Georgia Public Health Laboratory service manual

SERVICE MANUAL
2011

GEORGIA PUBLIC HEALTH LABORATORY 2011 SERVICE MANUAL TABLE OF CONTENTS
I. Table of Contents............................................................................................I,ii Director's Letter......................................................................................iii
Organizational Chart..................................................................................iv Directory of Central and Regional Laboratories...............................................v II. Diagnostic Laboratory Services Microbiology Services Overview...................................................................1 Bacteriology
Bordetella Pertussis.............................................................2 Chlamydia & Gonorrhea.........................................................6 Enteric Bacteriology.............................................................10 Foodborne Outbreaks..........................................................14 Streptococcus....................................................................23 Special Bacteriology...........................................................25 Immunology Infectious Disease.............................................................29 Mycobacteriology Mycobacteria....................................................................37 Parasitology Intestinal parasites.............................................................41 Blood and Tissue parasites..................................................44 Miscellaneous...................................................................47 Virology Human Immunodeficiency Virus ......................................... 50 HIV-1 Viral Load ..............................................................53 Rabies...........................................................................56
Virus Isolation and Identification...........................................60 III. Newborn Screening
Newborn ScreeningIntroduction.................................................................64 Specimen Collection.........................................................65
IV. Albany Regional Laboratory............................................................................70 Blood Lead Testing............................................................71 Chlamydia & Gonorrhea......................................................75 Rabies.............................................................................80 Syphilis...........................................................................83
V. Waycross Regional Laboratory.........................................................................87
Chlamydia & Gonorrhea....................................................88 Intestinal Parasites...........................................................93 Rabies...........................................................................97 Syphilis.........................................................................100

VI. Operations Support Services...............................................................104 Specimen Collection Outfit...... ...........................................109 Laboratory Fees...............................................................112 Laboratory Information System............................................113 Scientific Services.............................................................114
VII. List of Laboratory Services VIII. Laboratory Forms
Bacteriology Blood Lead Chemical Threat Immunology Molecular Biology Mycobacteriology Parasitology Rabies Virology Specimen Outfit Order Form (Decatur) Specimen Outfit Order Form (Albany) Specimen Outfit Order Form (Waycross)

GaonGla Dnpxnrarasr 0r e0nrmuxrrv l-{earru
David A. Cook, Commissioner
May,2011

Nathan Deal, Governor

2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov

Dear Georgia Public Health Laboratory Customer: We are pleased to provide you with the new revision of the "Laboratory Service Manual" for the Georgia Public Health Laboratory (GPHL). We have included material about additions to our service menu and changes in the way we provide services. For those of you who have lnternet access, the Laboratory Service Manual is available on the Division of Public Health Web Site at http://health.state.ga.us/prosrams/lab/manual.asp lf you have any questions or problems concerning the services provided by the Georgia Public Health Laboratory, please do not hesitate to contact me at 4041327-7900 or to call one of the Service Directors, Unit Supervisors or Managers listed in the following pages. As always, we solicit your comments and suggestions. Thank you for your continued, enthusiastic support of the Georgia Public Health Laboratory and our work on behalf of the citizens of Georgia.

Georgia Public Health Laboratory

Division of Public Health
Brenda Fitzgerald, MD, Director of Public Health & State Health Officer a Phone: 404-657-2100 t Fax: 404-657-2715
Equal Opportunity Employer

Georgia Public Health Laboratory
April 1, 2010

Albany Regional Lab Patrina Flood-Dawson

Georgia Public Health Laboratory Elizabeth A. Franko, Dr.P.H.
Laboratory Director

Waycross Regional Lab Alice Jeffers

Chemistry/Hematology Arthur Hagar, Ph.D.
Newborn Screening Germaine Stevens
Scientific Services Thomas Frederick

Microbiology/Immunology Mahin M. Park, Ph.D.
Bacteriology Lynett Poventud
Immunology Kimberly Kilgour
Mycobacteriology Jane Bush
Parasitology Mackevin Ndubuisi
Virology Romulo Morales

Emergency Response Tonia M. Parrott, Ph.D.
Molecular Biology Hietza Santiago
Chemical Terrorism Nije Thomas
Laboratory Response Network Vacant
Training LaTonya Clay
BioWatch Program

Administrative Operations William L. Shea, Jr.
Central Accessioning/ Data Processing Jenuryl Fluellen
Reports & Records Vacant
Billing Vacant
Services & Supply Deinance Lane
Reception Desk Peggy Baughns
Security Guards

Facilities Management Michelle Kirk

GEORGIA PUBLIC HEALTH LABORATORY BRANCHES

Decatur Laboratory:

Regional Public Health Laboratories:

Georgia Public Health Laboratory CLIA #11D0671793 (Specific Laboratory Unit) 1749 Clairmont Road Decatur, GA 30033-4050

Albany Regional Laboratory CLIA #11D0671770 1109 N. Jackson Street Albany, GA. 31701-2022 (229) 430-4122 FAX (229) 430-2297

Individual Units and Telephone Numbers:

Unit

Telephone

Administrative

(404) 327-7900

Office

FAX (404) 327-7919

Bacteriology

(404) 327-7990

Central Accessioning

(404) 321-2281

Laboratory Supply

(404) 327-7920

LIS Office

(404) 327-7931

Microbial Immunology (404) 327-7970

Mycobacteriology

(404) 327-7941

Newborn Screening

(404) 327-7950

Parasitology

(404) 327-7960

Reports and Records (404) 321-2240

Virology

(404) 327-7980

Waycross Regional Laboratory CLIA #11D0671837 1751 Gus Karle Parkway Waycross, GA. 31503 (912) 388-7050 FAX (912) 338-7061

Specimen Collection outfits: Order outfits from the Laboratory Branch that will perform the test (see above). Mailing labels are pre-addressed to the branch providing the outfits.

MICROBIOLOGY SERVICES
OVERVIEW
The Microbiology Section offers testing for infectious diseases in support of the Georgia Department of Community Health/ Division of Public Health programs and initiatives in the areas of bacteriology, immunology, parasitology, mycobacteriology, and virology. The mission of this section is to give assistance to public and private health-care providers in their investigation and control of diseases. This mission can be best accomplished by providing accurate and timely analysis of clinical and reference specimens submitted by the county health departments, hospitals, other clinical laboratories, and physicians in private practice. Our laboratory has provided valuable information on molecular typing of a number of isolates and has identified strains that have been implicated in foodborne outbreaks by utilizing Pulsed-field gel electrophoresis (PFGE) technology. In addition, molecular testing has been implemented for detection of Chlamydia and gonorrhea, determination of viral load in HIV infected patients, diagnosis of parasitic diseases and tuberculosis. Serological tests are offered to determine past or current infections with a variety of viruses including hepatitis and HIV among many other viruses tested. Luminex flow analyzer (BioPlex) technology is used for enhanced detection of West Nile Virus by immunoassay and detection of respiratory viruses by Polymerase Chain Reaction (PCR). In addition, viral culture is used for detection of respiratory viruses, herpes virus and other viruses listed in the "List of Laboratory Services" in this manual. Mycobacteriology Unit offers testing for TB by MGIT 960 and HPLC for a faster turnaround time and is capable of identifying most species of mycobacteria and fungi. In addition to clinical testing, rabies testing of suspected rabid animals is performed on the animal heads submitted through Animal Controllers. When deemed necessary, environmental specimens are tested to help investigate outbreaks of diseases. Microbiology Section also assists the Centers for Disease Control and Prevention (CDC) by participating in surveillance studies and by providing them with the results of our laboratory findings for a number of communicable diseases. The following sections of the manual provide more detail information on testing and specimen submission requirements for each type of test offered.
Mahin M. Park, Ph.D., HCLD Clinical Microbiology Service Director E-mail: mpark@dhr.state.ga.us Telephone No: (404) 327-7905
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BORDETELLA PERTUSSIS 404-327-7990
INTRODUCTION
The Bacteriology Unit accepts cultures for the isolation of Bordetella pertussis and Bordetella parapertussis, nasopharyngeal swabs in charcoal-blood transport medium for both agents, and slides for direct fluorescent antibody (DFA) testing. Specimens may be sent from public and private health care providers.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
Nasopharyngeal secretions are the optimal specimens for isolating pertussis bacterium and obtaining a lab confirmed diagnosis. A specimen should be collected as soon as possible after onset of illness, preferably before antibiotic treatment. Dacron (not cotton) or calcium alginate swabs are superior to other types of swabs and are recommended for use in collecting nasopharyngeal specimens. Regan Lowe semisolid transport medium tube is recommended for transport to the laboratory. The medium should be stored in a refrigerator at 2-8 degrees Celsius. Please note: Regan-Lowe medium should be removed from the refrigerator and warmed to room temperature before use.
A. Specimen for Nasopharyngeal Swab Culture: 1. Immobilize and tilt the patient's head. 2. Pass nasopharyngeal swab very gently into a nostril until it reaches the posterior nares. 3. Leave the swab in place for up to 10 seconds (this may induce a cough and in practice only a few seconds may be possible.) If resistance is encountered during insertion of the swab, remove it and attempt insertion on the opposite nostril. 4. Remove the swab slowly. 5. Streak slides (frosted side up) then insert and immerse swab into the tube of Regan-Lowe transport medium, available commercially. Cut the handle end of the swab extending above the transport tube if necessary and cap the container tightly. Note: If Regan-Lowe plate is used, streak the plate and then discard the swab. 6. Label slide holder with the patient's name and date of specimen collection (avoid using wax pencil or gummed labels on slides). 7. Label Regan-Lowe transport tube with the patient's name and date of specimen collection.
B. Specimen for Slides: Prepare 2 dime-sized smears on each of 2 microscope slides (one slide per nostril). Use frosted-end slides with prestamped circles if possible (frosted side up). Label slide holder with the patient's name or other unique identifier and date of specimen collection (avoid using wax pencil or gummed labels on slides).
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C. Culture (B. pertussis isolated at submitting laboratory): 1. Inoculate a pure culture onto a plate of charcoal agar with horse blood, such as Regan-Lowe medium, and send to GPHL within 24 hours or incubate at 35o C under high humidity. Schedule sub-culture so that time between optimal growth and transport of culture is <24 hours. 2. Examine medium beginning after 3 days incubation until confluent growth appears in the first quadrant of the plate. 3. Using a Dacron swab, aseptically harvest all growth from the first quadrant of the plate by sweeping the swab head through the area of confluent growth while rotating the swab shaft. Immerse swab containing harvested growth 2mm deep into the agar of a charcoal-blood transport tube, warmed to room temperature. 4. Aseptically cut the swab shaft flush with the top of the transport tube and replace cap. 5. Label transport tube with patient identifier information. 6. Maintain additional subculture(s) on plates at submitting laboratory until viability of referred culture is confirmed by the Bacteriology Unit.
Requisition Form Use form #3410 for specimen submission. It is extremely important that the form is entirely completed. Please include the following information:
1. Unique patient identifier (name or number). 2. Date of specimen collection. 3. Test requested, such as culture for B. pertussis and B. parapertussis or
DFA. 4. Submitter's name and address. 5. Name and telephone number of clinician to contact. 6. Source of specimen, such as nasopharyngeal. 7. Patient's race, sex, age, and address, if available. 8. Brief clinical history, if available. The patient identifier (name, number, or both) indicated on the requisition form should match that written on the slide holder, transport tube, or culture. Unlabeled specimens will not be tested.
SHIPMENT OF SPECIMENS AND CULTURES Note: Always submit the specimen/culture according to current DOT and IATA guidelines.
A. Slides: Place slides securely in the plastic slide holders provided (outfit #0525, available from Laboratory Services and Supply, 404-327-7920). Place plastic holder in a plastic biohazard bag. Insert requisition form in the pouch in the front of the bag. Place the bag with form affixed in the orange-labeled cardboard mailing container (Decatur address). Seal the lid of the outside container with tape. The specimens should be transported (room temperature) to the Bacteriology Unit immediately by
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courier or via Federal Express or UPS. If the shipment is delayed, the specimens should be refrigerated at 2-8 degrees Celsius and then sent the next day on ice packs by first class mail, common carrier, or courier. B. Nasopharyngeal Specimens for Culture: The method of shipment is dependent upon the selection of transport media used and the length of time required arriving at the Bacteriology Unit. Inoculated plates must be incubated at 35o C with increased humidity or transported (room temperature) to the Bacteriology Unit immediately by courier. Specimens in tubes of charcoal-blood transport media should be transported (room temperature) to the Bacteriology Unit immediately by courier, or if there is any delay in shipment, they should be stored and sent refrigerated (with ice packs) by first class mail, common carrier, or courier.
C. Isolates inoculated into charcoal-blood transport media may be shipped at room temperature within 24 hours.
REPORTING AND INTERPRETATION OF RESULTS
Results of DFA testing are completed the day of receipt or next day. Results of positive reports are telephoned to the submitter the day of testing. Nasopharyngeal smears are reported positive for Bordetella pertussis if there are > 5 organisms present with typical cellular morphology and intense fluorescence. Due to shortage of quality reagent, Bordetella parapertussis DFA testing is confined to confirmation of positive cultures for this organism.
Cultures are held for 7-10 days from the date of inoculation and read daily. Nasopharyngeal swabs received in transport medium tubes are inoculated immediately onto Regan-Lowe plates when received and then incubated. After the final day of incubation, if there are no colonies typical of B. pertussis or B parapertussis present, the culture is reported negative for these organisms. A positive culture report is based upon typical cellular and colonial morphology and is confirmed by fluorescent antibody testing. Positive cultures or cultures overgrown with mold or normal flora are reported immediately upon detection, and results are telephoned to the submitter.
Both culture and DFA procedures are recommended for diagnosis of B. pertussis whenever possible. "False negative" DFA results may occur from low numbers of organisms present in nasopharyngeal secretions. The DFA test is most valuable during the early phase of illness and before antibiotic treatment when the largest numbers of organisms are being shed. Positive FA results should be considered presumptive. As with any subjective test, "false positive" DFA results are possible. Only highly experienced staff in the Bacteriology Unit read slides and report results to minimize false positives. " False negative" culture results may follow from any procedures that render the organisms nonviable, such as improper handling of plates and transport medium after collection or prolonged antibiotic treatment. The DFA test will detect nonviable organisms. A positive culture result is the most reliable.
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UNACCEPTABLE SLIDES AND CULTURES 1. Smears too thick or too thin for accurate interpretation. 2. Slides broken in transit. 3. Cultures overgrown with mold or normal flora. 4. Cultures or transport medium improperly submitted (see above for the
recommended procedure). 5. No patient identifier on specimen or culture.
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CHLAMYDIA & GONORRHEA NUCLEIC ACID AMPLIFICATION TEST
404-327-7990
INTRODUCTION
The Bacteriology Unit uses Target-amplified direct nucleic acid amplification test for chlamydia and gonorrhea. Chlamydia trachomatis is the most commonly reported bacterial sexually transmitted disease in the US. Complications of untreated chlamydial infection in females include acute pelvic inflammatory disease, ectopic pregnancy, chronic pelvic pain, and infertility. Neisseria gonorrhoeae often pass unnoticed and asymptomatic carriers contribute significantly to the public health concern of gonorrhea. In women, gonorrhea is a common cause of pelvic inflammatory disease.
Client testing criteria: All female/male clients screened for chlamydia will also be screened for gonorrhea. Females with cervical stenosis should be included in the chlamydia/gonorrhea screening. If the client does not have a cervix, she will not be included in the chlamydia screening.
Family Planning Clinics. All females age 29 years or younger who receive a pelvic exam during a visit (initial, annual or comprehensive medical only) will be screened for chlamydia. A female will only be screened once per calendar year for chlamydia unless she has clinical signs or symptoms of chlamydia (cervicitis/MPC, friable cervix, cervical ectopy, abdominal pain, abnormal bleeding, dyspareunia or dysuria) or a new sex partner or multiple sex partners in the past 60 days. All females 30 years and older who meet these criteria will also be screened for chlamydia.
STD/General Clinics. All females age 10-29, who receive a pelvic exam during a visit, will be screened for chlamydia. This includes rescreening females who are returning for medical problems, receiving more than one pelvic exam a year and/or are currently on antibiotics. All females 30 years and older who present with clinical signs or symptoms of chlamydia (cervicitis/MPC, friable cervix, cervical ectopy, abdominal pain, abnormal bleeding, dyspareunia or dysuria) or have a new sex partner or multiple sex partners in the past 60 days will also be screened for chlamydia. Male clients presenting for services should also be screened for chlamydia.
Teen Clinics. All females who receive a pelvic exam will be screened for chlamydia. This includes rescreening females who are returning for medical problems, receiving more than one pelvic exam a year and/or are currently on antibiotics. Males should also be screened.
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SPECIMEN COLLECTION/LABELING/REQUISITION FORM
The APTIMA Combo 2 Assay is designed to detect the presence of C. trachomatis and N. gonorrhoeae in urine, endocervical and urethral specimens. Specimen collection kits are supplied to the health districts for clients seen at the Public Health STD and Family Planning Clinics.
Endocervical swab 1. Remove excess mucus from the cervical opening and surrounding mucosa using the cleaning swab (white shaft swab in the package with red printing). Discard this swab. Note: To remove excess mucus from the cervical opening, a large-tipped cleaning swab (not provided) may be used. Discard the swab after use. 2. Insert the specimen collection swab (blue shaft) into the endocervical canal. 3. Gently rotate the swab clockwise for 10 to 30 seconds in the endocervical canal to ensure adequate sampling. 4. Withdraw the swab carefully; avoid any contact with the vaginal mucosa. 5. Remove the cap from the swab specimen transport tube and immediately place the specimen collection swab into the transport tube. 6. Carefully break the swab shaft at the score line; avoid splashing the contents. 7. Recap the swab specimen transport tube tightly. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Male urethral swab
1. The patient should not have urinated for at least one hour prior to specimen collection.
2. Insert the specimen collection swab (blue shaft swab in the package with the green printing) 2 to 4 cm into the urethra.
3. Gently rotate the swab clockwise for 2 to 3 seconds in the urethra to ensure adequate sampling.
4. Withdraw the swab carefully. 5. Remove the cap from the swab specimen transport tube and immediately
place the specimen collection swab into the specimen transport tube. 6. Carefully break the swab shaft at the score line; avoid splashing the contents. 7. Recap the swab specimen transport tube tightly. Legibly label tube with
patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Urine
1. The patient should not have urinated for at least one hour prior to specimen collection.
2. Direct the patient to provide a first-catch urine (approximately 20 to 30 ml of the initial urine stream) into a urine collection cup which is free of any
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preservatives. Collection of larger volumes of urine may result in specimen dilution that may reduce test sensitivity. Female patients should not cleanse the labial area prior to providing the specimen. 3. Remove the cap and transfer 2 ml of urine into the urine specimen transport tube using the disposable pipette provided. The correct volume of urine has been added when the fluid level is between the black fill lines on the urine transport tube label. 4. Recap the urine specimen transport tube tightly. This specimen is now referred to as the processed urine specimen. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Requisition Form:
1. Use the Chlamydia and Gonorrhea requisition form #3568. 2. Fill out the form completely by printing or typing legibly. Only legible information
can be entered correctly into the laboratory database. Incomplete or illegible information may delay your results. Do not use computer-generated labels for patient information. 3. Information required is as follows: a. Submitter information (submitter code, submitter address, and phone
number). b. Patient information (name, patient ID number, county of residence, zip
code, State, race, ethnicity, gender, date of birth). c. Specimen information (test requested, reason for test, date collected,
source of specimen, specimen status). 4. Tear off the top section of form (white copy) and mail to the laboratory with the
specimen, making sure the names on the specimen and form are exact matches. Retain the other two copies of the form (pink and yellow) for clinic and program use. 5. Chlamydia and Gonorrhea Laboratory Submission forms will be provided to the participating Public Health Clinics by the STD Program Office.
SHIPMENT OF SPECIMENS
For best results, specimens should be transported to the laboratory on the date of collection; however, if this is impossible, specimens may be kept at room temperature and shipped as soon as possible. Urine specimens over 30 days old and/ or swab specimens over 60 days old at the time of arrival in the laboratory will be reported unsatisfactory.
1. Chlamydia/Gonorrhea APTIMA Combo 2 specimens may be transported at room temperature. Use the specimen transport cans and Decatur address labels (available from the laboratory).
2. Be sure the caps on the transport tubes are secure, and wrap each specimen in absorbent packing material. Place the wrapped specimen inside the aluminum
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can, and close the can securely. 3. Wrap the completed requisition form around the aluminum can and secure it with
a rubber band. 4. Place the aluminum can inside the labeled (Decatur address) fiberboard can,
close, and secure the lid with tape. 5. An alternate shipping method may be utilized by substituting the biohazard bag
for the inner aluminum container. If this method is chosen, the matching requisition forms should be placed in the pouch located in the front of each bag. 6. Specimens may be mailed or shipped by the method most convenient and expedient.
REPORTING AND INTERPRETATION OF RESULTS
The goal of the Bacteriology Unit is to test and report all Chlamydia/Gonorrhea APTIMA Combo 2 specimens within a 3 days turnaround period, unless confirmation testing is required. An electronic copy of all positive Chlamydia and Gonorrhea reports is transmitted to the State Sexually Transmitted Disease (STD) Program. A hard copy of all positives is also mailed to the State STD Surveillance Office. Results are reported as follows:
1. Positive for C. trachomatis and/or N. gonorrhoeae by Amplified Aptima Combo 2 Assay.
2. Negative for C. trachomatis and/or N. gonorrhoeae by Amplified Aptima Combo 2 Assay.
3. Indeterminate, a new specimen should be collected. 4. Unsatisfactory, specimen compromised in some manner making it
unsatisfactory for testing. The reason for each unsatisfactory result will be listed on the report form.
UNACCEPTABLE SPECIMENS
Specimens will be reported unsatisfactory for the following reasons: 1. No patient identifier on the specimen, or discrepancy between identifier on the specimen and requisition form. 2. Source other than urine, cervix or male urethra. 3. Two swabs received in the collection outfit. 4. No solution in the collection outfit. 5. No swab or improper swab (not from Gen-Probe kit) in the collection outfit. 6. Urine specimens over 30 days old and/ or swab specimens over 60 days old from date of collection when received. 7. Collection kit expired. 8. No specimen received. 9. Medical/legal specimens (Aptima Combo 2 is not intended for medical/legal cases). 10. Overfilled. Liquid level in the urine transport tube must fall between the two black indicators lines.
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ENTERIC BACTERIOLOGY 404-327-7990
INTRODUCTION
The Bacteriology Unit examines feces and other specimens for the presence of enteric pathogens, namely Salmonella serotypes, Shigella sp, Campylobacter sp., Aeromonas sp., Yersinia enterocolitica, and Shiga-like toxin producing E. coli (STEC), on a routine basis. Testing for Shiga-like toxin (SLT) will be done on all diarrheal stools and on all stools when STEC is requested. Stool specimens for other foodborne etiologic agents, such as Bacillus cereus, Staphylococcus aureus, Vibrio sp., and Clostridium perfringens, will be tested if the patient's clinical history and the epidemiological data warrant testing (see section on Foodborne Illness). Environmental samples may be accepted for enteric culture, testing only when implicated in cases of human illness or by prior consultation.
All isolates of Salmonella, Shigella, Campylobacter, STEC, Yersinia enterocolitica, and Vibrio recovered from specimens by other clinical laboratories in Georgia should be referred to the Bacteriology Unit, either directly or through the Emerging Infections Program (EIP) site. Referred isolates will be further characterized by various methods, such as biochemical reactions, serogrouping and serotyping, Polymerase Chain Reaction (PCR) and by Cell Wall Fatty Acid Analysis when necessary. Pulsed-Field Gel Electrophoresis (PFGE) will be performed on selected serotypes of Salmonella and STEC to determine if strains are related,
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
A. Feces Specimens for Salmonella, Shigella, Campylobacter, Aeromonas, Yersinia, STEC, Listeria, Staphylococcus aureus, and Vibrio 1. Feces specimens for the above agents should be collected in the ParaPak C&S outfit, orange-colored top (do not use the Parasitology O&P kit, blue and white-colored top, because it contains formalin that kills bacteria). Collect freshly passed feces as soon as possible after onset of illness and before antimicrobial therapy has been initiated (stools for S. aureus must be collected within 24 hours after onset). The patient should be cautioned against the use of antacid, barium, bismuth, anti-diarrheal medication or oily laxatives prior to specimen collection. An appropriate (i.e. bloody, slimy, watery) area of stool should be selected and sampled with the collection spoon provided on the cap of the container. Add specimen only to the red line on the vial, tighten the cap securely, and invert several times. The solution in the vial should be salmon colored before the specimen is added. Three consecutive specimens collected on
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different days during the acute stage of diarrheal disease are suggested (first three days). Ship at room temperature.
2. Rectal swabs containing detectable feces may be collected and placed in a Culturette with Stuarts, Cary-Blair, or other commercially available transport medium, if a feces specimen cannot be obtained. Ship under appropriate conditions for the transport medium and test to be performed. Please note: Pathogens are less likely to be recovered from rectal swabs than from feces.
3. Shiga toxin positive broths (GN or MC) are acceptable and should be sent to GPHL as soon as possible if culture is not performed onsite. Ship refrigerated and in compliance with current DOT and IATA guidelines.
B. Feces specimens for Clostridium perfringens, C. botulinum, and Bacillus cereus 1. Collect fresh stool specimens and place in a leak-proof, non-crushable, clean container (not provided by GPHL). Do not use the enteric ParaPakTM C&S stool culture outfit. 2. For C. perfringens and B.cereus, stool specimens must be collected within 48 hours from the time symptoms begin. 3. Store and ship refrigerated.
Requisition form:
A. Referred Cultures (for identification) Submit an overnight, pure culture of the isolated bacteria on carbohydrate-free media available commercially (TSA, TSI and LIA are acceptable). Label tube with the patient's name and complete the Isolation for Identification form #3410. If possible, please include any clinical data, cultural characteristics, biochemical reactions, or serology. The form must include the following information:
1. Patient identifier (name or number). 2. Date of collection. 3. Source of specimen. 4. Agent suspected. 5. Submitter's name and address.
B. Each stool specimen must be clearly labeled with the patient's name and accompanied by a properly completed Bacteriology form #3410. The form must include the following information:
1. Patient identifier (name or number). 2. Date of specimen collection. 3. Agent suspected, if applicable. 4. Submitter's name and address. 5. Symptoms.
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The patient identifier (name, number, or both) indicated on the requisition form should match that written on the specimen or culture. Unlabeled specimens or cultures will not be tested. SHIPMENT OF SPECIMENS AND REFERRED CULTURES
Note: Always submit the specimen/culture according to current DOT and IATA guidelines.

