clinical context. Treat according to BTS guidelines 2000* All isolates All isolates All isolates Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 26 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Mycobacterial sp. Rapid growing mycobacteria M. chelonae M. abscessus M. fortuitum M. peregrinum Quality Clinical syndromes Pulmonary disease in damaged lung e.g. CF Line associated infection Disseminated skin and tissue infection May disseminate in immunocompromised patients Status: Controlled for Internet Publication Site of Isolation Respiratory from CF or other damaged lung Blood culture isolate Comment Significance doubtful unless repeated isolation from damaged lungs e.g. in CF or bronchiectasis Sterile sites Doubtful significance unless isolated repeatedly or from sterile site. Please supply full clinical details if sensitivities required. Pulmonary infection Respiratory Significant if repeatedly isolated within relevant clinical context. Treat according to BTS guidance 2000* All may disseminate in immunocompromise All isolates Treat according to BTS guidance 2000* M. gordonae All isolates Significance doubtful Scotochromic psychrophiles All isolates Environmental mycobacteria – significance very doubtful. M. xenopi M. malmoense M. M. M. M. M. szulgai scrofulaceum celatum simiae genevense References: Joint Tuberculosis Committee Guidelines 1999: Management of opportunist mycobacterial infections Thorax 2000; 55:210-218. American Thoracic Society: Diagnosis and Treatment of Disease caused by Nontuberculous mycobacteria. Am. J Respir. Crit Care Med 156: S1 S25 1997 (see also 2007 update) Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 27 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 12 Quality Status: Controlled for Internet Publication Appendix E: MicrobiologicalMycobacterial Enquiries: Communication Algorithm for Wales Centre for Mycobacteria (WCM) Technical queries/ results enquiries re: Mycobacterial sampling Microscopy Culture Identification Drug sensitivity testing Senior technical staff WCM, Llandough Hospital: Tel: 029 20716408 Email: [email protected] Clinical enquiries or queries regarding: epidemiological investigations requests for IFN gamma testing requests for PCR and molecular resistance testing 1) WCM Consultant Medical Microbiologist (CMM) (Dr Michael Ruddy) Tel: Llandough Hospital: 029 20716408 West Wales Hospital: 01267 237271 Email: [email protected] For urgent queries: mobile: 07969 917709 Air call via Prince Philip Hospital: 01554 756567 2) if (1) above unavailable please contact Consultant Medical Microbiologist on call at University Hospital Wales (UHW): Tel: 029 20744515 Senior clinical scientist Wales Molecular Centre, University Hospital Wales: Tel: 029 20746581 Email: [email protected] Technical queries/results enquiries re: M tb strain typing PCR (molecular resistance markers) Additional expert advice on mycobacterial disease is available from: 1) microbiological mycobacterial queries: a. Dr Robin Howe CMM Microbiology Cardiff; tel 029 20744515; email [email protected] b. Dr Mark Hastings CMM/Director Public Health Wales Micro; tel 029 20744515; email [email protected] 2) Clinical queries: a. Should be addressed in the first instance to the local nominated TB physician (contact via local hospital switchboard) b. The lead Consultant Chest Physician for mycobacterial disease Llandough Hospital. 3) Public health related queries: Should be addressed in the first instance to the local Health Protection Team (contact via local authority/PHW directory) Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 28 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria 13 Quality Status: Controlled for Internet Publication APPENDIX F: WCM EXAMPLE FORMS 1) WCM specimen referral form 2) Public Health Wales QuantiFERON-TB Gold Patient Data Sheet and blood sampling instructions 3) UK MDRTB Services letter and Patient Data Sheet Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 29 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Wales Centre for Mycobacteria Microbiology Cardiff, Llandough Hospital Penlan Road, Penarth Vale of Glamorgan, CF64 2X DX: Public Health Wales Micro (Llandough)DX6070400 715134 Penarth 90 CF Tell 02920 716408 Fax: 029 20 Source Laboratory Reference Laboratory Nº _________________________ Date Received by Ref. Lab. ________________________ Specimen Details Source Lab Nº _________________________ Source Hospital _______________________________________ Specimen Date ________________________ Site of Lesion _________________________________________ Specimen Type ________________________ Microscopy + / - / not done / unknown Please Indicate Test Required: Culture Direct PCR for TB complex (please indicate below) Identification Sensitivity Detection of Mycobacterium Tuberculosis In non-processed smear-positive sputum Typing Detection of Mycobacterium