Mailing containers for submitting fecal specimens and referred enteric cultures are available from Laboratory Services and Supply (404) 327-7920. For stool culture specimens, order outfit #0555, and for culture referral for identification, order outfit #0505.

To facilitate handling, the following should be observed: 1. Wrap kyfax absorbent around the specimen/culture and place in the biohazard
bag provided. Put the Bacteriology form # 3410 in the pouch located in front of the bag. 2. Place the biohazard bag in the cardboard mailing container with the Decatur address label (orange). Seal the lid of the outside can with tape. 3. Ship specimens as soon as possible after collection. If there is a delay in transport, keep the specimen at room temperature; do not refrigerate (except as noted above for stool specimens for C. perfringens, C. botulinum, and B. cereus). 4. Specimens and referred cultures should be mailed first class, shipped by common carrier, or delivered to the Laboratory by courier. 5. When large numbers of specimens are expected (such as in an outbreak), please alert the Bacteriology Unit by telephone (404) 327-7990 before mailing so adequate amounts of media will be available for processing.

REPORTING AND INTERPRETATION OF RESULTS

Serotyping and confirmation or identification results are usually reported within 3 to 5 working days for Salmonella, Shigella, Aeromonas, Vibrio, and Yersinia; within 4 to 6 working days for STEC, and up to 10 working days for Campylobacter.

Stool specimen results are reported within 3 to 6 working days. A negative stool culture report reflects the organisms for which the stool specimen was routinely examined: No Salmonella, Shigella, Campylobacter, Aeromonas, Yersinia, or STEC found. Other organisms will be reported, as appropriate, per request. The results of SLT testing will be reported when performed.

The following enteric pathogens, whether isolated from stool specimens or submitted as

referred cultures are identified/confirmed to the species or serotype level:

Salmonella sp. or serotype

Aeromonas sp.

Shigella sp. and serotype

Vibrio sp.

Campylobacter sp.

Yersinia sp. and serotype

STEC

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UNACCEPTABLE SPECIMENS 1. Specimens submitted in wrong preservative, e.g., PVA or 10% formalin. 2. Refrigerated specimen for Shigella. 3. Multiple specimens collected on the same day (only one specimen will be
tested). 4. No patient identifier on specimen or culture. 5. Name or patient identifier mismatch. 6. Specimens received more than 7 days after collection. . 7. Swab submitted in Para-Pak C&S outfit.
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FOODBORNE OUTBREAKS 404-327-7990
INTRODUCTION
The Bacteriology Unit assists physicians and county health department officials in the diagnosis and epidemiological investigation of outbreaks of suspected foodborne illness. The laboratory examines food, feces, and other epidemiologically implicated specimens for the presence of disease-producing bacteria or toxins. Food samples from single cases of suspected foodborne illness will not be examined with the exception of suspected botulism cases. The Georgia Environmental Health and Injury Control Branch (404-657-6534) must be notified by the County Health Department in which the suspected outbreak has occurred, unless botulism is suspected, in which case the Georgia Epidemiology and Prevention Branch (404-657-2588) should be notified. The Bacteriology Laboratory must be advised by either the Environmental Health and Injury Control Branch or the County Health Department of the forthcoming samples, the method of shipment, and the expected time of arrival. This will facilitate the necessary preparations that must be made for processing and examining the samples. Suspect food samples from commercial or retail stores should be referred to the Georgia Department of Agriculture (404-656-3621).
Pulse-field gel electrophoresis will be done on STEC, Listeria monocytogenes, Salmonella, and Shigella isolates, as part of the foodborne illness investigation.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
All food items must be clearly labeled as to contents and type of food. Fecal or other specimens should be clearly labeled with the patient's name or other unique identifier and indicated as being associated with the outbreak under investigation. When submitting food samples, clinical signs and symptoms, incubation periods, duration of illness, the type of food being submitted, and other pertinent clinical or epidemiological data, must be indicated. This information should also be appropriate for the suspected organism before testing will be initiated. Unlabeled specimens will not be tested.
A. Food All food specimens (25 grams minimal, preferably 100 grams) should be collected under sterile conditions, placed in sterile plastic bags (whirl packs) or other suitable leak proof containers, and refrigerated. It is the responsibility of the environmental health specialist who collects the specimens to ensure that each food item is accompanied by a completed Bacteriology form #3410. The following minimum information must be included: source of sample; type of sample; date collected; incubation period; clinical symptoms; organism suspected; and submitter's name and address.
14

Botulism (testing performed at CDC) a. Contact the Bacteriology Unit (404-327-7990) for the initial coordination of specimen collection. b. The submitter must also contact the GA Epidemiology and Prevention Branch, (404-657-2593), to asses through epidemiological and patient clinical history and determine if testing is warranted. c. If approval is given, Epidemiology will notify both the Bacteriology Unit and CDC that specimens will be coming. d. Feces, food, and bowel contents (at autopsy) may be examined directly for C. botulinum specific neurotoxins A through G. These specimens may also be cultured for C. botulinum, and if an isolate is recovered, it may subsequently be tested for the presence of the specific neurotoxins. e. Collect feces and food samples in leak-proof, non-crushable containers, refrigerate immediately, and keep refrigerated after collection. f. Complete a CDC form #50.34 (available from the Bacteriology Unit) and a Bacteriology form #3410 (Environmental/ Food section) for each specimen or food sample submitted.
B. Fecal Specimen 1. Enteric Pathogens and Staphylococcus aureus: Refer to the Enteric Bacteriology section of this manual for instructions pertaining to collecting and shipping specimens in the ParaPakTM stool culture outfit. Do not refrigerate these stool specimens. Ensure that each specimen is properly collected and labeled and submitted with form #3410 (Environmental/ Food section). Indicate the enteric pathogens suspected on this form. 2. Clostridium perfringens and Bacillus cereus: Collect a stool specimen within 48 hours from the time symptoms begin, place in a leak-proof, non-crushable container and refrigerate immediately. Label the specimen with the patient's name or other unique identifier. Do not use the enteric ParaPakTM stool culture outfit, as this will result in erroneous quantitative count results. Form #3410 (Environmental/ Food section) must be filled out and C. perfringens or B. cereus, depending upon the request, checked the agent suspected.
C. Food Handlers 1. S. aureus: Swab the infected area and/or anterior nasal membranes. Place the swab in a culturette with Stuarts, Cary-Blair, or other commercially available transport medium. Label specimen with the patient's name or other unique identifier and complete form 3410 (Environmental/ Food section). 2. Enteric Pathogens: Follow procedure in section B.1, above.
15

D. Environmental Swab the suspected area(s) and submit as in C. above.
SHIPMENT OF SPECIMENS
A. Food: Keep food samples refrigerated. Do not freeze or use dry ice. However, if a food is received frozen, keep it frozen and ship on dry ice. Using a sturdy, waterproof shipping container, place samples and refrigerant in the shipper. Place form 3410 and other epidemiological and clinical information in an envelope attached to the outside of the shipper, or put the form(s) in a separate waterproof plastic bag inside the shipper with the food. Deliver sample(s) to the Bacteriology Unit by courier or ship by the most rapid method. Always notify the Bacteriology Unit of the expected time of arrival. Botulism a. Specimens may be sent to the Bacteriology Unit for referral to CDC and Epidemiology should be notified. b. All specimens for botulism must be shipped refrigerated.
B. Feces and Other Types of Clinical Specimens (except those for botulism): Feces for enteric pathogens and Staphylococcus aureus should be shipped according to the instructions in the Enteric Bacteriology section of this manual, they should not be sent refrigerated. Specimens for Clostridium perfringens and Bacillus cereus should be sent refrigerated and may be delivered to the Bacteriology Unit by courier or shipped separately by the usual transportation or mailing systems available.
REPORTING AND INTERPRETATION OF RESULTS
Examination of food samples and fecal specimens may require up to seven working days depending upon the suspected etiologic agent. Positive reports will reflect the etiological agent(s) which have been detected and/or enumerated and may include one or more of the following: Salmonella sp. or serotype, Shigella sp., Campylobacter sp., STEC, Clostridium perfringens, Staphylococcus aureus, Bacillus cereus, Vibrio sp., or other possible pathogens. Negative reports will be issued in those cases where the suspected organism is not detected. "Test Not Performed" will be indicated when the organism does not fit the epidemiological and clinical data indicated. Testing for Toxin may be performed in appropriate cases: enterotoxin for S. aureus and SLT for E. coli, and may take an additional two to three working days. Swab results from food handlers are usually reported within three days.
Confirmation that a certain food sample is involved in an outbreak is made by detecting the same pathogen (or toxin) in patient specimens and also in suspect food(s). See Table, Guidelines for Confirmation of Foodborne-Disease Outbreaks of Bacterial Origin.
16

UNACCEPTABLE SPECIMENS 1. No identifier on the specimen, or discrepancy between identifier on the specimen and requisition form. 2. Specimen or transport medium improperly submitted (see above for the recommended procedure). 3. Less than 25 grams of food (preferably 100 grams). 4. Other unacceptable food specimens will be assessed on an individual basis.
17

Guidelines for Confirmation of Foodborne-Disease Outbreaks of Bacterial Origin

Etiological Agent
Bacillus cereus Emetic toxin (heat stable)
Bacillus cereus Diarrheal toxin (heat labile)
Campylobacter sp.
Clostridium perfringens

Incubation Period
1 6 h
6 24h
2 10d; usually 2 5d
6 24h, median 12h

Clinical Syndrome Required Collection Submission

Specimen Vial

Form

Nausea & vomiting, sometimes diarrhea. Fever rare. Duration of < 1 day.

Stool w/in 48 h after onset
Food

Clean container
Zip-lock bags; clean container

#3410 #3410

Watery diarrhea, abdominal cramps; sometimes nausea & vomiting; fever rare. Duration of < 1 days.

Same as for emetic toxin

Same as for emetic toxin

Same as for emetic toxin

Diarrhea (often bloody), fever, abdominal pain. Duration 1 - 5 days.

Stool Food

Para-Pak #3410 #0555

Zip-lock bags; clean container

#3410

Diarrhea, abdominal cramps; vomiting, fever, & chills rare. Short

Stool w/in 48h after onset

Clean

#3410

container

How to Ship

Criteria for Outbreak Association

Refrigera Isolation of organism from > 2

-ted

people.

Refrigera -ted

Isolation of > 105 organisms/g from implicated food, provided specimen properly handled.

Same as for emetic toxin

Same as for emetic toxin

Ambient Isolation of organism from > 2 Temp. people.

Refrigera Isolation of organism from

-ted

implicated food.

Refrigera -ted

Isolation of > 105 organisms/g from > 2 people; Demonstration of enterotoxin from > 2 people.

18

duration of < 1 day. Food

Zip-lock bags; clean container

#3410

Refrigera -ted

Isolation of > 105 organisms/g from implicated food; isolation of enterotoxin-producing strain of C. perfringens

Clostridium botulinum Preapproval by Georgia Epidemiology & Prevention Branch and Prearrangement with CDC required.

2h - 8d; usually 12 - 48h

Illness of variable severity; nausea, vomiting, abdominal pain, & diarrhea may appear early. Head-ache, diplopia, blurred vision, & bulbar weakness common; paralysis, which is usually descending & bilateral may progress rapidly.

Serum Stool* Gastric Contents Food

Clean vials and/or container

CDC Form #50.34 one per specimen
&
#3410

Refrigera -ted

Detection of botulinal toxin in serum, stool, gastric contents, or implicated food; Isolation of organism from stool or intestine. Isolation of C. botulinum, but not the toxin, in a food consumed by a patient with suspected botulism is generally inadequate for confirming the illness.

Shiga-like toxin producing E. coli (STEC)

1 10d; usually 3 4d

Diarrhea (often bloody), abdominal cramps (often severe), little or no fever.

Stool** Food

Para-Pak #3410 #0555

Zip-lock bags; clean container

#3410

Ambient Isolation of STEC from > 2 Temp. people, same subtype (PFGE).

Refrigera -ted

Isolation of STEC from implicated food, same serotype/subtype as that found from stool specimens.

*Best for infant botulism. **Tests for detection of SLT from an overnight broth culture, or directly from a fresh stool, will be performed. The presence or absence of the SLT will be reported. These results must be interpreted according to the total clinical picture.

19

Listeria monocytogenes
Salmonella sp. Staphylococcus aureus

Invasive disease 2-6 wks

Meningitis, neonatal sepsis, fever

CSF, bld., placenta, amniotic fluid, fetal tissue

Sterile vial and/or Container

#3410

Pure Culture

Culture Referral Outfit #0505

#3410

Diarrheal disease Unknown

Diarrhea, abdominal Stool cramps, fever

Para-Pak #3410 #0555

Food

6h - 10d, usually 6 48h

Diarrhea, abdominal cramps, fever, chills, vomiting, headache, anorexia, malaise. Duration of several days.

Stool Food

Zip-lock bags; clean container

#3410

Para-Pak #3410 #0555

Zip-lock bags; clean container

#3410

30 min - 8h, usually 2 4h

Vomiting, diarrhea. Short duration of not more than a day or

Stool w/in 24h after onset

Para-Pak #0555

#3410

20

Refrigerated arrive w/in 48 hr.

Isolation of organism from normally sterile site, same serotype/subtype as implicated food.

Ambient Temp.

Confirmation of identification of organism & of same serotype/subtype as implicated food.

Ambient Temp.

Isolation of organism, same serotype /subtype: (a) from > 2 people exposed to implicated food, or (b) as isolate recovered from implicated food.

Refrigerated

Isolation of organism from implicated food, same serotype/subtype as isolates from > 2 people.

Ambient Temp.

Isolation of organism, same serotype/subtype, > 2 people.

Refrigerated

Isolation of organism from implicated food, same serotype/subtype as that found from stool specimens.

Ambient Temp.

Isolation of organism of same subtype (PFGE) from > 2 people.

Shigella sp.
Vibrio cholerae O:1 and O:139
Etiological Agent Vibrio parahaemolyticus

12h - 6d; usually 2-4d
1 5d
Incubation Period 4 30 h

two.
Diarrhea (often bloody), fever, abdominal cramps. Duration of several days.
Sudden onset, profuse watery diarrhea, often w/ mucus, abdominal pain, rapid dehydration.
Clinical Syndrome Diarrhea

Nasal or Wound Swab food handler
Food

Swab outfit (not supplied)

#3410

Zip-lock bags; clean container

#3410

Stool

Para-Pak #3410 #0555

Food Stool

Zip-lock bags; clean container
Para-Pak #0555

#3410 #3410

Food

Zip-lock bags; clean container

#3410

Required Collection Submission

Specimen Vial

Form

Stool

Para-Pak #3410 #0555

Ambient Temp.

Isolation of organism of same subtype (PFGE) as stool and/or food isolates.

Refrigerated

Detection of enterotoxin in implicated food; isolation of enterotoxin-producing strain of S. aureus; isolation of > 105 organisms/g from implicated food, provided specimen properly handled.

Ambient Temp.

Isolation of organism, same serotype/subtype, from > 2 people.

Refrigerated

Isolation of organism from implicated food, same serotype /subtype as stool isolates.

Ambient Temp.

Isolation of toxigenic organism from > 2 people.

Refrigera- Isolation of toxigenic organism

ted

from implicated food.

How to Ship
Ambient Temp.

Criteria for Outbreak Association
Isolation of Kanagawa-positive organism from > 2 people.

21

Yersinia enterocolitica

1 10d, usually 4 6d

Diarrhea, abdominal pain (often severe) may mimic appendicitis

Food
Stool Food

Zip-lock bags; clean container

#3410

Para-Pak #3410 #0555

Zip-lock bags; clean container

#3410

Refrigera -ted

Isolation of > 105 Kanagawapositive organisms/g from implicated food.

Ambient Isolation of pathogenic strain or Temp. serotype from > 2 people.

Refrigera Isolation of pathogenic strain or

-ted

serotype from implicated food.

References:

1.

Centers for Disease Control and Prevention. CDC Surveillance Summaries, March 17, 2000. MMWR 2000; 49(No. SS-1).

2.

Bryan, F.L. 1982. Diseases Transmitted by Foods. A Classification and Summary, 2nd ed. Centers for Disease Control, Atlanta.

3.

Bryan, F.L. 1995. Outbreaks of Food-Borne Disease, p. 209-226. In P. Murray et al. (ed.), Manual of Clinical Microbiology, 6th ed. ASM

Press,

Washington D.C.

22

THROAT CULTURE FOR GROUP A STREPTOCOCCUS 404-327-7990
INTRODUCTION
The Bacteriology Unit accepts specimens from public health care providers for the detection of Group A Streptococcus and other beta-hemolytic streptococci from throat. Reference cultures will be accepted from public and private health care providers for identification and/or serogrouping of beta-hemolytic streptococci. Culture is the method used for isolation of the organism, and latex agglutination is used for serogrouping isolates.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
The sterile swab supplied in outfit #0560 should be used for throats. Outfits are available from Laboratory Services and Supply, 404-327-7920. The Group A Streptococcus outfit may be used for the isolation of any beta-hemolytic Streptococcus from throat.
Specimen collection 1. After adequately exposing and illuminating the pharynx, rub tonsils and pharynx with the swab provided. Be careful to obtain any exudates present and avoid the tongue and uvula tissues. 2. Place swab in the silica gel envelope, according to instructions supplied with the outfit by placing the silica gel package in the polyfoil kraft envelope. 3. Clearly write the patient's name or other unique identifier in the space provided.
Requisition form Use requisition form #3410 and supply the following information: 1. Patient identifier (name or number). 2. Date of specimen collection. 3. Name and telephone number of clinician to contact. 4. Submitter's name and address. 5. Patient's race, sex, age, and address, if available. The patient identifier on the form should match that on the specimen. Unlabeled specimens will not be tested.
SHIPMENT OF SPECIMENS
Place the polyfoil envelope and requisition form in the brown mailing envelope provided. Specimens may be sent to the Laboratory by first-class mail, common carrier, or courier. If there is any delay in shipment, hold specimens at room temperature.
REPORTING AND INTERPRETATION OF RESULTS
23

Culture results of beta-hemolytic Streptococcus will be completed within 2 days after receipt of the specimen. Any Group A Streptococcus detected will be reported. Other groups of beta-hemolytic Streptococci will be reported if they are the predominate organism present. The report will read "No Group A Streptococcus Found by Culture" for negatives; if no growth is detected this also will be noted. For positives, the report will read, "Group A Streptococcus Found by Culture," or Group B, C, F, G Streptococcus Found by Culture, Predominate Organism Present." UNACCEPTABLE SPECIMENS 1. Specimens not submitted in the silica gel outfit (or other suitable transport outfit approved by the Bacteriology Unit). 2. Silica gel envelope not sealed. 3. Specimens received >4 weeks after collection. 4. No patient identifier on specimen.
24

SPECIAL BACTERIOLOGY 404-327-7990
INTRODUCTION
The Bacteriology Unit accepts reference cultures from public and private health care providers for the identification, confirmation, and/or serotyping of bacterial isolates. This includes a wide variety of aerobic, anaerobic, and facultative organisms isolated from clinical sources. Isolates should be submitted as pure cultures. Techniques used in the identification process include a combination of some or all of the following: cellular and colonial morphology, conventional biochemical tests, Cell Wall Fatty Acid Analysis (CWFAA), and DNA probes.
All isolates of Neisseria meningitidis, Haemophilus influenzae and Listeria monocytogenes, recovered from sterile sources should be forwarded to the Bacteriology Unit, either directly or through the Emerging Infections Program (EIP) site for grouping, typing or Pulsed-field gel electrophoresis (PFGE) testing.
Submission of Group A Streptococcus, Group B Streptococcus and S. peumoniae isolates to GPHL is no longer required. Nevertheless, these organisms remain reportable to the Notifiable Diseases Unit. In addition, CDC no longer provides typing and/or molecular characterization for them, unless by prior arrangement (please call 404-327-7997 for details).
Antimicrobial susceptibilities are not performed except as an aid to identification. Such requests can be forwarded to the CDC through the Bacteriology Unit by special arrangement. Any unidentified organisms isolated from sterile sources will also be sent to the CDC for further studies, upon request.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
A. Pure cultures for anaerobic identification from aspirated pus, transtracheal and lung aspirates, body fluids, tissue (biopsy, surgical, and autopsy), suprapubic aspirate of bladder urine, and sulfur granules from suspected cases of actinomycosis are acceptable. Clearly label referred cultures with the patient's name or other unique identifier.
B. Pure culture for aerobic identification from autopsy material, tissues, urine, respiratory and urogenital tract secretions, wounds, abscesses, spinal fluid, and blood are acceptable. Clearly label referred cultures with the patient's name or other unique identifier.
See Table 1 for aerobic and anaerobic organisms requiring special handling. In all of the cases noted in Table 1, notify the Bacteriology Unit prior to shipping.
25

Requisition Form: Complete form #3410 when sending referred cultures for aerobic or anaerobic identification, confirmation, and/or serotyping. Include the following information:
1. Unique patient identifier (name or number). 2. Agent suspected or test requested. 3. Submitter's name and address. 4. Name and telephone number of contact person. 5. Date of specimen collection. 6. Source of specimen. 7. Date of transplant (if applicable). 8. Brief clinical history. 9. Patient's race, sex, age, and occupation, if available.
The patient identifier (name or number) indicated on the requisition form should match that written on the specimen or culture. Unlabeled specimens or cultures will not be tested.
SHIPMENT OF SPECIMENS AND REFERRED CULTURES Note: Always submit the specimen/culture according to current DOT and IATA guidelines
Submit referred cultures as pure cultures in the appropriate medium. For anaerobic identification, chopped meat broth, thioglycollate broth, motility test medium (inoculate near the bottom of the tube), or anaerobic blood culture bottles are suitable choices and are commercially available. For aerobic identification, slants of solid medium appropriate for growth of the organism in question are recommended and are commercially available.
Use screw-capped tubes and tighten securely. Place a strip of parafilm around the cap of the tube to help prevent loosening of the cap in transit. In all cases, submit young, actively growing subcultures to ensure viability. Wrap the sides and bottom of culture tubes in kyfax packing material or paper towels to prevent breakage. Use outfit #0505, "Culture Referral Isolation for Identification," available from Laboratory Services and Supply, 404-327-7920, and follow these instructions: 1. Place culture wrapped in packing material in the biohazard bag provided. 2. Put the requisition form in the pouch in the front of the bag. 3. Place the biohazard bag in the orange-labeled cardboard mailing container
(Decatur address) and secure the lid with tape. 4. Place the return address on the outside of the container. 5. Send by first class mail, common carrier, or courier. Avoid submitting cultures in petri dishes, but if necessary, cushion them with absorbent material and securely package in leak-proof containers. Seal culture plates for anaerobic identification in an anaerobic "bag" system before packaging.
26

REPORTING AND INTERPRETATION OF RESULTS
Organisms are identified to the genus and species level when there is agreement with all appropriate data, such as cultural, morphologic, biochemical, and cell wall fatty acid analysis. Genus and species designations are current with new bacterial nomenclature. The identification of the organism will be reported. When serotyping is requested and available, the appropriate serotype or serogroup will be reported. Unidentified organisms isolated from sterile sources may be forwarded to CDC upon request, but those isolated from nonsterile sites must be accompanied by a detailed clinical history to justify sending to CDC and requires prior approval from CDC.
Culture results for the identification of aerobic, facultative, and anaerobic bacteria are usually completed within seven working days, but may require up to fifteen working days, depending upon the organism. Mixed cultures, fastidious, slowgrowing, or nutritionally-deficient bacteria may occasionally require additional time beyond the fifteen working days for a complete identification. Results of serotyping are usually completed as follows: Neisseria meningitidis (1-3 working days) and Haemophilus influenzae (2-3 working days). Cultures referred to the CDC may require up to six months for a final identification.
UNACCEPTABLE SPECIMENS
1. Cultures broken in transit. 2. Non-viable cultures: all cultures received will be subcultured upon
receipt. Every attempt will be made to obtain viable growth. If no growth occurs, the submitter will be notified, a report will be issued and another subculture will be requested, if available. 3. Cultures overgrown with contaminants. 4. No patient identifier on the specimen or culture. 5. Specimens improperly collected or submitted (see section on specimen collection and shipment).
27

Table 1. Organisms Requiring Special Handling

Organism

Special Instructions and Requirements

Clostridium botulinum Clostridium perfringens Corynebacterium diphteriae Haemophilus ducreyi

See section on Foodborne Illness for further details. For wound infections, submit material from wound, refrigerated with cold pack, in an anaerobic environment system. Send suspected isolate in chopped meat broth or motility test medium (inoculate near bottom of tube) in culture referral outfit (#0505) at ambient temperature. Specimens and isolates will be forwarded to CDC for isolation, confirmation, and/or toxin testing.
See Foodborne Outbreaks Section for further details. Submit material from site of infection, refrigerated with cold pack, in an anaerobic environment system; or send suspected isolate in chopped meat broth or motility test medium (inoculate near bottom of tube) in culture referral outfit (#0505) at ambient temperature.
Collect throat or skin lesion swabs (use Strep outfit #0560 or place on Loeffler's agar slant, available commercially. Subculture suspected isolates to Loeffler or cysteine tellurite blood agar slants. Toxigenicity testing will be performed at CDC. Send suspected isolates in culture referral outfit (#0505). Contact the Bacteriology Lab prior submission as special media is required for testing.
Collect specimens from lesions or inguinal bubo. Inoculate onto enriched chocolate agar with vancomycin. Incubate 33-35o C in 5-10% CO2 in watersaturated atmosphere. Referred cultures only will be accepted.

Haemophilus influenzae

For serotyping and/or culture confirmation, submit 18-24 hr. subculture on chocolate slant, available commercially. Submit through the EIP site, by mail, or by courier.

Leptospira

Collect blood during first 10 days of illness, and urine (3 consecutive samples) from second to fourth week of illness. Obtain instructions for inoculation from the Bacteriology Unit prior to specimen collection. Ellinhausen's medium is available commercially. Immediately inoculate tubes and submit at room temperature to the Bacteriology Unit. Specimens and isolates will be forwarded to CDC for isolation and confirmation.

Neisseria gonorrhoeae

For culture confirmation, submit 18-24 hr. subculture on chocolate slant or emulsify fresh growth in trypticase soy broth with 20% glycerol and freeze. Submit preferably by overnight mail (slant) or frozen on dry ice (broth). See separate section for GC culture screening.

Neisseria meningitidis Staphylococcus aureus

For serogrouping and/or culture confirmation, submit 18-24 hr. subculture on chocolate slant, available commercially. Submit through the EIP site, by overnight mail, or by courier.
Submit coagulase positive isolates from outbreaks or multiple isolates from different sources in same patient. Submit on nutrient or heart infusion agar slants.
28

INFECTIOUS DISEASE SEROLOGY 404-327-7970
INTRODUCTION
The Microbial Immunology Unit performs infectious disease serology. Serology for HIV (Human Immunodeficiency Virus), is performed in the Virology Unit. Various serologic procedures are performed for a variety of bacterial, parasitic, and viral agents. Hepatitis serology is performed for county health departments, and Georgia Department of Community Health agencies, only. Tests not performed in the Public Health Laboratory are forwarded to CDC, if they provide the requested testing.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
Collection Using Universal Precautions, and standard venipuncture technique, collect approximately six milliliters of whole blood (for serum) in a red top tube (no additive), labeled with patient's identifier (name, first and last, or number), date, and name of the submitter. Use a marker that will not fade, smear, or run during transportation. Use proper size needle (large enough to prevent hemolysis of the red blood cells) for the vein location and age of the patient. Allow blood specimen to clot, at least 30 minutes undisturbed, at room temperature, and transport, or place in the refrigerator for transporting. Collect blood specimens in, or transfer them to, non-breakable, leak resistant tubes. Specimens should be transported as soon as possible, do not hold over 7 days. Specimens over 14 days old are unacceptable. Many of the procedures we perform are not approved for use with plasma. Therefore, please submit only serum or whole blood without anticoagulants, not plasma.
Collect cerebrospinal fluids (CSF) according to proper hospital procedure. CSF contaminated with blood or grossly contaminated with bacteria is unacceptable.
Labeling All specimens must be labeled with patient identification (name or number), in acceptable testing condition, and accompanied by a completed requisition form. If the form is not specific for one test or a set of tests, the specific testing requested must be handwritten in the proper area, e.g., "viral serology" is not acceptable, the specific agent, e.g., "CMV", must be clearly requested. Failure to provide proper patient information may result in testing delays.
Requisition Form Use Form #3432 for all tests performed by the Microbial Immunology Unit. There is a single requisition form for all serological tests performed, including the RPR and EIA tests for syphilis, Hepatitis B (DCH facilities and county health departments only), and other Serology. Completely fill out the form and include the following information:
1. Unique patient identifier (name or number). 2. TEST(S) REQUESTED (Please check only the corresponding box for test(s)
requested).
29

3. Date specimen collected. 4. Submitter's name, address, and code number, where applicable. 5. For hepatitis the reason for testing, e.g., routine, or prenatal. 6. Any information the submitter needs for patient identification, e.g., chart number,
address. 7. The date of onset of illness, if applicable. 8. Race, sex, and age, where applicable, e.g., hepatitis testing.
SHIPMENT OF SPECIMENS
Use outfit #0500, available from Laboratory Services and Supply, 404-327-7920, and follow the specific instructions below. Specimens may be mailed or delivered to the laboratory by courier.
Shipping Instructions for USPS and Couriers: Place the tubes of blood in protective, leak resistant, double-walled containers, e.g., aluminum and cardboard box, for transport. Wrap the requisition form around the inner (aluminum) can, secure with a rubber band and place in the outer container. If a screw-cap outer container is used, the screw-cap must be secured with tape or the Postal Service will return it for taping. Up to 50 milliliters of blood may be transported in one package (U.S. postal regulations). Therefore, an individual tube of blood may be placed in the metal can, with the requisition form secured to the outside by a rubber band, and several aluminum cans placed in one cardboard box for transporting.
Shipping Instructions for Courier Services Only: Tubes of blood may be placed in leak proof biohazard bags. Wrap brown absorbent material around the tube, then secure with a rubber band. Place the requisition form in the sleeve located on the outside of the bag.
REPORTING AND INTERPRETATION OF RESULTS
Table 1 (pages IV-61 through IV-63) summarizes the interpretation of results for all serological tests performed in the Microbial Immunology Unit. Table 2 (page IV-64) gives the turnaround times for all of the same serological tests. The turnaround time after receipt of the specimen depends on the testing methodology and the frequency of testing. The frequency of testing depends on the demand for a specific test. Several tests are performed daily, while others are performed weekly. The turn-around time for specimens referred to CDC depends on CDC's schedule, which varies from laboratory to laboratory.
UNACCEPTABLE SPECIMENS
1. Spinal fluid obviously contaminated with bacteria or blood; 2. All specimens:
30

Not approved for testing by the indicated method, e.g., plasma for RPR. Grossly hemolyzed, lipemic, turbid, or contaminated. Over 14 days old. Broken in transit. Insufficient quantity for testing. No identification on specimen. Name on tube and form does not match. The submitter will be notified of all rejected specimens. Most serologic services are available to both the public and private sectors. However, hepatitis B testing is limited to the public health care providers, and not available to the private providers.
31

Agent

Test

California Encephalitis
Cytomegalovirus (CMV)

IgG1 IgM1
IgG IgM

Eastern

IgG

Equine

IgM

Encephalitis

Method IFA1 EIA1
IFA

Test Result Interpretation1 Negative Positive2 Diagnostic

Presumptive3

IgG <1:16 IgG >1:16 Four-fold rise in titer IgM <1:16 IgM > 1:16 between paired sera4

> 1:16

No IgG Detected No IgM Detected
IgG <1:16 IgM <1:16

IgG Detected IgM Detected
IgG >1:16 IgM > 1:16

IgM detected and/or significant rise in titer between paired sera4,5
Four-fold rise in titer between paired sera4

IgM Equivocal
> 1:16

IgG

EIA

Hepatitis A Total

IgM

EIA

Hepatitis C

EIA

HBs1

Hepatitis B Hbe1

Virus (HBV)6

EIA AntiHBs1

AntiHBc1

Herpes Simplex Virus (HSV)

Type 1 EIA Type 2

Negative

Positive

Negative Positive

Presumptive evidence of IgM antibodies to HAV

Negative Positive

Negative Negative Negative

Positive Positive Positive

s/co>/=10; samples confirm >/=95% positive. <10; confirm with Riba positive 2 or more 1+ bands. Positive HBs

None

Negative Positive

No IgG Detected

IgG Detected

Significant difference None between paired sera4,5

32

Agent

Test

Method

Test Result Interpretation1 Negative Positive2 Diagnostic

Presumptive3

Mumps

IgG

EIA

Murine

IgG

IFA

typhus

Rocky

IgG

IFA

Mountain

Spotted

Fever

(RMSF)

Rubeola (Measles)

IgG

EIA

IgM

IgG

Rubella

(German IgM

EIA

Measles)

St. Louis Encephalitis
Syphilis

IgG IgM
RPR1
Confirmatory EIA
FTA

IFA Agg1. EIA IFA

Syphilis Toxoplas-

VDRL (CSF1) IgG

Agg1 EIA

No IgG Detected
<1:16
< 1:16

IgG Detected
> 1:16
> 1:16

Significant difference between paired sera4,5

None

Four-fold rise in titer > 1:128 between paired sera4

Four-fold rise in titer > 1:128 between paired sera4

No IgG Detected
No IgM Detected
No IgG Detected
No IgM Detected

IgG Detected
IgM Detected
IgG Detected
IgM Detected

IgM detected and/or significant increase between paired sera4,5

IgM Equivocal

IgM detected and/or significant increase between paired sera4,5

Not Applicable

IgG <1:16 IgG >1:16 Four-fold rise in titer > 1:16 IgM <1:16 IgM > 1:16 between paired sera4

NonReactive
NonReactive

Reactive > 1:1
Reactive

RPR and EIA Reactive

Reactive RPR and Equivocal EIA

NonReactive
NonReactive
No IgG Detected

Reactive
Reactive
IgG Detected

RPR, EIA, FTA

Equivocal EIA

VDRL Reactive
IgM detected and/or significant increase

Reactive
VDRL IgM Equivocal

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mosis

IgM

Varicella Zoster

Agent

Test

EIA Method

No IgM Detected
No IgG Detected
Negative

IgM Detected
IgG Detected
Positive2

between paired sera4,5
Significant increase between paired sera4,5 Diagnostic

None Presumptive3

West Nile IgG

EIA

Virus

IgM

Western

IgG

IFA

Equine

IgM

Encephalitis

No IgG Detected No IgM Detected
IgG <1:16 IgM <1:16

IgG Detected IgM Detected
IgG >1:16 IgM > 1:16

IgM detected and/or significant increase between paired sera4,5
Four-fold rise in titer between paired sera4

IgM Equivocal
> 1:16

Abbreviations (in alphabetical order)1

Agg. Anti-HBs CSF Anti-HBc EIA IgM IgG FTA IFA RPR HBs VDRL HBe

Agglutination Hepatitis B surface antibody Cerebrospinal Fluid Hepatitis B core antibody Enzyme Immunoassay Immunoglobulin M Immunoglobulin G Fluorescent treponemal antibody Indirect Fluorescent Antibody Rapid Plasma Reagin Hepatitis B surface antigen Venereal Disease Research Laboratory Hepatitis B e antigen

2A positive result indicates natural or acquired immunity, especially for vaccine-preventable diseases 3Presumptive results identify a significant result for a single (not paired) serum, and need confirmation by clinical symptoms, recollection of specimen for retesting, or if applicable, submission of a convalescent specimen. 4Paired sera (acute and convalescent) dates of collection and date of onset of illness are needed for proper interpretation of results. 5A significant difference is determined by instructions given in individual enzyme immunoassay procedures, and may differ between manufacturers. 6Performed for county health departments and DCH facilities only.

FOR ADDITIONAL INFORMATION REGARDING TEST INTERPRETATION CALL THE MICROBIAL IMMUNOLOGY LABORATORY AT (404) 327-7970

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Table 2. Turnaround Times

Agent
California Encephalitis IgG2/IgM2 Cytomegalovirus IgG/IgM Eastern Equine Encephalitis IgG/IgM

Turnaround Time Working Days1
10-12 days 7-14 days 10-12 days

Hepatitis A Hepatitis C Hepatitis C (Confirmation) Hepatitis B Diagnosis
Surface antigen Total antibody core antibody e-antigen (performed on surface antigen(positive specimens only) (positive HBs specimens) Herpes simplex 1& 2 Mumps Murine typhus Rocky Mountain Spotted Fever (Misc. Serology) Rubella IgG / IgM Rubeola IgG/IgM St. Louis Encephalitis IgG/IgM

5-7 days 5-7 days 7-14 days
5-7 days 5-7 days 5-7 days 7-14 days
7-14 days 7-14 days 7-14 days 7-14 days 5-7 days
5-7 days 7-14 days 10-12 days

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Syphilis RPR2Non-Reactive

3-5 days

RPR Reactive

5-7 days

.

Confirmatory Non-Reactive

5-7 days

Confirmatory Reactive FTA2 Non-Reactive

5-7 days 5-7 days

FTA Reactive

5-7 days

FTA Repeats

7-14 days

Toxoplasmosis IgG /IgM

7-14 days

West Nile Virus IgG/IgM

10-12 days

Western Equine Encephalitis IgG/IgM

10-12 days

Varicella zoster VDRL2 (CSF2 only)

7-14 days 5-7 days

1 Special arrangements may be made in the case of an emergency. 2 Abbreviations: IgG, Immunoglobulin; G; IgM, Immunoglobulin M; EIA, Enzyme Immunoassay; RPR, Rapid
Plasma Reagin; FTA, Fluorescent treponemal antibody; VDRL, Veneral Disease Research Laboratory; CSF,
Cerebrospinal Fluid.