Tuberculosis In CSF (minimum 0.5ml needed) If requesting the following please discuss with our Consultant Microbiologist before submitting the sample: Smear negative and other samples (please state site) _______________ Patient Details Surname _______________________________ Forename (s) _____________________________________________ Male / Female / Unknown Date of Birth/Age __________________________________________ Address ________________________________________________________ Post Code __________________________ Ethnic Origin African Caribbean Indian Pakistani Previous TB Bangladeshi Indian Subcontinent Unspecified White Mixed yes / no / unknown. Previous Anti-TB Therapy Unknown Other (please state) __________________________ Country of Origin ____________________________ If yes, when and site of previous TB ___________________________________ yes / no / unknown. Drugs used, if known ___________________ Is the culture related to a possible outbreak? If yes, when ____________________________________________ Year Arrived in UK _______________________________________ Yes No Index Case (if known) ________________________ Place of contact: ________________________________________________________________________________ Why do you think this is an outbreak? ___________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you agree to provide further information to the WCM if needed? Yes Is the culture a lab contaminant: Yes No No Is the culture a bronchoscope contaminant Yes No If yes, please give details: ____________________________________________________________________________ Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 30 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Public Health Wales QuantiFERON®-TB Gold test Patient Data Sheet I, undersigned, authorise the WCM to carry out the Quantiferon®-TB test on this sample Please print your name___________________________Department________________ Consultant/Registrar/TB.CNS Signed_______________________________ Date_______________________________ Collection information Time taken _______________ Date ______________ Laboratory information Incubation Time in____________ Date__________ Name_____________ Time out___________ Date__________ Name_____________ Sent to ___________ Date __________ Name _____________ Contact details: Name of Consultant____________________________________________________ Department__________________________________________________________ Laboratory/Hospital____________________________________________________ ____________________________________________________________________ Postal Address ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Phone_____________________________DX address________________________ FOR WCM USE Patient’s number_______________________ Date received_________________________ Time Received____________________ Date of test: _____________ Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 31 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication If the answer requires specification, please specify. Please remember that complete answers are essential for the correct interpretation of the test results Baseline epidemiological data Patient‟s Surname _________________First names____________________________ Address________________________________________________________________ ________________________________Postcode code___________________________ DoB________________ Male / Female Occupation________________________ Was the patient born in the UK? Yes No If No: Where? ________________When did the patient come to UK (year)?__________ Has patient lived in, or spent more than 2 months travelling in another country Yes No Don’t know History of BCG vaccination and TB skin tests Has patient ever received the BCG vaccination? Yes No Don’t know If “Yes”, please specify the age: Neonatal School age (13-14) Other BCG scar: Yes No Mantoux test done Yes No Don’t know Reading ________________ mm Clinical data Is patient taking any of the following medications? None Oral steroids Cytotoxic drugs Other immunosuppressive drugs (please specify)__________________ Is patient immunocompromised? Yes No Don’t know Is patient HIV positive? Yes No Don’t know R L Does the patient have diabetes? Yes No Don’t know Does the patient have any of the following: Upper (circle appropriate answer(s): Fever Night sweats Loss of weight Cough Middle Is patients CXR abnormal? If yes, please specify the location: Lower Cavities? Yes No Don’t know Consolidation? Yes No Don‟t know Uni / Bilateral? Other relevant clinical data_____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _________________________________ History of TB disease, anti-TB treatment, and contacts with those with TB Has the patient been diagnosed with TB before? Yes No Don’t know If Yes: date (DD/MM/YYYY)____________________________ Previous TB treatment? Yes No Don’t know Previous TB chemoprophylaxis?: Yes No Don’t know Has the patient had previous contact with TB? Yes No Don’t know If Yes, when? ___________ What was the nature of the contact? Household Work Study/School Prison Other (please specify)________________________ Part of Outbreak/Contact screening? Yes No Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 32 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication GUIDELINES ON BLOOD COLLECTION, STORAGE AND TRANSPORTATION QuantiFERON®-TB Gold IT uses the following collection tubes: 1. Nil Control (Grey cap). 