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ISOLATION AND IDENTIFICATION OF MYCOBACTERIA 404-327-7945
INTRODUCTION
The Mycobacteriology Unit accepts specimens for the isolation and identification of Mycobacterium tuberculosis complex and other mycobacteria which may cause disease under certain circumstances. Susceptibility testing is performed on all isolates of the Mycobacterium tuberculosis complex. The services of this laboratory are available to both public and private health care providers.
SPECIMEN COLLECTION/LABELLING/REQUISITION FORM
A. Clinical Specimens
Although the most common specimen received in the TB Unit is sputum, the GPHL accepts specimens of various other types: bronchial washings, gastric lavage, urine (voided early morning or catheterized), pus (aspirated or on swab), tissue (biopsied lymph node or biopsied portions of lung or other organs), bone, stool, and body fluids (cerebrospinal, pleural, pericardial, or joint).
If a case has not been diagnosed as tuberculosis, a series of three early morning sputum specimens should be collected on successive days and transported to the laboratory as soon as possible. Specimen collection outfits (Item #0550) are available at no charge from the Laboratory Supply Office (404-327-7928). The patient's name must be clearly printed on the 50 ml specimen collection tube.
Mycobacteriology Submission Form 3412 should be filled out completely, giving the following information: patient's name (please print and be sure it is evident which is the patient's first and last name), address including county of residence, race, sex, date of birth, type of specimen, date collected, and name and address of submitter. All information requested on the form should be provided on all request forms, since the laboratory information system creates a unique tracking number for each patient based on these demographics.
B. Isolates or Cultures for Identification and/or Susceptibility Testing
Isolates/cultures for identification and/or drug susceptibility testing should be submitted on solid media or in liquid media after good growth has occurred. The patient's name must be clearly printed on the media. Mycobacteriology Submission Form 3412, appropriately marked for either "Culture for identification" or "Culture for susceptibility testing," should be filled out completely and legibly and submitted with each isolate. If an isolate submitted for identification is identified as M. tuberculosis complex, susceptibilities will automatically be performed.
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SHIPMENT
A. Clinical Specimens
GPHL specimen collection/shipping outfits (Category B) consist of a rigid mailing container that holds a specimen collection tube (50 ml plastic screw-cap tube), a biohazard bag, a square of absorbent material, and a white Tyvek envelope. The specimen collection tube is placed in the biohazard bag along with the square of absorbent material. The bag is sealed and placed inside the white Tyvek envelope. The white envelope is sealed and placed inside the outer rigid container. A Mycobacteriology Submission Form 3412, marked for "Clinical Specimen for smear, culture & susceptibility," is also placed in the rigid container. The lid of the rigid container is screwed on tightly and secured with tape. The specimen should be mailed or delivered to the laboratory as soon as possible after collection to avoid overgrowth of unwanted bacteria. If mailing is delayed overnight, the specimen should be refrigerated.
B. Isolates or Cultures for Identification and/or Susceptibility Testing
If isolates or cultures are submitted in glass tubes or bottles, they must be wrapped with absorbent cushioning material before being placed inside any shipper component.
MGIT tubes showing growth of acid-fast bacilli may be submitted for identification and drug susceptibility testing. The MGIT tube must be placed inside a plastic 50 ml conical tube, capped securely and then packaged according to federal shipping regulations. In case of breakage of the MGIT tube, the broth will still be contained inside the 50 ml conical tube, provided all caps have been securely tightened.
Category B Shippers are available from the Laboratory Supply Office (404-327-7928). Isolates which have been identified as Mycobacterium tuberculosis complex must be shipped as Category A. GPHL does not supply Category A shippers.
REPORTING/INTERPRETATION OF TEST RESULTS
Nucleic Acid Amplification Test for M. tuberculosis complex (MTD Test)
The MTD Test is a nucleic acid probe test for the detection of Mycobacterium tuberculosis complex rRNA in concentrated specimen sediments prepared from respiratory sources. This test is intended for use only with specimens from patients showing signs and symptoms consistent with active pulmonary tuberculosis, and who have not received antituberculosis drug therapy in the last 12 months; or if drug therapy has been started, the patient has received less than 7 days of such therapy. The MTD Test must be performed in conjunction with mycobacterial culture. MTD Test results are called to the submitters.
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Microscopic Examination
Fluorochrome stained slides are prepared from all clinical specimens and are examined using a fluorescent microscope for the presence of bacilli showing a yellow-green fluorescence. Results are reported as "No AFB found"; "+/-" (1-3 AFB/slide); "1+" (4-36 AFB/100 fields); "2+" (4-36 AFB/10 fields); "3+" (4-36 AFB/field); or "4+" (>36 AFB/field). Submitters are notified by telephone of a positive smear on a new patient.
Culture
A tube of solid medium (Lowenstein-Jensen agar) and a tube of liquid medium (BACTEC MGIT broth) are inoculated from each clinical specimen. These cultures are incubated for six weeks before a report of "No Mycobacteria Isolated" is issued. If growth in either medium occurs at any time during the six weeks, identification procedures begin. Lowenstein-Jensen agar slants are examined weekly for signs of growth and morphology.
Identification
As soon as growth has been detected, the culture is stained to determine if acid-fast organisms are present. Sometimes the growth is made up of other bacteria which are not acid-fast, and the specimen is then reported as "Contaminated." Cultures showing acid-fast organisms are tested by High Performance Liquid Chromatography (HPLC) to determine the identification of the organism.
Drug Susceptibility Testing
Drug susceptibility testing is performed only on M. tuberculosis complex organisms. Each new isolate is automatically tested at the time of identification, and testing is repeated every three months if the organism is still being isolated from culture. Results are usually available within 10-14 days after identification of the organism. Susceptibility testing is performed using the BACTEC 960 MGIT procedure with a panel of three drugs (isoniazid, rifampin, and ethambutol) initially. If any of the drugs show resistance, the test is repeated, and streptomycin is added to the panel. Isolates which are resistant to one or more drugs are sent to the Centers for Disease Control and Prevention for testing with an expanded drug panel. The CDC drug testing usually requires approximately 4-6 weeks. Reports on isolates showing drug resistance for the first time are called to submitters as soon as results are available.
Results for all mycobacterial testing are reported electronically to the submitter as soon as they are available. In addition, copies of reports for positive specimens (i.e. positive AFB smears, positive TB identification, and susceptibilities) are sent to the Georgia TB Control Program. Test results will only be released to the submitter of the specimen.
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UNACCEPTABLE SPECIMENS 1. No patient identifier on specimen or culture. 2. No specimen received (empty collection tube). 3. Specimen leaked or was damaged or crushed in transit. 4. Wrong type of specimen submitted. 5. Patient identifier on specimen does not match that on form.
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INTESTINAL PARASITES 404-327-7961/7963
INTRODUCTION
The Parasitology Unit accepts fecal specimens to be examined for human parasites from all county health departments. Reference specimens for confirmation of parasite identity or further identification are accepted from all laboratories and health care providers. Diagnosis of most intestinal parasitic infections is dependent upon finding the eggs or larvae of helminthes and trophozoites or cysts of protozoa in feces by microscopic examination. If particular infections are suspected, please alert our laboratory to your suspicions. Molecular methods are more sensitive than microscopy and may be required for the differentiation of morphologically identical Entamoeba histolytica and the non-pathogenic Entamoeba dispar as well as the different species of malaria parasites, Cyclospora and Cryptosporidium. In such instances, a fresh sample of stool preserved in potassium dichromate or unpreserved frozen specimen is preferred.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
All specimen containers should be properly labeled with the patient's name and date collected. It will be marked unsatisfactory and discarded if the patient's name is not on this container. The submission/report form should be filled out completely. When outfits are picked up or shipped in bulk the instruction sheets and submission form may be placed in the box with the specimen containers.
A. IP (formalin)/LV-PVA outfit: Only specimens preserved in 5% or 10% formalin and LVPVA should be submitted. Follow the instructions provided in the kit for collecting the stool sample. The kit systems are packaged in ziplock bags with illustrated, multilingual patient instructions to assist in safe and sanitary specimen collection by personnel and/or patients. Remove vials from ziplock bags and discard the bag. Do not contaminate specimen with dirt, urine, or paper. The ingestion of antidiarrheal compounds, antacids, bismuth, and mineral oils may also interfere with the diagnosis of parasites. Complete two Form 3414 per patient (1 for IP and 1 for PVA); fold completed forms in half and place in outside pouch of the biohazard bag. Three kits (per patient), collected on consecutive days that you have a bowel movement, should be sent for testing (e.g., one collected on Monday, one collected on Tuesday, and one collected on Thursday). We ask you to send in both the IP (5% or 10% formalin) and the LV-PVA because we see different organisms when these preservatives are used. If both containers are sent, we can diagnose Giardia lamblia, Entamoeba histolytica, Dientamoeba fragilis, Cryptosporidium sp., Cyclospora, Microsporidium, and all the helminth eggs and larvae. The LV-PVA container is a must for Dientamoeba fragilis and Entamoeba histolytica. Please make sure the patient's race/nationality and foreign travel is marked on the submission form. Please write the patient's last name then the first name on the submission form to avoid confusing the two names for data entry and reports and records. Intestinal worms shed eggs intermittently and in varying numbers,
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and certain protozoan cysts are shed in "showers"; therefore, we request three consecutive day specimens on each patient. An individual's report may be positive one day and negative the next day due to this shedding. If you only return 1 kit (IP/LV-PVA), we only have a 30% chance of recovering the organism, 90% chance if 3 kits are returned
B. Potassium dichromate outfit for PCR: Feces can be tested by molecular diagnostic procedures. Follow steps as in A above for collection of fecal specimen. Collect fecal specimens according to instructions. Do not contaminate specimen with dirt, urine, or paper. Place enough feces in container to bring the liquid up to the red line; mix thoroughly. Place in the biohazard transport bag; seal and complete appropriate form; fold completed form in half and place in outside pouch of the biohazard bag. Place biohazard transport bag in the fiberboard mailing container, secure lid and mail. Please make sure the patient's race/nationality and foreign travel is marked on the submission form. Please write the patient's last name then the first name on the submission form to avoid confusing the two names for data entry and reports and records.
C. Pinworm Outfits: Because the female Enterobius vermicularis (Pinworm) leaves the intestinal tract to lay her eggs around the anal opening, we have a special collection outfit to collect these eggs. The specimen needs to be immediately collected upon the patient's awakening in the morning since the eggs may be lost later during the day as a result of scratching, bowel movement or bathing. Collect the specimen following the printed instructions for Pinworm Slide Outfit. Do not let feces get on the tape or slide. Place slide inside the cardboard mailing container and close the top. Make sure patient's name is written on the cardboard mailing container label. Place container with slide inside the mailing envelope. Complete Form 3414.
D. Whole Worms or Proglottids: At times individuals will pass whole worms or small white segments (Proglottids) with feces; these should be separated from the feces and preserved in 70% alcohol. If the worm/Proglottids cannot be separated, please note on the submission form that worms or white segments were seen upon collection. If worms/proglottides were passed without feces, they should also be preserved in 70% alcohol. Place in a plastic or glass container to mail. Make sure the patient's name is on the container. Complete Form 3414.
SHIPMENT OF SPECIMENS
Specimens may be delivered to the laboratory by courier, shipped by common carrier, or mailed. Be sure specimens are placed in the correct mailing container; otherwise they may get lost in shipment or be delayed in delivery. The double-walled mailing containers for submitting fecal specimens are available from Laboratory Services and Supply (404-3277920). The round fiberboard-mailing container is not necessary for specimens delivered by courier. Place several biohazard transport bags containing specimens in a box or a large envelope for courier delivery. Parasitologic specimens sent through the mail have to conform to postal regulations. If a screw-cap outer container is used to mail the specimen, the screw cap must be secured with tape or the Postal Service will return it for taping. It is
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the responsibility of the sender to make sure any viable or preserved biological material conforms to the most recent postal regulations. When unusually large numbers of specimens are anticipated (such as outbreak situations), the Parasitology Unit should be alerted so that preparations may be made (404-3277961/7963).
REPORTING AND INTERPRETATION OF RESULTS
The turn around time for the diagnosis of intestinal parasitic infections is 24-72 hrs depending on the volume of specimens received. For all other miscellaneous specimens the turn around time is 12-24 hrs. Results of specimens sent to CDC for identification or confirmation may take up to two weeks. If there is an emergency situation, the specimen will be considered stat and immediately processed, and reported. Please notify us when you have an emergency. The Laboratory Findings section of the report form contains the results of our examination. The extent of testing informs the submitter the actual test that we performed. If the report indicates the presence of pathogenic parasites, the patient needs to be treated. Nonpathogenic parasites are also reported, but their presence indicates hand to mouth fecal contamination. Unsatisfactory results indicate the specimen was compromised in a way that might render the test results invalid. Below is the list of unsatisfactory specimen submissions.
Our new MLAB-EE laboratory data management system allows submitters with internet access to view and print results online. Laboratory results become available to the submitters upon verification by the testing personnel.
UNACCEPTABLE SPECIMENS
Formalin and LV/PVA Specimens 1. No patient identifier on specimen container. 2. No specimen (submission form only) received. 3. No feces (container only) received. 4. No preservative in container. 5. Severely leaked in transit and are considered a hazard to open. 6. Urine submitted instead of feces. 7. Multiple specimens collected on the same day (one specimen will be tested). 8. Insufficient material to examine. 9. Specimens submitted in Para-Pak C&S Outfit (for enteric bacteria). 10. Inappropriate specimen/collection outfit for test requested. 11. Refractile material interfering with diagnosis. 12. PVA solution jelled. 13. Frosted tape used for pinworm collection. 14. Pinworm tape stuck to applicator paddle. 15. Feces or powder on pinworm slide or tape. 16. Slide broken in transit.
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BLOOD AND TISSUE PARASITES 404-327-7961/7963
INTRODUCTION
The Parasitology Unit examines specimens for blood and tissue parasites. Due to the ease of foreign travel and the influx of immigrants and refugees, it is very important to fill out patient history on the form. Some "exotic" parasites enter this country by travelers who visit or those who come from a foreign country. We need to know any recent health problems, symptoms, travel history, place of residence, typical and unusual food preferences and environmental exposure. Many parasites have well-defined geographical ranges and unless an individual has traveled or resided within an endemic or enzootic zone, infection with the parasite is unlikely. There are other situations individuals may become infected with blood parasites. Ones to consider are - blood transfusions, use of hypodermic needles contaminated by prior use, possibly congenital infection and transmission in the United States by indigenous mosquitoes that acquired the parasites from imported infections. Food fads have introduced new parasites into the human population. Some of the blood and tissue parasites that we examine are malaria, microfilaria, Trypanosoma, Isospora, and Babesia. Molecular methods are used to confirm a diagnosis. The advantages of this method over the traditional blood film examination include (1) ability to detect lower parasitemia (2) confirmation of false-negative results by microscopy as true positive and (3) identification of organisms to the species level even in mixed infections. Parasites in human tissue are also examined in our lab, but are often sent to a reference lab for confirmation.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
Presently, the microscopic examination of blood parasites in stained blood smears offers the most accurate and reliable method of laboratory diagnosis of malaria and other blood parasites. The morphologic features of protozoan parasites such as malarias, trypanosomas, and babesias are demonstrated in these smears. In order to diagnose the malaria parasites, thick and thin blood smears are required. The most favorable time for collecting blood for making the smears would be halfway between the chill/fever. Prepare three thick and three thin smears immediately from capillary blood (fingerstick) or within one hour from venous blood, using EDTA as an anticoagulant. If possible the smear should be stained with Giemsa stain. If you do not have the capability of staining, send it as soon as possible. Morphological changes can occur within one hour of taking the blood. These changes make it very difficult to diagnose the species. An EDTA tube of blood (2 ml.) should be sent with smears. If necessary the EDTA blood is used for DNA extraction for PCR procedure. The Unit will request that you submit original slides (one that is stained and atleast one thin and one thick unstained slide) as well as one tube of EDTA preserved blood.
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Blood Parasites
A. Thick smear preparation
1. Cleanse the finger-tip with alcohol and allow to dry thoroughly. 2. Puncture the skin deeply enough to allow the blood to well up in a large drop. Do not
squeeze the finger; this will dilute the blood with tissue fluid. 3. Touch the clean slide to the crest of the drop of blood, or place a drop of venous
blood using a Pasteur pipette, in the center of the slide. 4. With a wooden applicator stick, using a circular motion spread the blood to the size of
a dime. The thick smear should just be thick enough so that newspaper print can barely be read through it. Do not place a large a drop of blood on the slide. Too much blood will cause it to flake off the slide after drying. 5. Allow the smear to air dry in a flat, horizontal position so that the blood will be evenly distributed. Protect from dust and insects (roaches enjoy eating the blood on the slide). Do not fix with alcohol. 6. Write patient identifier number or name, and the date the smear was made on the frosted-end portion of the slide. Place in the cardboard mailing container with completed Form 3415.
B. Thin Smear Preparation
1. Cleanse the fingertip with alcohol and allow to dry thoroughly. 2. Puncture the skin deeply enough to allow the blood to well up in a large drop. Do not
squeeze the finger; this will dilute the blood with tissue fluid. 3. Touch the clean slide to the crest of the drop of blood, or place a drop of venous
blood using a Pasteur pipette, at the frosted end of the slide. 4. Hold a second spreader slide at a 40-45-degree angle and touch edge of blood, allow
blood to spread by capillary action along the edge of the slide. 5. Rapidly and smoothly push the spreader slide to the opposite end of the slide while
pulling the blood behind it. The smear should have a feathered edge. 6. Air dry at room temperature. Protect from dust and insects. Remember that roaches
will eat the blood on the slides. 7. Write patient identifier number or name, and the date the smear was made on the
frosted end portion of the slide. Place in the cardboard mailing container with completed Form 3414.
Tissue Parasites
Histology preparations from biopsy material are prepared in the hospital or private laboratories and mailed to our lab for review, consultation, or confirmation. Most of these smears are H&E or Giemsa stained. Place patient identifier number or name, and the date the smear was made on the frosted end portion of the slide. Place in a cardboard mailing container with completed Form 3414.
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SHIPMENT OF SPECIMENS
Specimens may be delivered to the laboratory by courier, shipped by common carrier, or mailed. Be sure specimens are placed in the correct mailing container; otherwise they may get lost in shipment or be delayed in delivery. The mailing containers for submitting blood and tissue specimens are available from Laboratory Services and Supply (404-327-7920). The round fiberboard-mailing container is not necessary for specimens delivered by courier. Place several biohazard transport bags containing specimens in a box or large envelope for courier delivery. Prepared slides can be packed in boxes, cardboard slide holders, or any other suitable container that will prevent damage or breakage. Specimens for Parasitology sent through the mail have to conform to postal regulations. If a screw-cap outer container is used to mail the specimen, the screw cap must be secured with tape or the Postal Service will return it. It is the responsibility of the sender to make sure any biological material preserved, or viable, conforms to the most recent postal regulations.
REPORTING AND INTERPRETATION OF RESULTS
Specimens are reported as quickly as possible. The specimen results may be reported the same day that they are received. We strive for a 12-24 hour turn around time. If there is an emergency situation, the specimen will be considered stat and immediately processed, and reported. Please notify the lab of any emergency. Malaria parasites are identified to species when possible. The four species reported are Plasmodium malariae, Plasmodium ovale, Plasmodium vivax and Plasmodium falciparum. At times when species diagnosis cannot be made from the smears a PCR test is performed if blood is available to determine the species. This may delay the reporting in some cases.
PCR results in some areas of parasitology are considered experimental and are provided for information only.
At times, we report a specimen unsatisfactory. Unsatisfactory results indicate the specimen was compromised in a way that might render the test results invalid. Below is the list of unsatisfactory specimen submissions.
UNACCEPTABLE SPECIMENS
Blood and Tissue Parasites 1. No patient identifier on specimen container. 2. No specimen received. 3. Smear is too thin or too small. 4. Smear damaged by flies or roaches. 5. Smear is improperly dried. 6. Thick smear is too thick (portion flaked off). 7. Thin smear not feathered at the end. 8. Grease on slide. 9. Smear improperly fixed. 10. Blood coagulated or dried up.
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MISCELLANEOUS SPECIMENS 404-327-7961/7963
INTRODUCTION
The Parasitology Unit examines specimens collected from the environment as well as from humans for identification. There are many arthropods of medical importance that transmit diseases to man and other animals. Transmission may be mechanical or biological. Some of the common vectors that are sent in are flies, midges, lice, bedbugs, ticks, mites, chiggers, spiders and many more. Some specimens sent in for identification are pseudoparasites and artifacts. These need to be distinguished from the true parasite because of the physical and mental relief it has upon individuals. Parasites such as Entamoeba histolytica, Giardia lamblia, Cryptosporidium parvum, Cyclospora cayetanensis and Microsporidia spp. can cause waterborne and foodborne illness.
We have the capability of capturing images of parasites with our digital camera set up and transmitting them by Internet access to our submitters. This is used for reference and training purposes.
SPECIMEN COLLECTION/LABELING/SUBMISSION FORM
All specimen containers/slides should be properly labeled with the patient's name, date collected, and time of collection. It will be marked unsatisfactory and discarded if the patient's name is not on the container/slide. When outfits are picked up or shipped in bulk, the instruction sheet and the submission form may be placed in the box with the specimen containers. Complete Form 3414 for each specimen type submitted.
A. Skin scrapings: Gently scrape the skin with a scalpel. Collect the scrapping on a piece of paper and transfer into a bottle containing 70% alcohol.
B. Impression Smears: Smears from the aspirated material/tissue can be made and examined for parasites. To prepare the smear, press the material/tissue to the slide, air dry, and fix if needed.
C. Arthropods: Place in 70% alcohol or on a pad of tissue or loose cotton to avoid damaging fragile body structures. Do not place on cellophane tape. Place in plastic or glass container and mail.
D. Water Samples for Giardia/Cryptosporidium: Water samples thought to be the source of human giardiasis or cryptosporidosis will be accepted by special arrangement. Please contact your local County Health Department's environmental specialist to collect the water and notify the laboratory before submitting the water sample. Three gallons of water need to be collected in sterile containers and sent to the lab. We would ask that one gallon be from the well-head, one from an inside faucet and one from an outdoor faucet. Before the water is accepted for testing, a positive test for
47

Giardia/Cryptosporidium infection must be confirmed in stool specimens of people who have used the water. Complete Form 3414, one for each location that water was collected.
E. Worms for Identification: When worms are found in diapers, on bed linens, in the toilet bowel, etc., they should be retrieved as carefully as possible and placed in a bottle containing 70% alcohol. Some of the worms have delicate structures used for identification and should be collected carefully. Make sure the patient's name is on the container.
SHIPMENT OF SPECIMENS
Specimens may be delivered to the laboratory by courier, shipped by common carrier, or mailed. To avoid delay, loss or damage during shipment specimens must be sent in appropriate container. It is the responsibility of the sender to ensure that any specimen sent through regular mail conforms to most recent postal regulations.
A. stool: Double-walled mailing containers are available from Lab Services and Supply (404-327-7920). The round fiberboard-mailing container is not necessary for specimens delivered by courier. Several specimens in separate biohazard transport bags may be placed in a box or a large envelope for courier delivery.
B. blood: The mailing containers for submitting blood and tissue specimens are available from Laboratory Services and Supply (404-327-7920). Prepared slides can be packed in boxes, cardboard slide holders, or any other suitable container that will prevent damage or breakage.
C. miscellaneous samples: If a screw-cap outer container is used to mail the specimen, the screw cap must be secured tightly with cellophane tape so as to avoid leakage. The Postal Service will not deliver leaky biological materials. Specimens are to be packaged in suitable boxes and sent to the lab by the sender's preferred method of shipment.
REPORTING AND INTERPRETATION OF RESULTS
Specimens are reported as quickly as possible. The specimen results may be reported the same day that they are received. We strive for a 12-24 hour turn around time. If there is an emergency situation, the specimen will be considered stat and immediately processed, and reported. Please notify the lab or any emergency. If we have to send it to a reference lab, it may take up to two weeks to get the results back. PCR results in some areas of parasitology are considered experimental and are provided for information only.
At times, we report a specimen as unsatisfactory. Unsatisfactory results indicate the specimen was compromised in a way that might render the test results invalid. Below is a list why the report may have been marked unsatisfactory.
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UNACCEPTABLE SPECIMENS Arthropods and Misc. Specimens 1. No patient identifier on specimen container/slide. 2. No specimen received. 3. Smear is to thin or to small. 4. Smear damaged by flies or roaches. 5. Smear is improperly dried. 6. Sample amount is insufficient for accurate diagnosis. 7. Identifying structure is missing. 8. No preservative in container. 9. Severely leaked in transit and considered a hazard to open. 10. Slide or container broken in transit.
TELE-DIAGNOSIS 404-327-7961/7963
The DPDx project DPDx is a Web site developed and maintained by CDC's Division of Parasitic Diseases (DPD) that uses the power and speed of the Internet to assist laboratories and pathologists in parasite identification within and outside the United States. The Georgia Public Health Laboratory uses this technology to view images submitted for diagnosis by labs that are equipped to send images and was one of the first beneficiaries of the DPDx program. The diagnosis DPDx is also used to strengthen and expedite diagnosis of parasitic diseases via e-mail from minutes to hours. The consultation and assistance is provided free of charge by the DPDx staff. In addition to the diagnostic assistance, the DPDx also offers a Reference and Training function which enables you to browse through concise reviews of parasites and parasitic diseases, an image library and a review of recommended procedures for collecting, shipping, processing and examining biologic samples are available at http://www.dpd.cdc.gov/dpdx.
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HUMAN IMMUNODEFICIENCY VIRUS SEROLOGY 404-327-7980
INTRODUCTION
Serologic assays are available for the detection of antibodies to the human immunodeficiency virus (BioRad HIV-1/2 plus O). An enzyme immunoassay (EIA) is used as a screening test for antibodies to HIV. All reactive EIAs are repeated in duplicate to verify the initially reactive test result. All repeat-reactive EIA tests (two or more reactive EIAs) are confirmed by the Western Blot (WB) Assay. If the HIV-1 WB is indeterminant or negative, HIV-2 antibody needs to be ruled out by confirming with CDC.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
Using Universal Precautions, and standard venipuncture technique collect approximately five milliliters of whole blood (or serum) in a red top tube (no additive), labeled with patient's identifier, date, and name of the submitter, use a marker that will not fade, smear, or run during transportation. Use proper size needle (large enough to prevent hemolysis of the red blood cells) for the vein location and age of the patient. Wrap the specimen in the absorbent packing paper provided to absorb any fluid from leaking or broken specimens (do not use rubber bands or tape). Place the wrapped specimen inside a biohazard bag. Place the completed Virology submission form (Form 3595, Rev. 1/2010) in the pouch of the biohazard bag. Allow blood specimen to clot and transport, or place in the refrigerator if not transporting at that time. Do not hold over seven days before transporting.
Requisition form
The Routine HIV-1 Ab Screen test request is included in the attached Virology submission form. Order the test by checking the box for routine HIV-1 Ab Screen. The Virology Submission Form #3595 rev. 1/2010 is found at the Georgia Public Health Laboratory website http://health.state.ga.us/pdfs/lab/HIVsubmission-singlepage.pdf and includes the following:
1. Unique patient identifier (number not name). 2. Test(s) requested. 3. Date specimen collected. 4. Submitter's name, address, and code. 5. Any information submitter needs for patient identification, e.g., chart number,
address, physician name, contact person and phone number. 6. Race, sex and age/DOB.
SHIPMENT OF SPECIMENS
Specimens may be mailed, shipped by common carrier, or delivered to the laboratory by courier. Place the biohazard bag with its contents inside the cardboard outer can. Place only one or two specimens in the cardboard can so that they can be removed without
50

mishap. If a screw-cap mailer is shipped by the Postal Service, the cap must be secured by tape, or the Postal Service will return them for taping. Be sure to use the proper mailing label for the final specimen destination. Virology HIV outfits can be obtained from Laboratory Services and Supply, telephone number is (404) 327-7920.

REPORTING AND INTERPRETATION OF RESULTS

The following chart provides information regarding turn-around times (the time the specimen is received to the time the test is completed) and interpretations.

DESCRIPTION
HIV Antibody Screening
HIV Antibody Confirmation

TEST PROCEDURE
EIA
Western Blot

TURNAROUND TIME
2-3 working days
5-7 working days

When EIA results are negative, the test results will be reported as "Negative" and no further testing will be required.

The Georgia Public Health Laboratory uses the APHL/CDC criteria shown below for the interpretation of the Western Blot.

Interpretation Negative Indeterminate
Positive

Criteria The absence of any and all bands-not just viral bands.
The presence of any viral or non-viral band or bands that fail to meet the positive criteria. The presence of any two of the following bands: P24 Gp41 Gp120/gp160

Reference: Centers for Disease Control. Interpretation and Use of the Western Blot Assay for Serodiagnosis of Human Immunodeficiency Virus Type 1 Infections. MMWR 1989;38:17.

The following recommendations are made regarding follow-up specimens: 1. If the result of a Western Blot is indeterminate, submit another specimen for testing
within a month. If the second specimen is also indeterminate, the patient should be tested again at three and six months. 2. When a patient receives his/her first positive test result and has not identified a high risk behavior, collect a verification specimen at the time the patient is given the results of the first test.

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Interpreting Routine HIV EIA Screening and WB Results 1. Specimens that are initially Non-Reactive by HIV-1/HIV-2 PLUS O EIA will be reported
as negative for HIV-1 (M and O Groups) and HIV-2 antibodies. 2. Specimens that are initially Reactive by HIV-1/HIV-2 PLUS O EIA are retested in
duplicate to validate the initial test results. If, after repeat testing, both duplicate specimens are Non-Reactive results will be reported as negative for HIV-1 (M and O Groups) and HIV-2 antibodies. 3. If, after repeat testing, either of the duplicates are Reactive the result is considered repeatedly reactive. Repeat-reactive specimens will be confirmed by HIV-1 WB. If HIV-1 Ab Screen and WB results are positive, the results will be reported as positive for HIV-1 (M and O Groups), and appropriate follow-up (e.g., referral for HIV-related medical evaluation/care) should be conducted with the patient. 4. If the HIV-1 WB is indeterminant or negative, the results will be reported as indeterminant or negative, and GPHL will submit a sample to CDC to test for HIV-2.
UNACCEPTABLE SPECIMENS 1. ID on form and specimen do not match (ID mismatch). 2. No ID on form. 3. No name on form or tube. 4. No ID on specimen. 5. Over 14 days old. 6. Broken in transit. 7. Insufficient quantity for testing (QNS). 8. No sample received with form.
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INTRODUCTION

HIV-1 VIRAL LOAD TESTING 404-327-7980

The Versant HIV-1 RNA 3.0 Assay bDNA is an in-vitro signal amplification nucleic acid probe assay that is performed on plasma of confirmed HIV-1 positive patients to determine the level of infection and is not a diagnostic test for HIV infection. Currently, this test is offered to patients in the Ryan White Program in the management of individuals infected with HIV-1. Evaluation of HIV-1 RNA levels is valuable in the clinical assessment of disease progression prior to initiation of therapy, in monitoring the progression of infection and in assessing a response to anti-retroviral therapy. The Versant HIV-1 RNA 3.0 Assay uses the (bDNA) technology to achieve the quantitative detection of HIV-1 RNA. The results received in the Versant HIV-1 RNA 3.0 Assay test procedure are reported as HIV-1 RNA copies/ml and log copies/ml. The bDNA test has a linear range of 75-500,000 copies/ml.

SPECIMEN COLLECTION/LABELING/REQUISITION FORM
1. Follow all safety precautions when drawing blood from patients. 2. No special patient preparation is necessary before collection. Use proper size needle
(large enough to prevent hemolysis of the red blood cells) for the vein location and age of the patient. 3. Please collect all specimens in a sterile collection tube with EDTA as the anticoagulant or in the Prepared Plasma Tube (PPT) provided by the Georgia Public Health Lab (GPHL). 4. Collect one PPT tube using standard venipuncture techniques. After collection of the whole blood in the PPT tube, gently invert the PPT tube 8-10 times.
5. Label the specimen with the patient's identification number, submitter code and the date.
6. Centrifuge the whole blood specimen for a minimum of 10 minutes at 1,100xg at room temperature within two hours of collection.
7. Place the specimen in a biohazard bag and store in a refrigerator at 4o C for no longer than 72 hours instead of freezing. If longer storage is required, the plasma should be transferred to a secondary tube prior to freezing with at least 2.5 ml plasma.

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Requisition form
The Virology Submission Form #3595 rev. 01/2010 may be found at the Georgia Public Health Laboratory website http://health.state.ga.us/pdfs/lab/HIVsubmission-singlepage.pdf and include the following:
1. Unique patient identifier number. 2. Date specimen collected. 3. Submitter's name, address, and code, if applicable. 4. Check the "Viral Load bDNA" box. 5. Any information submitter needs for patient identification, e.g., chart number, or
address. 6. The date of onset of illness, if applicable. 7. Race, ethnicity, sex and age.
Place the HIV form in the pouch of the biohazard bag along with the specimen so that it is ready for courier pickup.
SHIPMENT OF SPECIMENS
Specimens will be delivered to the laboratory by courier according to a schedule provided for your facility.
REPORTING AND INTERPRETATION OF RESULTS
The sensitivity of the VERSANT HIV-1 RNA 3.0 Assay (bDNA) is 75 copies/Ml with a linearity range of 75-500,000 copies/mL. The test results are reported as:
1. Samples with values less than 75 copies/ml are below the quantitative limit of the assay and are reported <75 copies/ml (<1.88 log copies/ml).
2. Samples with values equal to or greater than 75 copies/ml contain HIV-1 RNA in the quantity identified in the report.
3. Samples with values greater than 500,000 copies/ml are above the upper quantitative level of the assay and are reported >500,000 copies/ml (>5.70 log copies/ml).
Treatment evaluation
Viral load tests are used to help doctors determine which treatments are best for HIV positive individuals. This testing is also used to determine whether the chosen treatment is working effectively. If viral load drops more than three-fold during the treatment, the therapy is considered to be working. Healthcare providers should consider changing therapy if:
1. Viral load fails to drop at least three-fold. 2. Viral load does not fall below detectable levels (<75copies/mL) within five to
seven months. 3. Viral load rises, or drops to undetectable levels and then rises, suggesting
resistance to anti-HIV therapies.
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4. CD4 count fails to rise. 5. Clinical deterioration exists. Note: The aim of treatment is to reduce viral load to undetectable levels <75 copies/ml (<1.88 log copies/ml) for as long as possible. A result of 10,000 to 20,000 copies/ml and below is considered low, while 50,000 copies/ml and above is considered high. UNACCEPTABLE SPECIMENS 1. No ID on form. 2. No name on form or tube. 3. No ID on specimen. 4. ID on specimen and form do not match. 5. Not approved for testing by the indicated method, e.g., blood for VDRL. 6. Serum instead of plasma. 7. Grossly hemolyzed, lipemic, turbid, or contaminated. 8. Broken in transit. 9. With an insufficient quantity for testing (QNS).
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RABIES 404-327-7980
INTRODUCTION
The Virology Unit accepts animal heads submitted for testing rabies in accordance with the Georgia Rabies Animal Control Manual for testing at the Central Laboratory in Decatur. The goal is to report an accurate and reliable diagnosis so that rabies treatment can be initiated or terminated as necessary. The current methodology for rabies detection is the direct fluorescent antibody (DFA) test, which is the most accurate microscopic test available for the diagnosis of rabies. The key factor in obtaining quality results is the condition of the specimen received. Due to the importance of rabies diagnosis, the specimen must not be compromised.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
1. Only specimens received in good condition with at least two identifiable principal brain parts are approved for reporting test results. Brain parts must include the cerebellum and the brain stem.
2. In all cases, there must have been exposure of human or domestic animals to the suspected rabid animal.
3. The Virology Unit is not equipped to handle whole carcasses; therefore, only the head is accepted as a specimen, except bats and animals of similar size, which should be submitted whole. Whole carcasses of any larger animal will be returned to the sender for resubmission.
4. The following guidelines are recommended for the removal of animal heads: (Whenever possible, this procedure should be performed by a person who has received pre-exposure rabies vaccine). a. Protective gloves and clothing as well as face and eye protection should be worn while the head is being removed and packaged. b. Sever the head between the foramen magnum and the atlas so as not to damage the skull. Local veterinarians or trained animal control personnel can assist in this removal. Never advise clients to remove animal heads! c. Allow fluids and blood to drain from the head. Keep the head as clean as possible and place the head in a double plastic bag for transport to the laboratory. d. If fleas or ticks are present, spray insecticide into the plastic bag containing the head before closing. Do not send maggots. e. Gloves should be cleaned and disinfected or discarded following use, and cutting surfaces and instruments should be thoroughly cleaned and disinfected.
5. Only brain material (not the entire head) of very large animals (e.g. cows/horses) will be accepted, as the laboratory is not equipped to handle these large heads due to limited hood and sterilizer space. Removal of the brain should only be attempted by a
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veterinarian. Whole heads of large animals received by the laboratory will be returned to the sender for resubmission of the brain only. 6. Rodents (rats, rabbits, mice, gerbils, hamsters, guinea pigs, chipmunks,, squirrels, moles, etc.) are not usually involved in the rabies cycle and will not be accepted for testing without prior arrangements with the Epidemiology Branch (404-657-2588) or the Georgia Public Health Lab in Decatur (404-327-7980). 7. If specimens cannot be delivered to the laboratory immediately, refrigerate, but do not freeze. Frozen specimens cannot be tested until they thaw, which may cause a delay in reporting. 8. Do not send tissue in a preservative such as formalin, as rabies testing cannot be performed on such specimens.

Requisition Form

1. A Rabies Submission Form #3062 should accompany each specimen submitted for

rabies examination. This form should be filled out completely and legibly, making

sure to include accurate addresses and phone numbers for use in reporting results. If

you do not have a GPHL submitter code, please call GPHL at 404-321-2240 to have

one assigned to you prior to submission.

2. The Rabies Submission Form #3062 may be found on the Georgia Department of

Community

Health

website

at

http://state.health.ga.us/pdfs/epi/zvbd/Rabies%20submission%20form.pdf. Fill out the

form completely and legibly. Include accurate addresses and phone numbers for

reporting.

3. A copy of the rabies report is forwarded to the Georgia Department of Community

Health Office of Epidemiology for data collection and review. Rabies reports are kept

for a period of three years.

SHIPMENT OF SPECIMENS

Containers for rabies shipment are available from the Decatur Central Lab Virology Unit (404-327-7980).

1. Properly package the specimen by placing the animal head in a double plastic bag and secure the bag by twisting and knotting. For bats or similar size animals, do not remove heads, but submit the whole animal. For large animals (e.g. cows, horses, bears, goats, etc.) submit the brain only.

2. Place the sealed bag containing the specimen on top of the cold packs in the shipper container. Seal the Styrofoam shipper. Place the completed submission form in the brown envelope, and tape to the lid of the sealed shipper. Place the shipper in a cardboard box and tape the address for shipment. Do not seal the box until shipment, so the animal control officer can inspect the container.

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3. The package should be shipped prepaid to the Virology Unit. Use a method of shipment that will assure prompt delivery such as Greyhound, Federal Express (FedEx) or UPS next day.
4. Any bite case in which the case history reveals a strong probability of rabies, particularly in a case of human exposure, should be handled with utmost speed. Call the Virology Unit ahead of time and advise the laboratory of expected time of arrival if rabies detection test need to be done same day. Hand deliver such specimens to the laboratory.
5. Avoid shipping specimens on weekends or holidays without prior approval. A better alternative is to refrigerate and ship on Monday, unless the test result is urgent.
6. Rabies outfits can be obtained from the GPHL Virology Unit; the telephone number is (404) 327-7980. The Virology Unit does not furnish cold packs.
REPORTING AND INTERPRETATION OF RESULTS/CONSULTATION
Rabies testing is available Monday through Friday. All results are called to the submitters and reports will be issued the next business day following the receipt of the specimen, provided the specimen is received by 10:00 a.m. Reporting will be delayed on specimens that are received frozen.
1. Specimens received on Friday or those involved in emergency situations such as severe human head or neck exposures or human exposure for which emergency testing has been approved by Epidemiology Branch at 404-657-2588) will be tested and reported the same day received.
2. If the brain is damaged or decomposed to the point that the laboratory is uncertain as to whether the specimen is, in fact, the appropriate brain tissue, testing will not be done. Report will read "Unsatisfactory" with the comment: "brain tissue is damaged or decomposed beyond recognition of at least two identifiable brain parts." Only in case of human or animal exposure will the specimen be tested. If the test is positive, we will report as such. If the test is negative, a report of "Unsatisfactory" will be made with the comment: "brain tissue is damaged or decomposed beyond recognition of at least two identifiable brain parts." In this situation, an unsatisfactory test result should be managed as if positive.
3. All positive, negative, and unsatisfactory rabies results are telephoned to the contact submitter listed on the Rabies Submission form with follow-up electronic reporting (if available) or hard copy of the report sent by mail. For human exposures, the Virology lab contacts the health district office as well. Copies of each rabies submission form and results are mailed to the Georgia Public Health Epidemiology Office. All specimens should be submitted through animal control/environmental/health department only (not from victims, veterinarians office, etc).
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4. If you have any more specific questions, please refer to the Georgia Rabies Animal Control Manual at the following website: http://health.state.ga.us/pdfs/epi/zvbd/Rabies%20Manual%202007%20Final%20with %20Cover.pdf.
If you need consultation for a rabies exposure call Poison Control statewide 1-800-2825846, Atlanta (404) 589-4400, or if you have difficult or emergency cases, contact the Epidemiologist-On-Call, (404) 657-2588. UNACCEPTABLE SPECIMENS The Central Laboratory specimen acceptance policy requires that all specimens be received in good condition with at least two (2) identifiable brain parts and there must have been exposure of humans or domestic animals to the suspected rabid animal. Specimens will be reported "Unsatisfactory" with comments for the following reasons:
1. No known exposure of humans or domestic animals. 2. Brain tissue is damaged or decomposed beyond recognition of at least two (2)
identifiable brain parts. 3. Tissue in preservative such as formalin.
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VIRUS ISOLATION AND IDENTIFICATION 404-327-7980
INTRODUCTION
Virus culture provides a mechanism for the detection and identification of many human viruses which cause a wide variety of common illnesses. Viruses are isolated in cell culture and confirmed by enzyme immunoassay tests, and indirect fluorescence antibody tests. Respiratory viruses and herpes zoster virus can be detected by a direct fluorescent antibody test. Respiratory virus panel can be detected by PCR. Norovirus from gastrointestinal viral outbreaks can be detected by electron microscopy and PCR.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
Refrigerate specimens promptly after collection at 2-6o C for no more than 3 days prior to transporting. Specimens that must be held for longer intervals before transporting should be promptly frozen to 70o C or below. Avoid freezing specimens to 20o C because infectivity of viruses is rapidly lost at this temperature and they can not be recovered by culture. Any container used for viral culture specimens should be sterile.
Swab Collection Procedures: 1. Do not use calcium alginate swabs to collect specimen as it inactivates some viruses. 2. Use only transport media supplied with outfit or approved by the Virology Laboratory. 3. After collection, place swab in tube of transport medium, break off stem where
handled and discard, and cap tube. Nasal/Pharyngeal:
Swab each nostril leaving the swab in nose for a few seconds to absorb secretions. Rub the walls of the posterior pharynx with either dry swab or swab wetted with transport media. Oral: Swab oral lesions.
Eye: Use sterile swab to remove any exudate or pus present in eye and discard. Moisten second swab with transport medium/saline rubbing affected conjunctiva. An Ophthalmologist or trained physician should collect corneal specimens using a spatula.
Cervical: Use sterile swab to remove mucus from cervix and discard. Inserts second swab about 1 cm into cervical canal, rotate, swabbing lesions and remove.
Rectal: Swab rectum in a manner to collect feces.
Vesicle Fluids/Skin Scrapings: Do not prepare site with disinfectants such as alcohol or betadine as these may inactivate virus; use only after specimen collection. In the case of primary infections with herpes simplex, virus may be recovered up to 7-10 days after onset. Collect specimen
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from base of lesions. Aspirate vesicle fluid with 26/27-gauge tuberculin syringe or capillary pipette. Promptly rinse fluids collected into small volume of transport medium to prevent clotting. Swab open lesions to obtain both fluid and cells from the lesion base.
Other Collection Procedures: Throat Washings: Adults-Gargle with smallest convenient volume (10 to 20 ml) of cell culture medium or general-purpose bacteriological broth expectorates into paper cup. Pour contents of the cup into screw-cap vial. Pediatrics to be collected in similar manner, however, throat swabs is sufficient. Stools: Collect stool in a sterile container, transfer small portion (1 to 4 grams) into empty screw cap vial. Urine: Collect urine in a sterile container; refrigerate immediately at 2 to 6 degrees Celsius. CSF: Adults-obtain at least 2 ml, infants-1 ml, place in sterile screw cap vial. Do not dilute, refrigerate immediately. Serum/Blood: Although serum is rarely used to recover viruses it is a suitable specimen for isolation of enterovirus from infected infants. Autopsy/Biopsy: Aseptically collect specimens as soon as possible after death. Use separate sterile instrument for each collection site. Collect fresh tissue (1-2 grams) from affected site/lesion. Place each specimen in separate sterile container containing small amount of transport medium or saline, clearly label, and refrigerate. Specimen should not be fixed or placed in any sort of preservative solution.
Requisition Form
The Virology Submission Form #3595 rev. 1/2010 is found at the Georgia Public Health Laboratory website http://health.state.ga.us/pdfs/forms/3595.virology.pdf and must include the following:
1. Physician or contact person's name and phone number. 2. Patient's name, age and sex. 3. Date of illness onset, symptoms. 4. Submitter name/address ("send report to") box. 5. Type of specimen collected, date collected. 6. Test requested.
SHIPMENT OF SPECIMENS
For shipping instructions, refer to the transportation section of this manual
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Wrap packing material around specimen container, secure cap to prevent leakage; place the wrapped specimen inside a biohazard bag and seal tightly. Place the completed Virology requisition form #3595 rev. 1/2010 in the pouch of the biohazard bag. Place the biohazard bag with specimen in a Styrofoam shipper with adequate ice/cold packs to keep cold until the specimen is received. Dry ice is not recommended. Mail, ship common carrier or deliver by courier to GPHL, Attn: Virology Unit, 1749 Clairmont Road, Decatur, GA 30033 with deliveries made between 8:00am-4:30pm Monday-Friday. Viral culture outfits are available from the Laboratory Services and Supply, 1749 Clairmont Road; Decatur, GA 30033-4050, telephone number is 404-327-7920. REPORTING AND INTERPRETATION OF RESULTS Turn-around time (time specimen is received to the time the test is completed) for cultures varies from two to five weeks. See Table 1, for summary. Cultures yielding virus isolates may require more or less time for identification of the virus, depending upon the isolate involved. Failure to isolate a virus may be the result of a number of factors, including improperly collected specimens, specimens collected at a period in the disease when the patient is not shedding virus, improperly transported specimens, or a lack of test sensitivity. Failure to isolate a virus should not rule out the virus as a cause of the illness. Conversely, since people may asymptomatically carry a variety of viruses, viruses may be isolated which are unrelated to the current clinical illness.
UNACCEPTABLE SPECIMENS 1. Improperly identified specimens (name on tube/form do not match). 2. No identification on form or tube. 3. Specimens with insufficient quantity for testing (QNS). 4. Improper specimen type sent.
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Table 1. Viral Isolation and Identification

AGENT

METHOD

SPECIMEN TYPE

TURN-AROUND TIME

Adenovirus
Coxsackievirus Cytomegalovirus

Cell Culture/ Fluorescent Antibody(FA)/PCR
Cell Culture/ FA Cell Culture/ FA

Throat washing (TW) or throat swab (TS), NasoPharyngeal (NP) washing or swab, conjunctival swab, urine, feces TS, feces, CSF, pericardial fluid Urine, TS, buffy coat,

3 weeks for cell culture 1-2 days for direct FA 1 week for PCR
3 weeks for cell culture 5 weeks for cell culture

Echovirus Enterovirus
Herpes simplex virus Influenza Virus
Measles Virus Mumps Virus Norovirus Parainfluenza Virus Poliovirus

Cell Culture/FA Cell Culture/FA
Cell Culture/ELVIS Cell Culture/FA/ PCR

TS, feces, CSF, pericardial fluid TS, feces, CSF, pericardial fluid vesicle scraping Vesicle scraping (lesion), brain biopsy TW or TS, NP washing or swab

Cell Culture/FA

TS, Urine, CSF

Cell Culture/FA

TS, Urine, CSF

Electron Microscopy (EM) Cell Culture/FA/ PCR

Feces/stool TW or TS, NP washing

Cell Culture/FA

TS, Urine, CSF

3 weeks for cell culture
3 weeks for cell culture
3 days for cell culture
3 weeks for cell culture 1-2 days for direct FA 1 week for PCR 3 weeks for cell culture 1-2 days for direct FA 3 weeks for cell culture 1-2 days for direct FA 2 days
3 weeks for cell culture 1-2 days for direct FA 1 week for PCR 4 weeks for cell culture

Respiratory Syncytial Virus

Cell Culture/FA/ PCR

Respiratory Panel Cell Culture/FA/ PCR

Rotavirus

EM, EIA

NP washing or swab, TS
TW or TS, NP washing or swab
Feces/stool

3 weeks for cell culture 1-2 days for direct FA 1 week for PCR 3 weeks for cell culture 1-2 days for direct FA 1 week for PCR 1-2 days

Varicella (Herpes) Zoster Virus Viral Culture Confirmation and Identification

Cell Culture/FA

Vesicle Scraping

Cell Culture/EIA/FA Frozen isolate or infected cell culture

3 weeks for cell culture 1-2 days for direct FA 4 weeks for cell culture 1-2 days for direct FA

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NEWBORN SCREENING SERVICES

INTRODUCTION

Newborn screening is performed as mandated by Georgia Law. Effective January 1, 2007, Georgia law (OCGA 31-12-6 & 31-12-7) and Rules and Regulations (Chapter 290-5-24) require that every live born infant have an adequate blood test for 28 disorders. These disorders include: Phenylketonuria (PKU), Congenital Hypothyroidism, Maple Syrup Urine Disease (MSUD), Galactosemia, Tyrosinemia, Homocystinuria, Congenital Adrenal Hyperplasia (CAH), Biotinidase Deficiency, Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCAD), Sickle Cell Disorders (SS, SC, S-beta thalassemia), Isovaleric acidemia (IVA), Glutaric acidemia type I, 3-hydroxy 3-methyl glutaric aciduria (HMG), Multiple carboxylase deficiency, Methylmalonic acidemia, 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC), Propionic acidemia, Beta-ketothiolase deficiency, Very long-chain acylCoA dehydrogenase deficiency (VLCAD), Long-chain 3-hydroxy acyl CoA dehydrogenase deficiency (LCHAD), Trifunctional protein deficiency, Carnitine uptake defect, Citrullinemia, Argininosuccinic acidemia, and Cystic Fibrosis.

Newborn screening analyses are only performed on dried blood spot (DBS) specimens. Specific instructions for specimen collection, preparation of the requisition form, and guidelines for proper packaging and transport of specimens are described below. Details regarding procurement of collection kits, specimen acceptance policies, turn-around time, result reporting, and result interpretation are also given.

Reports are printed and mailed the day following completion of all testing. Results for presumptive positive specimens are faxed and/or called to the follow-up centers. For Sickle Cell Disorders, follow-up is performed by the Georgia Health Science University and the Newborn Screening Program in the Department of Community Health. For all other disorders, follow-up is performed by the Division of Medical Genetics at the Emory University School of Medicine.