2. TB Antigen (Red cap). 3. Mitogen Control (Purple cap). Blood collection tubes should be kept at room temperature (DO NOT REFRIGERATE). Never use blood collection tubes after the expiry date (printed on the tube label). Antigens have been dried onto the inner wall of the blood collection tubes so it is essential that the contents of the tubes be thoroughly mixed with the blood. The following procedures should be followed for optimal results: 1. For each subject collect 1mL of blood by venepuncture directly into each of the QuantiFERON®-TB Gold IT blood collection tubes (with red, grey, and purple caps). As 1mL tubes draw blood relatively slowly, keep the tube on the needle for 2-3 seconds once the tube appears to have completed filling, to ensure that the correct volume is drawn. The black mark on the side of the tubes indicates the 1mL fill volume. QuantiFERON®-TB Gold blood collection tubes have been validated for volumes ranging from 0.8 to 1.2mL. If the level of blood in any tube is not close to the indicator line, it is recommended to obtain another blood sample. If a “butterfly needle” is being used to collect blood, a “purge” tube should be used to ensure that the tubing is filled with blood prior to the QuantiFERON®TB Gold tubes being used. 2. Mix the tubes by turning the tube end-over-end 8 to 10 times or shaking the tube for 5 seconds ensuring that the entire inner surface of the tube has been coated with the blood. Thorough mixing is required to ensure complete mixing of the blood with the tube’s contents. 3. Label tubes appropriately (Patient’s name, surname, DoB, Hospital No) Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 33 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication 4. After the blood collection and mixing, keep tubes in upright position in the rack at room temperature. DO NOT REFRIGERATE OR FREEZE THE BLOOD SAMPLES. After blood collection, bottles with blood can be: - either delivered to the WCM Cardiff or Public Health Wales Microbiology Swansea on the same day (before 5 pm) - OR, where practical, incubated overnight in the incubator at 37 oC. There is no need for CO2 supply in the incubator. The overall time of incubation at 37 oC should not exceed 20 hours. After incubation at 37oC blood specimens should be sent to Microbiology Swansea either with courier, or DX, or First Class Royal Mail in appropriate biosafety containers. The overall time in transit should not exceed 3 days. Postal address: FAO: Dr Michael Isaac Microbiology Dept PHW Microbiology Swansea Singleton Hosp Swansea SA2 8QA DX: Hays DX DX 6070300 Swansea 90 SA Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 34 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document Public Health Wales Microbiology Cardiff Wales Centre for Mycobacteria Quality Status: Controlled for Internet Publication Wales Centre for Mycobacteria Public Health Wales Microbiology Cardiff Dear Dr Re: Case of multi-drug resistant tuberculosis (MDRTB) We understand that you have recently had a patient diagnosed with multidrug resistant tuberculosis. You may be aware that there now exists a national MDRTB service, whose aim is to collate information on all MDRTB cases identified in the UK and, if required, provide advice and support in the management of these patients. This initiative is endorsed by the Department of Health and has financial support from Genus Pharma. Therefore we are writing to you with two aims:(a) to invite you to provide information on the patient, their management and their outcome to enable the collection of data on a sufficiently large group of MDR TB cases to draw valid conclusions and share good practice. (b) to offer you ready access to expert advice on the management of patients with MDR TB (see the attached list of experts and their contact details ). We would be grateful if you would complete and return the attached form to the MDRTB service, via email, at [email protected] Yours sincerely Dr Michael Ruddy Reference Laboratory Microbiologist Peter Davies, Coordinator MDR TB Service Date Authorised: 8 May 2012 Document and Version: WCMQMS 035.5 Page: 35 of 35 If printed, please ensure the version number matches the version number on the electronic controlled document
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