Questions concerning the collection and submission of newborn screening specimens or the reporting of test results should be directed to:

Ginger Stevens, Manager Newborn Screening Phone: 404/327-7951 email: gestevens@dhr.state.ga.us

Arthur Hagar, Ph.D., Director Chemistry & Hematology Phone: 404/327-6800 email: afhagar@dhr.state.ga.us

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SPECIMEN COLLECTION/LABELLING/REQUISITION FORM
See "Blood Collection on Filter Paper for Newborn Screening Programs", CLSI Document LA4-A5, Vol. 27 No. 21
Materials Needed
1. Form 3491 is a FDA-licensed medical collection device. It consists of a form and an attached filter paper strip for collection of the specimen. A pre-addressed UPS envelope is available for hospitals. Form 3491 and the pre-addressed envelope can be ordered from: Laboratory Services and Supply, 1749 Clairmont Road, Decatur, GA 30033, (phone: 404-327-7921). Clients should order amounts that can be used within six months. Store forms upright in a cool dry area. When submitting metabolic screens to the GPHL, use only the material supplied. The filter paper collection devices must be used prior to the expiration date, which is two years from the printing date. The expiration date is printed on the filter paper portion of the form. Destroy all forms after the expiration date. The forms currently in use include a protective wraparound cover for the filter paper, and do not require an individual envelope for each specimen card.
2. 75% isopropanol
3. Sterile lancets with a point of 2.5 mm in length. A longer point should not be used, because it may pierce the heel bone. Sterile prepackaged lancets designed for pediatric use are available through private vendors.
4. Sterile gauze
5. Gloves
Recommendations for Blood Collection
a. Infants - The infants should preferably be on a protein diet 24 hours prior to collecting the blood sample. The sample should be collected between 24 hours and 72 hours of birth.
b. Early Discharge of an Infant - If the infant is discharged earlier than 24 hours after birth, or before a 24 hour period of protein feeding, a specimen should still be collected. The parents should be informed in writing that the child must be retested by one week of age.
c. Preterm, Low Birth Weight, and/or Sick Infants Infants born at less than 36 weeks gestation or who weigh less than 5 1/2 pounds (2500 grams) should be retested when the child is four weeks of age. Collect the first specimen 24 hours after protein feeding or 48 hours after birth. If the infant is transferred to a Special Care Baby Unit (i.e., NICU) prior to collection of a newborn screening specimen, a specimen should
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be collected upon admission and prior to initiation of any treatment (e.g., transfusion, parenteral nutrition, or antibiotics). A second specimen should be collected 48 72 hours after birth, and ideally at least 24 hours after any transfusion. A third specimen should be collected 28 days after birth or at discharge, whichever occurs first. For more information, see "Newborn Screening for Preterm, Low Birth Weight, and Sick Newborns", CLSI Document I/LA31-A, Vol. 28, No. 34.
Blood Collection Procedure
In order to provide sufficient blood, if retesting is required, six (6) spots of blood should be submitted. If the infant is not bleeding freely, three spots completely filled are better than five partially filled spots.
If the infant is to be transfused, collect a specimen before the transfusion regardless of the age. If the child is less than 24 hours old, collect a second sample 24 hours after the last transfusion and a third sample 4-6 months after the last transfusion.
The blood collector should wear gloves and take universal precautions for handling blood.
Collect the blood from the infant's heel, using the most medial or lateral portion of the plantar surface of the heel, where "medial" is defined as that closest to the midline of the body, and "plantar surface" as the walking surface of the foot. Do not use previous puncture sites or the curvature of the heel. Do not perform skin punctures on the central area of a newborn's or infant's foot (area of the arch) as this may result in injury to the nerves, tendons or cartilage. Do not perform skin punctures on the fingers of newborns or infants.
Warming the skin-puncture site can increase blood flow to the site. A warm, moist towel or diaper at a temperature no higher than 42o C may be used to cover the site for three minutes.
Clean the skin with an alcohol swab (75% isopropanol). Wipe off the excess alcohol with dry sterile gauze, and allow the skin to air-dry. Alcohol residue remaining on the skin may dilute the specimen and adversely affect test results.
To obtain sufficient flow of blood, forcefully puncture the infant's heel with a sterile lancet with a tip no longer than 2.5 mm, or with an automated lancet device. Wipe away the first drop of blood with sterile gauze.
Hold the infant's heel loosely so not to impede the flow of blood. If bleeding does not immediately occur, massage the lower portion of the leg in a downward direction. Avoid milking or squeezing the puncture site, because this may cause hemolysis of the specimen and/or dilute the blood with tissue fluid. If this occurs, the specimen will be rejected as "unsatisfactory, contaminated".
When a large drop of blood appears, fold back the protective wrap-around cover and gently touch the filter paper to the drop of blood. Allow a sufficient quantity of blood to soak
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through to completely fill a printed circle on the filter paper. Only apply blood to one side of the filter paper. Do not layer successive drops of blood in the printed circle. If blood flow diminishes so that the circles are not completely filled, repeat the sampling in a new circle. Examine the opposite side to be sure that blood has penetrated through to make a circle which is approximately the same size as the printed circle. Success lies in allowing the blood drop to grow to its full size, and touching with the filter paper when it is about to fall. Repeat this process until all circles are filled. Keep the cover folded away from the wet blood while it is being air-dried. Each circle should be filled with only one application of freeflowing blood. If not, the specimen will be rejected as "unsatisfactory, unevenly saturated".
After blood has been collected from the heel of the newborn, the foot should be elevated above the body, and a sterile gauze, pad or cotton swab pressed against the puncture site until the bleeding stops.
After the blood has been collected, keep the cover folded away from the wet blood. Allow the blood to dry at room temperature for a minimum of three hours by placing the form horizontally on a table top or rack with the wet blood spots extending over the edge to allow air drying from both sides. Do not place the form inside an envelope until completely dry. Do not put near a heat source, in direct sunlight, or on an absorbent surface. Do not touch the filter paper with your hand at any time.
Requisition Form
The test requisition (form 3491) is combined with the collection device (i.e., filter paper). All of the information requested on the form is important for test result interpretation or physician/parent notification. The infant's name, date and time of birth, hospital of birth, sex, date and time of specimen collection, hospital of birth, the physician of record, and the telephone number to report abnormal test results are mandatory. The birth weight, protein feeding source, and transfusion status are needed to interpret the results. Complete all fields with block print letters. To aid in researching missing reports, keep the submitter's copy of the requisition. This can be useful in tracking and identifying missing reports.
SHIPMENT
Due to the life threatening nature of several of these diseases, the law requires that the specimen collection, testing, follow-up of suspected cases, and specific diagnosis be performed before the infant is three weeks old. For this reason the blood specimen must be collected when the infant is no less than 24 hours old, but not later than one week of age. In order to expedite testing and to insure the integrity of the sample, all specimens should be shipped to the laboratory on the day of collection. Specimens must be completely dry before covering and inserting in the mailing envelope. The dried blood spot specimens must not be packaged in airtight, leak-proof bags. The lack of air exchange in the inner environment of a sealed plastic bag may cause heat buildup, moisture accumulation and/or chemical leaks from the plastic that can damage the specimen
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integrity. Once collected, specimens can either be mailed to the testing laboratory using the pre-addressed enveloped that is part of the collection device, or they may be sent by courier. Precautions should be taken that mailed specimens are not put in mail boxes. The specimen must reach the laboratory within seven days of the collection date or it will be rejected as "unsatisfactory, delayed".
REPORTING/INTERPRETATION OF TEST RESULTS
Normal results for all tests other than hemoglobins are reported as Within Normal Limits. Abnormal results for Galactosemia are reported as Positive or Inconclusive. For all other diseases, abnormal results are reported as Above Normal Limits or Below Normal Limits with the value for the `outside normal limit' analyte.
Normal hemoglobin results are reported as FA. Heterozygote results (abnormal hemoglobin plus A) are reported as traits. Homozygote abnormal results (absence of hemoglobin A) are reported as a disease. Traits that cannot be identified by the methods used by the GPHL are reported as "FA-Variant"; confirmation is recommended.
Initial tests for all diseases are performed (or, in the case of overnight assays, started) the day of receipt in the lab or the next working day. Reports are mailed to the hospital of birth and the physician of record on the day after completion of all testing. This is generally 3-4 working days after specimen receipt. All abnormal results are also reported by telephone and/or fax to the appropriate follow-up center (see above) for diagnosis, treatment, and counseling of presumptive positive results.
UNACCEPTABLE SPECIMENS
Specimens will be deemed unsatisfactory to test for the following reasons: 1. Inadequate blood collection/Quantity not sufficient (QNS) - A specimen will be
considered QNS if at least three filled and evenly soaked circles are not submitted, if the blood spot has an inadequate quantity of blood, or if the spots are not soaked completely through the filter paper. 2. Oversaturated A specimen will be considered to be oversaturated if too much blood is allowed to soak into the filter paper, causing the paper to bend, fold or crumple. Oversaturation may also result in clots on the surface of the paper. 3. Delayed A specimen will be considered to be delayed if it is received in the lab more than seven days after the date of collection. 4. Contaminated A specimen will be considered to be contaminated if there is visible evidence of dilution of the specimen with a disinfectant, alcohol, water, tissue fluid, or other foreign substance. 5. Unevenly Saturated A specimen will be considered to be Unevenly Saturated if there is visible evidence of multiple applications of blood causing a layering effect of blood on the filter paper.
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6. Capillary - Recognizable as unevenly soaked blood in a circular pattern with roughed up filter paper tracks caused by dragging the tip of the capillary across the surface of the filter paper.
7. Obsolete or wrong device The use of an expired or recalled filter paper device. 8. Roughed Up - Collection of specimen on damaged filter paper so that fibers from
paper are standing on end. 9. No Blood Collection device submitted with no blood applied. 10. No Information - Specimens without a name (infant or mother). **A training videotape titled "How to Collect Acceptable Filter Paper Specimens" is available from the Genetics Program upon request. Call (404) 657-4143 for details.
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ALBANY REGIONAL LABORATORY 229-430-4122
INTRODUCTION The Albany Regional Laboratory is a multi-function clinical laboratory which operates under the Public Health Division of the Georgia Department of Community Health. The laboratory which is licensed by the State of Georgia and the Federal Government (CLIA), is located in the District Health Building at 1109 North Jackson Street in Albany, Georgia, with Dr. E.A. Franko serving as Director.
The laboratory performs testing mandated by State Law as well as testing required by various Health and Environmental Programs. Services are available on a limited basis to private sector customers, but some may be subject to a nominal fee. The goal of the Albany Regional Laboratory is to provide timely, accurate, and reliable test results. This goal can only be accomplished by following proper specimen collection and handling procedures. The following pages are a composite of the testing performed in the Albany Regional Laboratory, with specific requirements for specimen collection and submission for each type of test. Also included are guidelines for reporting, interpretation, specimen acceptance policies, and information on expected turn-around times. A list of services for all the laboratories in the State Public Health System is also included in this manual. The Albany Regional Laboratory provides specimen collection outfits only for the services it provides. Outfits for tests performed in other State Laboratories must be ordered from the laboratory that performs that particular test. For additional information contact: Albany Regional Laboratory 1109 North Jackson Street Albany, GA 31701-2022 Telephone: (229) 430-4122
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BLOOD LEAD TESTING 229-430-4122
INTRODUCTION
The Albany Regional Laboratory performs blood lead testing on children from birth to six years of age for the Georgia Childhood Lead Poisoning Prevention Program (GCLPPP). The laboratory uses graphite-furnace atomic absorption spectrometry to analyze capillary and venous specimens. Blood lead concentrations > 10 micrograms/deciliter (g/dl) are reported to the GCLPPP for follow-up.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
I. FINGER-STICK SPECIMENS A. Preparation of Finger 1. Powder-free examination gloves should be used to avoid contaminating the specimen. 2. Thoroughly wash the patient's hands with soap and water, and dry using a clean, low-lint towel. A foam-type soap can be used if water is not available. 3. Do not let the finger to be punctured come into contact with any surface, including the patient's other fingers. 4. The finger to be punctured (usually the middle finger) must be free of any visible infection or wound. 5. Grasp the finger to be punctured between your thumb and index finger with the palm of the patient's hand facing up. 6. If not done during the washing step, gently massage the fleshy portion of the patient's finger. 7. Clean the ball or pad of the finger with an alcohol swab. 8. Dry the finger with a sterile gauze. 9. It is not recommended to puncture the fingers of infants less than one year of age. Puncturing the heel is more suitable for these children (see GDHR Child Health Manual, Section B10, #1).
B. Puncturing of Finger 1. Grasp the finger and quickly puncture it with a sterile lancet in a position slightly lateral to the center of the fingertip. 2. Wipe away the first drop of blood with a sterile gauze. (This drop contains tissue fluids that will produce inaccurate results.) 3. If blood flow is inadequate, gently massage the proximal portion of the finger and then press firmly on the digital joint of the finger. A well-beaded drop of blood should form at the puncture site.
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4. Do not let the blood run down the finger or onto the fingernail. (This blood is unsuitable for analysis and will give inaccurate results.)
C. Filling the Collection Container 1. The collection container must contain EDTA as the anticoagulant. No other anticoagulant is acceptable. These tubes have purple or lavender tops. 2. Touch the tip of the collection container to the beaded drop of blood. 3. Draw the blood into the container while maintaining a continuous flow of blood. 4. Fill the microcontainer at least have full, or to the middle line. Cap the microcontainer. 5. Holding the microcontainer between your thumb and forefinger, immediately invert the tubes several times to mix the blood and anticoagulant thoroughly. If this is not done the blood may clot. The specimen will be reported as unsatisfactory if any clots are observed, or if the quantity of blood is insufficient. 6. After filling and mixing the container, put a sterile gauze on the puncture site and have the patient or patient's mother apply pressure until bleeding stops. If bleeding continues for more than 5 minutes, consult a physician. 7. Label the container with the patient's first and last names. The specimen will be rejected if the name is missing or illegible.
II. VENOUS SPECIMENS 1. Use powder-free gloves to avoid contamination of the specimen. 2. Clean the puncture site with an alcohol swab, and dry with a sterile gauze. 3. Apply a tourniquet, and perform venipuncture using a butterfly needle of the appropriate size. 4. The vacutainer tube must contain EDTA as the anticoagulant (purple or lavender top). Allow the tube to fill to the appropriate mark. 5. Immediately invert the tube several times to thoroughly mix the blood and the anticoagulant. Specimens exhibiting clotting will be reported as unsatisfactory. 6. Label the tube with the patient's first and last names. The specimen will be rejected if the name is missing or illegible.
Requisition Form
1. Use Georgia Public Health form number 3583 (Rev. 8-01). 2. Fill out the form completely and legibly. Required fields include:
a. Submitter name, address, and phone number b. Patient name c. County of residence
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d. Patient date of birth e. Patient race, ethnicity, & gender f. Date of collection g. Collection method (capillary, venous) h. Reason for test (screen, confirmation, follow-up, other) 3. Make sure that the patient name on the sample matches the patient name of the form.
SHIPMENT OF SPECIMENS
For best results specimens should be shipped to the Albany Regional Laboratory on the day of collection. If this is not possible, specimens may be refrigerated at 2-8oC and mailed as soon as possible. The specimens may be shipped at ambient temperature.
1. Make sure the caps are on securely. 2. Wrap each specimen in absorbent packing material (kyfax), place specimens inside
the aluminum can provided; and close the can securely. Alternatively, the specimens can be placed in a biohazard bag. If a biohazard bag is used, place the requisition in the outer pocket of the bag. 3. Place the aluminum can inside the labeled (Albany Regional Laboratory address) fiberboard container. Place the lid on the container, and secure with tape. 4. Specimens must be received by the laboratory within 14 days of collection or they will be reported as unsatisfactory.
UNACCEPTABLE SPECIMENS
Specimens will be reported "No test Unsatisfactory" for the following reasons:
1. No patient identification on the specimen (first and last names much be legible); 2. Discrepancy between the patient identification on the specimen and the requisition
form; 3. Insufficient quantity for testing; 4. Specimen broke or leaked in transit; 5. More than 14 days elapsed from specimen collection to receipt in Albany Regional
Laboratory; 6. Specimen clotted; and 7. Wrong anticoagulant used (only EDTA is acceptable).
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REPORTING AND INTERPERATION OF RESULTS The laboratory strives to test all blood lead specimens on the day of arrival. Result reports are printed and mailed the day after the analysis is completed. Specimens with blood lead concentrations > 10 g/dl are considered elevated. All elevated results are called to the submitter and faxed to the GCLPPP coordinator for immediate action.
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CHLAMYDIA & GONORRHEA NUCLEIC ACID AMPLIFICATION TEST
229-430-4122
INTRODUCTION
Chlamydia trachomatis is the most common treatable sexually transmitted infection affecting females of reproductive age in the United States today, with an estimated three million new cases each year. The majority of infected females have few or no symptoms, and asymptomatic infection in females can persist for up to 15 months. Women are frequently re-infected if their sex partners are not treated. Complications of untreated chlamydial infection in females include: acute pelvic inflammatory disease; ectopic pregnancy; chronic pelvic pain; and infertility.
Neisseria gonorrhoeae affects males and females from symptoms of purulent discharge in males, a few days after exposure, to very mild symptoms in females. Symptoms may pass unnoticed with a consequence that asymptomatic carriers contribute significantly to the public health problem of gonorrhea.
The Albany Regional Laboratory uses Target-amplified direct nucleic acid amplification test for chlamydia and gonorrhea.
SPECIMEN COLLECTION/ LABELING/ REQUISITION FORM
The APTIMA Combo 2 Assay is designed to detect the presence of C. trachomatis and N. gonorrhoeae in the following specimens: endocervical and male urethral specimens, and in female and male urine specimens. Only the swabs and the specimen transport tubes contained in the APTIMA Unisex Swab Specimen Collection Kit for Endocervical and Urethral Swab Specimens can be used to collect patient swab specimens. A unisex swab is used for both male and female specimens. Swab specimens must be transported to the laboratory in the swab specimen transport medium and tube. Swab specimens must be transported to the laboratory at 2C to 30C and tested within 60 days of collection. Urine specimens must be transferred into the GEN-PROBE specimen transport tube within 24 hours of collection and before being assayed. Urine specimens can be transported to the laboratory at 2 to 30C in the urine specimen transport tube provided in the urine specimen collection kit. The fluid (urine plus transport media) level in the urine transport tube must fall within the clear pane on the tube label. After transfer, urine specimens can be stored at 2 to 30C for up to 30 days after collection.
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Use the Gen-Probe collection kits supplied by the District or County services and supply representative.
CLIENT TESTING CRITERIA:
Family Planning Clinics: All females age 29 years or younger who receive a pelvic exam during a visit (initial, annual or comprehensive medical only) will be screened for chlamydia. A female will only be screened once per calendar year for chlamydia unless she has clinical signs or symptoms of chlamydia (cervicitis/MPC, friable cervix, cervical ectopy, abdominal pain, abnormal bleeding, dyspareunia or dysuria) or a new sex partner or multiple sex partners in the past 60 days. All females 30 years and older who meet these criteria will also be screened for chlamydia.
STD/General Clinics: All females age 10-29, who receive a pelvic exam during a visit, will be screened for chlamydia. This includes rescreening females who are returning for medical problems, receiving more than one pelvic exam a year and/or are currently on antibiotics. All females 30 years and older who present with clinical signs or symptoms of chlamydia (cervicitis/MPC, friable cervix, cervical ectopy, abdominal pain, abnormal bleeding, dyspareunia or dysuria) or have a new sex partner or multiple sex partners in the past 60 days will also be screened for chlamydia. Male clients presenting for services should also be screened for chlamydia.
Teen Clinics : All females who receive a pelvic exam will be screened for chlamydia. This includes rescreening females who are returning for medical problems, receiving more than one pelvic exam a year and/or are currently on antibiotics. Males should also be screened.
All female/male clients screened for chlamydia will also be screened for gonorrhea.
Females with cervical stenosis should be included in the chlamydia/gonorrhea screening.
If the client does not have a cervix, she will not be included in the chlamydia screening.
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SPECIMEN COLLECTION:
Endocervical swab specimens 1. Remove excess mucus from the cervical opening and surrounding mucosa using the cleaning swab (white shaft swab in the package with red printing). Discard this swab. Note: To remove excess mucus from the cervical opening, a large-tipped cleaning swab (not provided) may be used. Discard the swab after use. 2. Insert the specimen collection swab (blue shaft swab in the package with green printing) into the endocervical canal. 3. Gently rotate the swab clockwise for 10 to 30 seconds in the endocervical canal to ensure adequate sampling. 4. Withdraw the swab carefully; avoid any contact with the vaginal mucosa. 5. Remove the cap from the swab specimen transport tube and immediately place the specimen collection swab into the transport tube. 6. Carefully break the swab shaft at the score line; avoid splashing the contents. 7. Recap the swab specimen transport tube tightly. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Male urethral swab specimens 1. The patient should not have urinated for at least one hour prior to specimen collection. 2. Insert the specimen collection swab (blue shaft swab in the package with the green printing) 2 to 4 cm into the urethra. 3. Gently rotate the swab clockwise for 2 to 3 seconds in the urethra to ensure adequate sampling. 4. Withdraw the swab carefully. 5. Remove the cap from the swab specimen transport tube and immediately place the specimen collection swab into the specimen transport tube. 6. Carefully break the swab shaft at the score line; avoid splashing the contents. 7. Recap the swab specimen transport tube tightly. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
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Urine Specimens 1. The patient should not have urinated for at least one hour prior to specimen collection. 2. Direct the patient to provide a first-catch urine (approximately 20 to 30 mL of the initial urine stream) into a urine collection cup which is free of any preservatives. Collection of larger volumes of urine may result in specimen dilution that may reduce test sensitivity. Female patients should not cleanse the labial area prior to providing the specimen. 3. Remove the cap and transfer 2 mL of urine into the urine specimen transport tube using the disposable pipette provided. The correct volume of urine has been added when the fluid level is between the black fill lines on the urine transport tube label. 4. Recap the urine specimen transport tube tightly. This specimen is now referred to as the processed urine specimen. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Requisition Form 1. Use the Chlamydia and Gonorrhea requisition form #3568 . 2. Fill out the form completely by printing or typing legibly. Only legible information can be entered correctly into the laboratory database. Incomplete or illegible information may delay your results. Do not use computer-generated labels for patient information. 3. Information required is as follows: a. Submitter information (submitter code, submitter address, and phone number). b. Patient information (name, patient ID number, county of residence, zip code, State, race, ethnicity, gender, date of birth). 4. Specimen information (test requested, reason for test, date collected, source of specimen, specimen status). 5. Tear off the top section of form (white copy) and mail to the laboratory with the specimen, making sure the names on the specimen and form are EXACT matches. Retain the other two copies of the form (pink and yellow) for clinic and program use. 6. Chlamydia and Gonorrhea Laboratory Submission forms should be ordered as indicated by the STD Program Office.
SHIPMENT OF SPECIMENS
For best results, specimens should be transported to the laboratory on the date of collection; however, if this is impossible, specimens may be kept at room temperature and shipped as soon as possible. Urine specimens over 30 days old and/ or swab specimens over 60 days old at the time of arrival in the laboratory will be reported unsatisfactory.
1. Chlamydia/Gonorrhea APTIMA Combo 2 specimens may be transported at room temperature. Use the specimen transport cans and Albany address labels (available from the laboratory).
2. Be sure the caps on the transport tubes are secure, and wrap each specimen in
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absorbent packing material. Place the wrapped specimen inside the aluminum can, and close the can securely. 3. Wrap the completed requisition form around the aluminum can and secure it with a rubber band. 4. Place the aluminum can inside the labeled (Albany address) fiberboard can, close, and secure the lid with tape. 5. An alternate shipping method may be utilized by substituting the BIOHAZARD BAG for the inner aluminum container. If this method is chosen, the matching requisition forms should be placed in the pouch located in the front of each bag. 6. Specimens may be mailed or shipped by the method most convenient and expedient.
REPORTING AND INTERPRETATION OF RESULTS
The goal of the Albany Regional Laboratory is to test and report all Chlamydia/Gonorrhea APTIMA Combo 2 specimens within a 3 days turnaround period, unless confirmation testing is required. An electronic copy of all positive Chlamydia and Gonorrhea reports is transmitted to the State Sexually Transmitted Disease (STD) Program. A hard copy of all positives is also mailed to the State STD Surveillance Office.
Results are reported as follows:
Positive = Positive for C. trachomatis and/or N. gonorrhoeae rRNA was detected in the specimen, and as indicated by Aptima Combo 2 Assay.
Negative = Presumed negative for C. trachomatis and/or N. gonorrhoeae rRNA.
Equivocal = Indeterminate, a new specimen should be collected.
Unsatisfactory = Specimen compromised in some manner making it unsatisfactory for testing. The reason for each unsatisfactory result will be listed on the report form.
UNACCEPTABLE SPECIMENS
Specimens will be reported unsatisfactory for the following reasons: 1. No patient identifier on the specimen, or discrepancy between identifier on the specimen and requisition form. 2. Source other than urine, cervix or male urethra. 3. Two swabs received in the collection outfit. 4. No solution in the collection outfit. 5. No swab, or improper swab (not from Gen-Probe kit) in the collection outfit. 6. Urine specimens over 30 days old and/ or swab specimens over 60 days old from date of collection when received. 7. Collection kit expired. 8. No specimen received. 9. Medical/legal specimens (Aptima Combo 2 is not intended for medical/legal cases).
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RABIES 229-430-4122
INTRODUCTION
The goal of the Albany Regional Laboratory is to confidently report an accurate and reliable diagnosis so that rabies treatment can be initiated if necessary. The Laboratory currently uses the Fluorescent Antibody (FA) methodology which is the most accurate microscopic test available for the diagnosis of rabies. One key factor in obtaining accurate results is the quality or condition of the specimen received. Due to the importance of rabies diagnosis, the specimen must not be compromised.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
1. Only specimens received in good condition with at least two identifiable principal brain parts are approved for reporting.
2. In all cases, there must have been exposure of human or domestic animals to the suspected rabid animal.
3. The Albany Regional Laboratory is no equipped to handle whole carcasses; therefore, only the heads of animals are accepted, except bats or small rodents. Bats or rodents should be submitted whole.
Environmentalists should follow these instructions for the removal of animal heads: A. Rubber gloves and protective clothing as well as face and eye protection should be worn while the head is being removed and packaged. B. Sever neck so as not to damage the skull. Local veterinarians can assist in this removal. Never advise clients to remove animal heads! C. Allow fluids and blood to drain from the head, and keep head as clean as possible. Place head in a double plastic bag for transportation to the laboratory. D. If fleas or ticks are in evidence, spray insecticide into the plastic bag containing the head before closing. E. Gloves should be cleaned and disinfected or discarded following use and cutting surfaces should be carefully cleaned and disinfected.
4. Only brain material (not the entire head) of very large animals (cows/horses) will be accepted, as the laboratory is not equipped to handle these large heads due to limited hood and sterilizer space. Veterinarians should be requested to perform this necropsy procedure.
5. Rodents or rabbits are not accepted for laboratory examination unless the animal attacks a person unprovoked. Bites from animals that constitute no risk from rabies are hamster, guinea pigs, gerbils and white mice that are obtained directly from pet shops and have never been exposed to carnivorous animals or bats.
6. Reporting will be delayed on specimens that are received frozen. If specimens cannot be delivered to the laboratory immediately, refrigerate, but do not freeze.
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Requisition Form
3. Rabies History/Report Form #3062 should accompany each specimen submitted for rabies examination. This form provides the laboratory with the needed information for accurate results.
3. Fill out the form completely and legibly, being careful to include accurate addresses and telephone numbers for reporting.
3. A copy of each rabies report is forwarded to the State Office of Epidemiology for review and data collection.
SHIPMENT OF SPECIMENS
1. Properly package the specimen by placing the severed animal head in a double plastic bag and secure the bag by twisting and knotting. For bats or rodents, do not remove heads, but submit the whole animal.
2. Place the bag containing the specimen into a shipper with wet ice. Do not use dry ice! Seal the shipper. Place the completed history form in a separate plastic bag, and tape to the lid of the sealed shipper. Place the shipper in a cardboard box, tape, and address for shipment.
3. The package should be shipped prepaid to the laboratory. Use the method of shipment that will assure prompt service.
4. Any bite case in which the history reveals a strong probability of rabies should be handled with utmost speed. Hand-deliver such specimens to the laboratory after calling ahead to inform the laboratory manager of estimated time of arrival.
5. Do not ship specimens on the weekends unless prior approval has been obtained from the laboratory manager.
REPORTING AND INTERPRETATION OF RESULTS/CONSULTATION
1. Rabies testing is available Monday through Friday excluding official state holidays. Due to the required period of tissue fixation, reports will be issued the day following the receipt of the specimen. Reporting will be delayed on specimens that are received frozen.
NOTE: Specimens involved in emergency situations, and Monday and Friday morning specimens will receive only four hours of fixation; and reports will be issued the same day if received by 10:00. Otherwise, reporting will be next day or following the weekend.
2. If the brain material found inside the skull is decomposed or damaged to the point of uncertainty about its being brain tissue, no slides will be prepared unless human exposure to the suspected rabid animal is involved.
a. No Exposure Reported "unsatisfactory" and comment is made "Test requires at least two identifiable brain parts."
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b. Exposure Routine testing is performed. If the test results are positive, a report can be issued as such. If the results are negative, a report of "unsatisfactory" is made and the comment "Test requires at least two identifiable brain parts" is added.
3. All Rabies reports are telephoned immediately to the submitter listed on the history form. Copies of each report are mailed to the submitter, County Environmentalist (County of animal), and to the State Epidemiology Office.
4. Test results may be given to concerned individuals, such as owners of animals, persons bitten, etc.
UNACCEPTABLE SPECIMENS Rabies specimens will be reported as "unsatisfactory" for the following reasons: 1. There is no known exposure to humans or domestic animals. 2. Brain tissue is damaged or decomposed beyond recognition of at least two principal
parts. 3. Tissue in preservative, such as formalin.
NOTE: See #2 under Reporting/Interpretation Section above.
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SYPHILIS 229-430-4122
INTRODUCTION
All serologic services provided by the Albany Regional Laboratory are available to both public and private sector customers. Currently the Rapid Plasma Reagin (RPR) 18 mm Circle Card Test (a non-treponemal test) is the screening procedure for the diagnosis of syphilis. All reactive RPR tests will be confirmed by the Syphilis IgG Enzyme Immunoassay (EIA) or the Fluorescent Treponemal Antibody-Absorption Double Staining (FTA-ABS DS) test* unless the requisition form is marked no confirmatory test needed.
The current methodology for determining the immune status of an individual with regard to resistance or susceptibility to primary rubella infection is latex agglutination.
*FTA is performed on all specimens when the EIA results are equivocal, or the RPR results are greater than 1:16 with a negative EIA.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
For routine testing, whole blood from a venipuncture or serum transferred to a clean, leak resistant, non-breakable tube may be used.
NOTE: Plasma is not approved for use.
1. No special preparation of the patient is required prior to specimen collection. 2. Using universal precautions and standard venipuncture technique, collect
approximately five (5) ml of blood in a plain (no additive) red-top vacuum blood collection tube. Use appropriate size needle (large enough to prevent hemolysis of the red blood cells) for the vein location and age of the patient. 3. Properly label with patient identifier (name, first and last), collection date, and name of submitter. Use a waterproof marker that will not fade, smear, or run during transportation and handling. 4. Allow blood specimen to clot undisturbed at room temperature for 20-30 minutes before transporting or storing.
Requisition Form Legibly complete laboratory requisition form GDHR #3432 (Rev. 4-00) in full providing:
1. Submitter information a. Submitter code (6 digits) b. Name and address of submitter
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c. Submitter phone number 2. Patient information
a. Patient name b. Patient ID# (e.g. chart #) c. Birth date/age d. Race, ethnicity, gender e. Treatment status 3. Specimen information a. Reason for test b. Date specimen collected c. Specimen type d. Special test request
SHIPMENT OF SPECIMENS
In order to expedite the testing of all of the blood samples, and to insure the integrity of the sample, all specimens should be sent to the Albany Regional Laboratory on the day of collection:
1. Transport specimens using the doubled-walled mailing containers (aluminum and cardboard mailer provided by the Albany Regional Laboratory) or package in a cardboard box complying with federal regulations pertaining to the transportation of clinical specimens and etiological agents.
2. Wrap each specimen with absorbent material to cushion it from breakage or in case of leakage.
3. Place wrapped specimen in aluminum container and close lid. 4. Wrap the requisition form around the aluminum container, secure with a rubber band
and place in: a. The outer fiberboard mailer with the Albany Regional Laboratory address,
(secure the lid with tape); or b. A cardboard box sealed with plastic tape with an Albany Regional Laboratory
address label. Labels are available from Albany Regional Laboratory. 5. An alternate shipping method may be utilized by substituting the Biohazard Bag for
the inner aluminum container. If this method is chosen, the accompanying requisition form should be placed in the pouch located on the side of each bag.
NOTE: U.S. postal regulations allow up to 50 ml of blood to be transported in one package.
6. Transport specimen promptly to the laboratory. When mailing must be delayed, refrigerate at 2-8o C pending transport.
7. Transport by U.S. mail or courier.
8. While refrigeration during transport is not necessary, avoid exposure to extreme temperatures.
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REPORTING AND INTERPRETATION OF RESULTS Turnaround time for a RPR specimen is the same day if received in early morning, otherwise testing and reporting will be next business day. Arrangements may be made however, for "special request specimens" that are received after 9am for same-day testing and reporting. Results will be reported as follows:
RPR Nonreactive - negative RPR test Reactive - positive RPR test Titer - Endpoint (highest dilution giving a reaction NOTE: All reactive RPR specimens will be confirmed by the EIA or FTA-ABS DS test unless the requisition form is marked no confirmatory test needed. RPR test is performed on all specimens submitted for EIA or FTA.
EIA Nonreactive negative EIA (tested by FTA if RPR is greater than 1:16) Equivocal - +/- EIA (If specimen is repeatedly equivocal, it will be tested by FTA-ABS DS) Reactive Positive EIA
FTA-ABS DS Nonreactive negative FTA-ABS DS Minimal Reactive weakly positive FTA-ABS DS (1+ fluorescence) Reactive Positive FTA-ABS DS (2+ - 4+ fluorescence)
UNACCEPTABLE SPECIMENS In order to expedite testing and to insure the integrity of the sample, all specimens should be sent to the Albany Regional Laboratory on the day of collection. If kept refrigerated at 2-
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8O C until ready for transport, specimens can be tested satisfactorily for 14 days before the red blood cells lyse to the extent that tests cannot be accurately interpreted. The Albany Regional Laboratory specimen acceptance policy requires that all specimens must be properly labeled with unique patient identifier (name) with matching identifier on requisition form, in acceptable testing condition, and accompanied by a completed requisition form. Failure to provide proper patient information may result in testing/reporting delays. Plasma is not approved for any procedure; therefore, submit only venous blood without anticoagulants or serum. Specimens will be reported "No Test Unsatisfactory" for the following reasons: 1. No patient identifier on specimen (first and last names must be legible); 2. Discrepancy between patient identifier on specimen and requisition form; 3. Insufficient quantity for testing; 4. Specimen broken or leaked in transit; 5. Specimen grossly hemolyzed; and 6. Plasma submitted instead of serum.
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WAYCROSS PUBLIC HEALTH LABORATORY 912-338-7050
INTRODUCTION The Waycross Public Health Laboratory is a multi-functional clinical public health laboratory which operates under the Public Health Division of the Georgia Department of Community Health. The laboratory is located at 1751 Gus Karle Parkway in Waycross, Georgia with Dr. E. A. Franko serving as the Laboratory Director. It is licensed by the State of Georgia and the Federal Government under the Clinical Laboratory Improvement Act of 1988 (CLIA).
The laboratory performs tests mandated by state laws as well as those examinations required to support the State of Georgia's public health programs. These services are available free of charge to county health departments and units of the Department of Community Health. Services are also available on a limited basis to the private sector customers and may be subject to a nominal fee. The following pages describe the examinations available at the Waycross Public Health Laboratory with specific requirements for specimen collection and handling for each test category. Included also, are expected turn-around times for reports, specimen acceptance policies, and guidelines for interpretation of reported results. Specimen collection outfits are provided free of charge for those services performed in the Waycross Public Health Laboratory and may be ordered using the Specimen Collection Outfit order form. For additional information contact: Waycross Public Health Laboratory 1751 Gus Karle Parkway Waycross, Georgia 31503 Telephone: 912-338-7050
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CHLAMYDIA/GONORRHEA 912-338-7050
INTRODUCTION
Chlamydia trachomatis is the most common treatable sexually transmitted infection affecting females of reproductive age in the United States today, with an estimated three million new cases each year. The majority of infected females have few or no symptoms, and asymptomatic infection in females can persist for up to 15 months. Women are frequently reinfected if their sex partners are not treated. Complications of untreated chlamydial infection in females include: acute pelvic inflammatory disease; ectopic pregnancy; chronic pelvic pain; and infertility.
Neisseria gonorrhoeae affects males and females from symptoms of purulent discharge in males, a few days after exposure, to very mild symptoms in females. Symptoms may pass unnoticed with a consequence that asymptomatic carriers contribute significantly to the public health problem of gonorrhea.
The Waycross Public Health Laboratory uses Target-amplified direct nucleic acid amplification test for chlamydia and gonorrhea. The Dual Kinetic Assay (DKA) measures Relative Light Units by using the chemiluminescent kinetic profiles of CT and GC labeled probes which allow for the differentiation of photon signals.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
The APTIMA Combo 2 Assay is designed to detect the presence of C. trachomatis and N. gonorrhoeae in the following specimens: endocervical and male urethral specimens, and in female and male urine specimens. Only the swabs and the specimen transport tubes contained in the APTIMA Unisex Swab Specimen Collection Kit for Endocervical and Urethral Swab Specimens can be used to collect patient swab specimens. A unisex swab is used for both male and female specimens. Swab specimens must be transported to the laboratory in the swab specimen transport medium and tube. Swab specimens must be transported to the laboratory at 2C to 30C and tested within 60 days of collection. Urine specimens must be transferred into the GEN-PROBE specimen transport tube within 24 hours of collection and before being assayed. Urine specimens can be transported to the laboratory at 2 to 30C in the urine specimen transport tube provided in the urine specimen collection kit. The fluid (urine plus transport media) level in the urine transport tube must fall within the clear pane on the tube label. After transfer, urine specimens can be stored at 2 to 30C for up to 30 days after collection.
Use the Gen-Probe collection kits supplied by the District or County services and supply representative.
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CLIENT TESTING CRITERIA:
Family Planning Clinics: All females age 29 years or younger who receive a pelvic exam during a visit (initial, annual or comprehensive medical only) will be screened for chlamydia. A female will only be screened once per calendar year for chlamydia unless she has clinical signs or symptoms of chlamydia (cervicitis/MPC, friable cervix, cervical ectopy, abdominal pain, abnormal bleeding, dyspareunia or dysuria) or a new sex partner or multiple sex partners in the past 60 days. All females 30 years and older who meet these criteria will also be screened for chlamydia.
STD/General Clinics: All females age 10-29, who receive a pelvic exam during a visit, will be screened for chlamydia. This includes rescreening females who are returning for medical problems, receiving more than one pelvic exam a year and/or are currently on antibiotics. All females 30 years and older who present with clinical signs or symptoms of chlamydia (cervicitis/MPC, friable cervix, cervical ectopy, abdominal pain, abnormal bleeding, dyspareunia or dysuria) or have a new sex partner or multiple sex partners in the past 60 days will also be screened for chlamydia. Male clients presenting for services should also be screened for chlamydia.
Teen Clinics: All females who receive a pelvic exam will be screened for chlamydia. This includes rescreening females who are returning for medical problems, receiving more than one pelvic exam a year and/or are currently on antibiotics. Males should also be screened.
All female/male clients screened for chlamydia will also be screened for gonorrhea.
Females with cervical stenosis should be included in the chlamydia/gonorrhea screening.
If the client does not have a cervix, she will not be included in the chlamydia screening.
SPECIMEN COLLECTION:
Endocervical swab specimens 1. Remove excess mucus from the cervical opening and surrounding mucosa using the
cleaning swab (white shaft swab in the package with red printing). Discard this swab. Note: To remove excess mucus from the cervical opening, a large-tipped cleaning swab (not provided) may be used. Discard the swab after use. 2. Insert the specimen collection swab (blue shaft swab in the package with green printing) into the endocervical canal. 3. Gently rotate the swab clockwise for 10 to 30 seconds in the endocervical canal to ensure adequate sampling. 4. Withdraw the swab carefully; avoid any contact with the vaginal mucosa. 5. Remove the cap from the swab specimen transport tube and immediately place the specimen collection swab into the transport tube. 6. Carefully break the swab shaft at the score line; avoid splashing the contents.
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7. Recap the swab specimen transport tube tightly. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Male urethral swab specimens Note: The patient should not have urinated for at least one hour prior to specimen collection. 1. Insert the specimen collection swab (blue shaft swab in the package with the green
printing) 2 to 4 cm into the urethra. 2. Gently rotate the swab clockwise for 2 to 3 seconds in the urethra to ensure adequate
sampling. 3. Withdraw the swab carefully. 4. Remove the cap from the swab specimen transport tube and immediately place the
specimen collection swab into the specimen transport tube. 5. Carefully break the swab shaft at the score line; avoid splashing the contents. 6. Recap the swab specimen transport tube tightly. 7. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled
specimens will not be tested.
Urine Specimens The patient should not have urinated for at least one hour prior to specimen collection. Direct the patient to provide a first-catch urine (approximately 20 to 30 mL of the initial urine stream) into a urine collection cup which is free of any preservatives. Collection of larger volumes of urine may result in specimen dilution that may reduce test sensitivity. Female patients should not cleanse the labial area prior to providing the specimen. 1. Remove the cap and transfer 2 mL of urine into the urine specimen transport tube using
the disposable pipette provided. The correct volume of urine has been added when the fluid level is between the black fill lines on the urine transport tube label. 2. Recap the urine specimen transport tube tightly. This specimen is now referred to as the processed urine specimen. Legibly label tube with patient name, patient ID# and date of collection. Unlabeled specimens will not be tested.
Requisition Form
Use the Chlamydia and Gonorrhea requisition form #3568 . Fill out the form completely by printing or typing legibly. Only legible information can be entered correctly into the laboratory database. Incomplete or illegible information may delay your results. Do not use computer-generated labels for patient information. Information required is as follows:
a. Submitter information (submitter code, submitter address, and phone number).
b. Patient information (name, patient ID number, county of residence, zip code, State, race, ethnicity, gender, date of birth).
c. Specimen information (test requested, reason for test, date collected, source of specimen, specimen status).
Tear off the top section of form (white copy) and mail to the laboratory with the specimen, making sure the names on the specimen and form are exact matches. Retain the other two copies of the form (pink and yellow) for clinic and program use.
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Chlamydia and Gonorrhea Laboratory Submission forms should be ordered as indicated by the STD Program Office.
SHIPMENT OF SPECIMENS
For best results, specimens should be transported to the laboratory on the date of collection; however, if this is impossible, specimens may be kept at room temperature and shipped as soon as possible. Urine specimens over 30 days old and/ or swab specimens over 60 days old at the time of arrival in the laboratory will be reported unsatisfactory.
Chlamydia/Gonorrhea APTIMA Combo 2 specimens may be transported at room temperature. Use the specimen transport cans and Waycross address labels (available from the laboratory).
1. Be sure the caps on the transport tubes are secure, and wrap each specimen in absorbent packing material. Place the wrapped specimen inside the aluminum can, and close the can securely.
2. Wrap the completed requisition form around the aluminum can and secure it with a rubber band.
3. Place the aluminum can inside the labeled (Waycross address) fiberboard can, close, and secure the lid with tape. An alternate shipping method may be utilized by substituting the biohazard bag for the inner aluminum container. If this method is chosen, the matching requisition forms should be placed in the pouch located in the front of each bag.
Specimens may be mailed or shipped by the method most convenient and expedient.
REPORTING AND INTERPRETATION OF RESULTS
The goal of the Bacteriology Unit is to test and report all Chlamydia/Gonorrhea APTIMA Combo 2 specimens within a 3 days turnaround period, unless confirmation testing is required. An electronic copy of all positive Chlamydia and Gonorrhea reports is transmitted to the State Sexually Transmitted Disease (STD) Program. A hard copy of all positives is also mailed to the State STD Surveillance Office.
Results are reported as follows:
Positive = Positive for C. trachomatis and/or N. gonorrhoeae rRNA was detected in the specimen, and as indicated by Aptima Combo 2 Assay.
Negative = Presumed negative for C. trachomatis and/or N. gonorrhoeae rRNA.
Equivocal = Indeterminate, a new specimen should be collected.
Unsatisfactory = Specimen compromised in some manner making it unsatisfactory for testing. The reason for each unsatisfactory result will be listed on the report form.
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UNACCEPTABLE SPECIMENS Specimens will be reported unsatisfactory for the following reasons:
1. No patient identifier on the specimen, or discrepancy between identifier on the specimen and requisition form.
2. Source other than urine, cervix or male urethra. 3. Two swabs received in the collection outfit. 4. No solution in the collection outfit. 5. No swab, or improper swab (not from Gen-Probe kit) in the collection outfit. 6. Urine specimens over 30 days old and/ or swab specimens over 60 days old from date
of collection when received. 7. Collection kit expired. 8. No specimen received. Medical/legal specimens (Aptima Combo 2 is not intended for medical/legal cases).
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INTESTINAL PARASITES 912-338-7050
INTRODUCTION
Stool specimens may be submitted for examination for intestinal parasites by county health departments and for confirmation purposes by the private sector. There is only a minimal charge for this service and for the collection outfit. The current tests performed at the Waycross Public Health Laboratory to detect intestinal parasites include a Formalin ethyl acetate concentration, a Kinyoun acid-fast stain and a Trichrome stained PVA permanent slide on each specimen.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
Each collection outfit kit contains two unbreakable plastic vials, each having a color-coded cap and label, a clearly marked "fill to here" line, and a built-in collection spoon in the screw cap top. The kit systems are packaged in ziplock bags with illustrated, multilingual patient instructions to assist in safe and sanitary specimen collection by personnel and/or patients. A biohazard bag for secure transportation to the laboratory completes the outfit.
Health Department Instructions 1. Collection instructions should be reviewed with the patient. 2. It should be stressed to the patient that each specimen must be properly identified
with the patient's name. Unidentified or misidentified specimens will not be tested. 3. It should be made clear to the patient that multiple specimens collected on the same
day will be considered unsatisfactory. 4. Patient should bring the specimen back to the Health Department upon completion.
Patient Instructions 1. Remove IP/PVA vials from ziplock bags and collect fecal specimens as directed by
instructions included in outfit. 2. Carefully label each vial with the patient's name. 3. Replace only the vials in original ziplock bag. 4. Place ziplock bag inside biohazard bag and seal.
Requisition Form Health Department Instructions: 1. Fill in submitter return address in proper area on form #3414. 2. Instruct patient in the correct manner to complete remainder of form.
Patient Instructions: 1. Complete Form #3414 as directed. 2. Fold form in half and place in outside pouch of biohazard bag.
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3. Return the outfit to the Health Department for transportation to the Waycross Public Health Laboratory.
SHIPMENT OF SPECIMENS The specimen vials correctly placed and sealed within the provided ziplock bag within the biohazard bag may be carried by courier or mailed in a sturdy fiber board box which meets U.S. postal regulations to:
Waycross Public Health Laboratory 1751 Gus Karle Parkway Waycross, Georgia 31503
REPORTING AND INTERPRETATION OF RESULTS
Submitters may expect to have test results reported within two to three working days after receipt in the laboratory.
The following results are reported: 1. No parasites found; 2. A specific parasite found
Note: Reported parasites are classed as pathogenic or nonpathogenic.
3. Unsatisfactory results indicate that the specimen was compromised in a way that might render the test results invalid. The reason for the unsatisfactory report is indicated on each form.
UNACCEPTABLE SPECIMENS
Specimens will be reported unsatisfactory for the following reasons. 1. Overfilled; 2. Quantity not sufficient; 3. No preservative in bottle; 4. Leaked or broken in transit; 5. Expired outfit; 6. More than one specimen collected on same day; 7. No specimen received; 8. Non-fecal material received; 9. No specimen in bottle; 10. Specimen unidentified.
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PINWORMS 912-338-7050
INTRODUCTION
The female Enterobius (Pinworm) leaves the intestinal tract to lay her eggs in the area surrounding the anus. For this reason, Enterobius (Pinworm) ova are not often present in detectable numbers within fecal specimens. The outfit best suited for the detection of pinworm infections consists of a clear, plastic tape and glass slide outfit. This outfit is designed for the direct collection of the eggs from around the anal area upon the awakening of the patient and the transportation of the specimen to the laboratory for examination. Please note that this examination is satisfactory only for detection of Enterobius (Pinworms) and no other intestinal parasites.
SPECIMEN COLLECTION/LABELING/ REQUISITION FORM
Each collection outfit kit contains collection instructions, a glass slide with clear plastic tape, a tongue blade, a labeled cardboard slide holder, and requisition form # 3414.
Health Department Instructions: 1. Collection instructions should be carefully reviewed with the collector. 2. It should be stressed to the collector that each specimen must be properly identified
with the patient's name. Unidentified or misidentified specimens will not be tested. 3. It should be made clear to the collector that multiple specimens collected on the
same day will be considered unsatisfactory.
Collection Instructions: 1. Collect the specimen immediately upon patient's awakening in the morning since the
eggs maybe lost later during the day as a result of scratching, bowel movements or bathing. 2. Place the round end of tongue blade at middle of the slide. Hold the slide near center with one hand; grasp the blade and white tab on end of tape with the other hand. 3. Rotate slide while lifting up on blade and tape. 4. Continue to rotate slide until one half of tape is stripped from it. 5. Turn the slide back over tongue blade and grasp other tab with thumb. 6. Strip tape completely off slide. 7. Spread the buttocks apart to expose the anus and press the tape firmly against each side at the level of the zone between the moist anal canal and dry skin surrounding it. 8. Replace tape and tongue blade on slide. 9. Smooth tape down with tongue blade. 10. Place slide in holder and discard tongue blade. 11. Label cardboard slide holder with patient's name.
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Requisition Form
Health Department Instructions 1. Fill in submitter return address in proper area on the form #3414. 2. Instruct patient in the correct manner to complete remainder of form. 3. Indicate type of specimen submitted (for example, Pinworm slide)
Patient Instructions 1. Complete Form #3414 as directed. 2. Fold form in half and wrap around the slide holder securing with rubber band before
placing in mailing envelope.
SHIPMENT OF SPECIMEN
The specimen may be returned to the health department or after attaching proper amount of postage mailed to:
Waycross Public Health Laboratory 1751 Gus Karle Parkway Waycross, Georgia 31503
REPORTING AND INTERPRETATION OF RESULTS
Submitters may expect to have test results reported within 1 to 2 working days after receipt in the laboratory.
The following results are reported:
1. No parasites found; 2. Enterobius (Pinworm); 3. Unsatisfactory results indicate that the specimen was compromised in a way that
might render the test results invalid. The reason for the unsatisfactory report is indicated on each form.
UNACCEPTABLE SPECIMENS
Specimens will be reported unsatisfactory for the following reasons: 1. No specimen on tape; 2. Crushed in transit; 3. Cream or powder on tape; 4. More than one specimen collected on the same day; 5. No specimen received; 6. Excess Feces on tape; 7. Specimen unidentified or misidentified; 8. Frosted tape used instead of clear plastic tape.
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RABIES 912-338-7050
INTRODUCTION
The goal of the Waycross Public Health Laboratory is to confidently report an accurate and reliable diagnosis so that rabies treatment can be initiated if necessary. The Laboratory currently uses Fluorescent Antibody (FA) methodology, the most accurate microscopic test available for the diagnosis of rabies. One vitally important factor in obtaining accurate results is the quality of the specimen received. The importance of rabies diagnosis makes it imperative that the condition or identity of the specimen not be compromised.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
1. Only specimens received in good condition with at least two identifiable principal brain parts are approved for reporting.
2. In all cases, there must have been exposure of human or domestic animals to the suspected rabid animal.
3. The Waycross Public Health Laboratory is not equipped to handle whole carcasses; therefore, only the heads of animals are accepted except for bats or small rodents. Bats or small rodents should be submitted whole.
Environmentalists should follow these instructions for the removal of animal heads:
a. Rubber gloves and protective clothing as well as face and eye protection should be worn while the head is being removed and packaged.
b. Sever neck so as not to damage the skull. Local veterinarians can assist in this removal. Never advise clients to remove animal heads!
c. Allow fluids and blood to drain from the head, and keep head as clean as possible. Place head in a double plastic bag for transportation to the laboratory. Leak proof.
d. If fleas or ticks are in evidence, spray insecticide into the plastic bag containing the head before closing.
e. Gloves should be cleaned and disinfected or discarded following use and cutting surfaces should be carefully cleaned and disinfected.
4. Only brain material (not the entire head) of very large animals (cows or horses) will be accepted, as the laboratory is not equipped to handle these large heads due to limited hood and sterilizer space. Veterinarians should be requested to perform this necropsy procedure.
5. Rodents or rabbits are not accepted for laboratory examination-unless the animal attacks a person unprovoked. Bites from animals that constitute no risk from rabies
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are hamster, guinea pigs, gerbils and white mice that are obtained directly from pet shops and have never been exposed to carnivorous animals or bats.
6. Reporting will be delayed on specimens that are received frozen. If specimens cannot be delivered to the laboratory immediately, refrigerate, but do not freeze.
Requisition Form
One Rabies History/Report Form #3062 should accompany each specimen for rabies examination. This form provides the laboratory with the needed information for accurate results. Fill out the form completely and legibly, being careful to include accurate addresses and telephone numbers for reporting. A copy of each Rabies report is forwarded to the State Office of Epidemiology for review and date of collection.
SHIPMENT OF SPECIMENS
Notify the Waycross Public Health Laboratory of the shipment or expected arrival of all rabies specimens so that tracking can be initiated immediately on those which become misdirected.
1. Properly package the specimen by placing the severed animal head in a double plastic bag and secure the bag by twisting and knotting. For bats and rodents, do not remove heads, but submit the whole animal.
2. Place the bag containing the specimen into a shipper with wet ice. DO NOT USE DRY ICE! Seal the shipper. Place the completed history form in a separate plastic bag, and tape to the lid of the sealed shipper. Place the shipper in a cardboard box, tape, and address for shipment.
3. The package should be shipped prepaid to the laboratory. Use the method of shipment that will assure prompt service.
4. Any bite case in which the history reveals a strong probability of rabies should be handled with utmost speed. Hand deliver such specimens to the laboratory after calling ahead to inform the laboratory manager of the emergency situation and the estimated time of arrival.
5. Do not ship specimens on the weekends unless prior approval has been obtained from the lab manager.
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REPORTING AND INTERPRETATION OF RESULTS
1. Rabies testing is available Monday through Friday excluding official state holidays. Due to the required period of tissue fixation, reports will be issued the day following the receipt of the specimen. Reporting will be delayed on specimens that are received frozen.
Note: Specimens involved in emergency situations, and Monday and Friday morning specimens will receive only four hours of fixation; and reports will be issued the same day if received by 10:00. Otherwise, reporting will be next day or following the weekend.
2. If the brain material found inside the skull is decomposed or damaged to the point of uncertainty about its being brain tissue, no slides will be prepared unless human exposure to the suspected rabid animal is involved.
a. No Exposure Reported "Unsatisfactory" and comment is made "Test requires at least two identifiable brain parts."
b. Exposure - Routine testing is performed. If the test result is positive, a report is issued as positive. If the test result is Negative, a report of Unsatisfactory is made and the comment "Test requires at least two identifiable brain parts" is added.
3. All Rabies reports are telephoned immediately to the submitter listed on the history form. Copies of all reports are mailed to the submitter, County Environmentalist (county of the animal) and to the State Epidemiology Office.
4. Test results may be given to concerned individuals, such as owners of animals, persons bitten, etc.
UNACCEPTABLE SPECIMENS
Rabies specimens will be reported as Unsatisfactory for the following reasons:
1. There is no documented exposure to humans or domestic animals. 2. Brain tissue is damaged or decomposed beyond recognition of at least two principal
parts. 3. Tissue in preservative, such as formalin.
Note: See #2 under Reporting/Interpretation Section above.
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SYPHILIS 912-338-7050
INTRODUCTION
All serologic services provided by the Waycross Public Health Laboratory are available to both the public and private sector customers.
Currently the Rapid Plasma Reagin (RPR) 18mm Circle Card Test (a nontreponemal test) is the screening procedure for the diagnosis of syphilis. All reactive RPR tests will be confirmed by the Enzyme Immunoassay (EIA) unless the requisition form is marked "No Confirmatory Test Needed." The fluorescent Treponemal Antibody-Absorption Double Staining (FTS-ABS DS) test will be performed only on specimens when the EIA results are equivocal, or the RPR results are reactive1:16 or greater with a negative EIA.
SPECIMEN COLLECTION/LABELING/REQUISITION FORM
For routine testing, whole blood from a venipuncture or serum transferred to a clean, leak resistant, non-breakable tube may be used.
Note: Plasma is not approved for use.
1. No special preparation for the patient is required prior to specimen collection. 2. Using Universal Precautions and standard venipuncture technique collect approxi-
mately five (5) milliliters of blood in a plain (no additive) redtop vacuum blood collection tube. Use appropriate size needle (large enough to prevent hemolysis of the red blood cells) for the vein location and age of the patient. 3. Properly label with patient identifier (name, first and last, or number), collection date, and name of submitter. Use a waterproof marker that will not fade, smear, or run during transportation. 4. Allow blood specimen to clot undisturbed at room temperature for 20-30 minutes before transporting or storing.
Requisition Form
Legibly complete laboratory requisition form GDCH #3432 (Rev. 4/200) in full providing:
1. Unique patient identifier (name); 2. Tests requested; 3. Race, sex, and date of birth; 4. Collection date; 5. Complete and accurate mailing address of submitter; and
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6. Any information the submitter needs for patient identification, e.g., chart number, address.
NOTE: For those specimens requiring EIA regardless of RPR result, mark confirmatory testing required section of GDCH #3432 (Rev. 4/2000).
SHIPMENT OF SPECIMENS
In order to expedite the testing of all of the blood samples, and to insure the integrity of the sample, all specimens should be sent to the Waycross Public Health Laboratory on the day of collection.
1. Transport specimens using the doubled-walled mailing containers (aluminum can or biohazard bag and cardboard mailer provided by the Waycross Public Health Laboratory) or package in a cardboard box using U. S. postal regulations.
2. Wrap each specimen with absorbent material to cushion it from breakage or in case of breakage, to absorb the leakage.
3. Place wrapped specimen in aluminum container or biohazard bag. 4. Wrap the requisition form around the aluminum container or place in pocket of
biohazard bag and place in either of the following: a. The outer cardboard mailer with the Waycross Public Health Laboratory ad-
dress. Reinforce the metal cover of the can with tape around the circumferential seam. To aid the laboratory in removing the tape, please do not use reinforced tape. b. A cardboard box sealed with plastic tape with a Waycross Public Health Laboratory label. Labels are available from Waycross Public Health Laboratory (912) 338-7050. U.S. postal regulations allow up to 50 ml of blood to be transported in one package. 5. Transport specimen promptly to the laboratory. When mailing is delayed, refrigerate at 2-8o C pending transport. 6. Transport by U.S. mail, or courier.
NOTE: If U.S. mail is used, precautions should be taken that specimens are put in mail boxes that have a daily pick-up.
7. While refrigeration during transport is not necessary, avoid exposure to extreme temperatures and avoid mailing over long weekends and holidays.
INTERPRETATION AND REPORTING OF RESULTS
Turn-around-time for a RPR specimen is same day if received by 9:00 am, otherwise testing and reporting will be next business day. Arrangements may be made however, for "special request specimens," that are received after 9:00 am for same-day testing and reporting.
Results will be reported as follows:
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RPR

Nonreactive Reactive Titer Unsatisfactory

negative RPR test positive RPR test Endpoint (highest dilution giving a reactive result) Specimen was compromised in a way that might render the test results invalid. The reason for the unsatisfactory report will be indicated on each requisition form.

NOTE: All reactive RPR specimens will be confirmed by the EIA or FTA-ABS DS test unless the requisition form is marked "NO CONFIRMATORY TEST NEEDED." RPR test is performed on all specimens submitted for EIA and/or FTA.

CONFIRMATORY EIA
Nonreactive Equivocal
Reactive Unsatisfactory

Negative EIA (tested by FTA-ABS DS if greater than 1:16) +/- EIA (IF specimen if repeatedly equivocal, it will be tested by FTA-ABS DS) Positive EIA Specimen was compromised in a way that might render the test results invalid. The reason for the unsatisfactory report will be indicated on each requisition form.

FTA-ABS DS

Nonreactive Minimal Reactive Reactive Unsatisfactory

Negative FTA-ABS DS Weakly positive FTA-ABS DS (1+ fluorescence) Positive FTA-ABS DS (2+ - 4+ fluorescence) Specimen was compromised in a way that might render the test results invalid. The reason for the unsatisfactory report will be indicated on each requisition form.

NOTE: The FTA-ABS DS will be performed on all specimens when the EIA test results are equivocal, or the RPR results are reactive 1:16 or greater with a negative EIA.

UNACCEPTABLE SPECIMENS
The Waycross Public Health Laboratory specimen acceptance policy requires that all specimens must be properly labeled with unique patient identifier (name) with matching identifier on requisition form, in acceptable testing condition, and accompanied by a completed requisition form. Failure to provide proper patient information may result in testing/reporting delays. Plasma is not approved for many procedures. Therefore, submit only one venous blood or serum sample without anticoagulants.
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In order to expedite testing and to insure the integrity of the sample, all specimens should be mailed or delivered to the Waycross Public Health Laboratory on the day of collection. If kept refrigerated at 2-8o C until ready for transport, specimens can be tested satisfactorily for 14 days before the red blood cells lyse to the extent that tests cannot be accurately interpreted. The submitter will be notified of all specimens unacceptable for testing with the reason for the unsatisfactory report indicated on the requisition form. When possible, the unacceptable specimen will be held in the refrigerator for 14 days. At the end of 14 days the specimen will be discarded without further notification. Specimens will be reported "No Test Unsatisfactory for Testing" for the following reasons: 1. No patient identifier on specimen (first and last name must be legible); 2. Discrepancy between identifier on specimen and identifier on requisition form; 3. Insufficient quantity for testing; 4. Specimen broken or leaked in transit; 5. Specimen grossly hemolyzed, lipemic, turbid or contaminated; and 6. Plasma samples.
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LABORATORY SUPPORT SERVICES INTRODUCTION
Non-technical laboratory functions are performed by several specialized units that comprise Laboratory Support Services. This section is supervised and administratively represented by the Director, Administrative Operations.
The Support Services Section exists to provide the support necessary to enable the Georgia Public Health Laboratory perform the testing that it does. It is responsible for the pre- and post- analytical processes for specimen testing and reporting, and it acquires and warehouses the supplies needed. Additionally, budget, personnel, billing, purchasing, contracts, building security and the reception desk are also managed in this unit.
Components of the Georgia Public Health Laboratory Support Services Unit are briefly described below:
Central Accessioning and Data Processing With few exceptions, specimens sent to the Public Health Laboratory are received in the Central Accessioning area. Packages are opened and each specimen is numbered with a bar code label. The patient's demographic information and requested tests are entered into the Laboratory Information System (LIS).
Reports and Records Office This office distributes laboratory test result reports electronically, by U.S. Mail and courier services (when provided by submitters). Electronic copies of reports are kept on file for reference in accordance with record retention schedules that are coordinated through DCH.
Service and Supply Unit This unit provides all purchasing services for the Laboratory and oversees all equipment maintenance and agency contracts. It also includes warehouse operations, the mail room, the outfit room, and courier service for outbound deliveries.
Laboratory Billing Unit This unit handles the billing for all fee-based testing at the GPHL.
The Support Services Unit's goal is to provide the administrative support necessary to its internal and external customers to ensure the efficient and effective delivery of laboratory services to the residents of Georgia.
Bill Shea Director, Administrative Operations
104

BILLING UNIT

The Laboratory Billing Unit prepares and mails invoices for infectious disease and newborn metabolic screening tests. We have replaced the previous fee stamp (pre-payment) process with an automated invoicing system.

INFECTIOUS DISEASE

Effective April 1, 2010 the fee schedule at the Georgia Public Health Laboratory was revised for infectious disease tests. The changes are summarized below:

1. Fee stamps are no longer sold for laboratory testing. Customers receive a monthly invoice from the GPHL at the end of each month for their billable tests. Customers may continue to use any fee stamps already purchased. Invoices will be sent for any billable test not accompanied by the appropriate fee stamp.

2. Laboratory test fees will increase for the five tests listed below. These tests are billable to all GPHL customers, including Public Health providers.

Blood Lead Test Hepatitis C Test Routine HIV Test Syphilis Serology Test Well Water Test (total coliform)

$10.00 $10.00 $10.00 $10.00 $30.00

3. The fees for all other billable infectious disease tests will remain $8.00 and are billable to private health care providers. Public Health providers are exempt from these fees.

NEWBORN SCREENING

Effective July 1, 2010 the fee for Newborn Screening is increased to $50.00 per specimen submitted, subject to exclusions for mandated repeats. The Medicaid and PeachCare reimbursement rates have been increased accordingly.

Please call the Georgia Public Health Laboratory Billing Unit at (404) 327-7933 with any questions.
OCGA 31-2-1 (18) states, in part: "The individual who requests the services authorized in this paragraph, or the individual for whom the laboratory services authorized in this paragraph are performed, shall be responsible for payment of the service fees. As used in this paragraph, the term "individual" means a natural person or his or her responsible health benefit policy or Title XVIII, XIX, or XXI of the federal Social Security Act of 1935."
105

CENTRAL ACCESSIONING / DATA PROCESING (CA/DP)

The Accessioning Unit is the entry point for specimens submitted for testing at any of the Georgia Public Health Laboratory locations.

The Decatur CA/DP Unit consists of two sections. Central Accessioning is where the specimens are opened and sorted, and a numbered bar code label is affixed to the both specimen and the submission form that accompanies the specimen. Georgia Public Health Laboratory policy dictates that all specimens are accessioned the day they are received, without exception. All specimens must have a submission form indicating the test(s) requested. Central Accessioning staff checks to see that a name or unique identifier on the specimen matches the name and identifier on the submission form.

It is critically important that all of the information on the submission form is complete and legible, and that the data on the submission form is an exact match of the data on the specimen. If the information does not match, or if it is missing, the specimen is not delivered to the laboratory for testing and a report of "unsatisfactory" is sent to the submitter.

Customers are strongly encouraged to include a specimen manifest for multiple specimens with every shipment. This enables Central Accessioning to identify any discrepancies quickly so they can notify the sender of any missing or additional specimens in the shipper. It is important to remember that proof of delivery provided by UPS, the USPS or other couriers, documents only that a package arrived, it does not account for the contents of that box.

The second area is the Data Entry Section where the patient and testing information for each specimen is entered into the Laboratory Information System (LIS). The Data Entry section is responsible for entering patient demographics and requested tests into the LIS in an accurate and timely manner.

The two regional laboratories have accessioning areas arranged to meet their specific requirements.

For information concerning the receipt of specimens, or accessioning information, please contact:

Decatur Laboratory

404-327-2281

Albany Regional Laboratory

229-430-4122

Waycross Laboratory

912-338-7050

106

REPORTS AND RECORDS UNIT

The Reports and Records Units in the Public Health Laboratories in Decatur, Albany and Waycross perform three essential functions:

1. Generating laboratory test result reports in electronic and paper formats. 2. Maintaining laboratory records and statistical data. 3. Serving as liaisons to clinicians, Public Health officials and the general public
regarding test results.

Each GPHL location produces its own test result reports. Questions regarding reports should be directed to the location that performed the testing.

The Reports and Records Unit in the Decatur Laboratory reports laboratory findings for the majority of the tests performed at this location. To inquire about the status of a particular specimen, please contact the Reports and Records Unit at 404-321-2241. If testing has not been completed and reported, or if you have technical questions regarding the test, your call will be referred to the testing unit for further information.

Please note: Test results will be provided only to the official submitter of record; we cannot release results to the patient or other health care provider that was not the submitter, with or without the patient's permission. Laboratory test records are retained by the Georgia Public Health Laboratory for two years and are then destroyed. The Health Insurance Portability and Accountability Act (HIPAA) requires that paper records are cross-cut shredded to ensure complete privacy. Electronic records are purged from the LIS. Duplicate copies of laboratory test reports can be provided upon request from the original submitting clinician with proper identification. All requests for more than five duplicate reports must be requested in writing.

For additional information about Reports and Records, please contact:

Decatur Laboratory:

404-321-2241

Albany Regional Laboratory

229-430-4122

Waycross Laboratory

912-338-7050

107

LABORATORY SERVICES AND SUPPLY UNIT The Laboratory Services and Supply Unit provides support services in the areas listed below to the Decatur, Albany and Waycross Public Health Laboratories. Additionally, employees in this unit assemble and distribute specimen collection outfits to customers of the Decatur Laboratory. Purchasing: The Laboratory Services and Supply Manager oversees purchasing for all laboratory testing materials and reagents used in the three public health laboratories. These purchases are accomplished with state and federal funds, adhering to strict purchasing guidelines imposed by the Department of Administrative Services (DOAS or State Purchasing) and the Department of Community Health (DCH). This unit maintains a large supply warehouse to ensure availability of the items used by the GPHL. This unit is also responsible for all of the agency contracts for equipment maintenance, reagents, and reagent/rental agreements. Mail Handling: All incoming and outgoing mail is processed through the Service & Supply Unit. Incoming mail is processed through the new modular mail screening facility, sorted, and delivered to the appropriate areas. Outbound mail is processed twice daily to coincide with USPS pick-up schedules, and UPS packages are shipped daily. Shipping and Receiving: All deliveries for the Decatur laboratory are received and signed for in the mail screening facility. Outgoing shipments are also prepared for shipment by the Services and Supply staff. The Services & Supply Unit provides the courier service for the Decatur facility. This service is for deliveries between the laboratory and the state office and for other outbound deliveries. The GPHL does not currently provide specimen pick-up service for our submitters. The "Outfit Room" recycles used specimen shippers that have been sterilized and refurbishes them so that they may be used again. They also provide specimen collection outfits.
108

ITEM NO

SPECIMEN COLLECTION OUTFIT INFORMATION

TYPE TESTS

OUTFIT COMPONENTS

BACTERIOLOGY 505

Cultural Referral

555

Stool Culture

525

Pertussis

560

Streptococcus

MICROBIAL IMMUNOLOGY OUTFITS

500

Microbial

Immunology with

Blood Tubes

501

Microbial

Immunology

without Blood

Tubes

1 - medium mailing can/lid 1 - biohazard transport bag 1 - absorbent packing paper 1 - requisition form #3410
1 - short mailing can/lid 1 - biohazard transport bag 1 - vial preservative (Para-Pak) 1 - requisition form #3410
1 - short mailing can/lid 1 - biohazard transport bag 1 - slide holder w/2 glass-etched ring slides 1 - requisition form #3410
1 - preaddressed #10 envelope #3547 1 - pack preservative (Dripaz) 1 - Self-seal HS Envelope 1 - cotton tip applicator 1 - requisition form # 3410
1 - medium mailing can/lid 1 - biohazard transport bag 1 - absorbent packing paper 1 - 5ml plastic blood collection tube 1 - requisition form #3432
Same as #0500 without 5ml blood tube

109

SPECIMEN COLLECTION OUTFIT INFORMATION

MYCOBACTERIOLOGY (TB) OUTFITS

550

Sputum

585

Identification

NEWBORN SCREENING OUTFITS

3491

Metabolic Disease

3603

Mailing Envelope

PARASITOLOGY OUTFITS

520

Intestinal

Parasites/PVA

521

Amebiasis/E.

Histolytica PCR

530

Pinworms

542

Blood Smears

1 - medium mailing can/lid 1 - biohazard transport bag 1 - absorbent packing paper 1 - 50ml conical tube 1 - requisition form #3412
1 - medium mailing can/lid 1 - biohazard transport bag 1 - absorbent packing paper 1 - requisition form #3412
1 - 4 part snap-out form #3491 w/filter paper attached
1 - preaddressed envelope
1 - tall mailing can/lid 1 - biohazard transport bag 1 - prepackaged kit (2 vials preservative) 2 - requisition forms #3414
1 - medium mailing can/lid 1 - biohazard transport bag 1 - 5% Potassium dichromate/absolute ethanol 1 - requisition form #3414
1 - preaddressed Kraft envelope #3602 1 - slide holder w/1 glass slide w/tape attached 1 - wooden depressor 1 - requisition from #3414
1 - small mailing can/lid 1 - double slide holder w/2 glass slides 1 - requisition form #3414

110

SPECIMEN COLLECTION OUTFIT INFORMATION

VIROLOGY OUTFITS

515

HIV (AIDS)

575

Viral Culture**

565

Viral Load

1 - medium mailing can/lid 1 - biohazard transport bag 1 - absorbent packing paper 1 - 5ml plastic blood collection tube 1 - requisition form #3595R
1 - tall aluminum can/lid 1 - vial w/preservative 2 - 6" cotton swabs 1 - requisition form #3595R
1 - medium mailing can/lid #3570
1 - biohazard transport bag 1 - absorbent packing paper 1 - Vacutainer PPT - Tube 1 - 12 x 75mm tube

** Shipping containers are NOT provided. Address to Virology Laboratory.
INSTRUCTIONS FOR THE COLLECTION, STORAGE AND TRANSPORT OF SPECIMENS ARE INCLUDED WITH EACH OUTFIT

111

LABORATORY FEE All private and public health care providers are required to pay $10 fee for the following tests:
HIV serology Hepatitis C serology Lead testing Syphilis serology (RPR and EIA) Syphilis serology by FTA Syphilis serology by VDRL Note: Well water testing, offered in Albany and Waycross Public Health Laboratories, is charged at $30/test. Private healthcare providers are charged $8/test for all the other tests listed in the "List of Laboratory Services," payable by purchasing the laboratory fee stamps. There will be no charge for all the tests performed for the followings: Surveillance of infectious diseases, when coordinated through the Epidemiology
Branch. Routine testing for public health districts and county health departments.
112

LABORATORY INFORMATION SYSTEM The Georgia Public Health Laboratory IT infrastructure is managed by Public Health Information Technology group(PH/IT). The Laboratory Information Systems (LIS) Unit provides the support function for all of the information and data system needs at the GPHL. The Laboratory Information Systems are key elements of the laboratory for maintenance of precise records on all specimens that are handled by the laboratory. The Unit is staffed to cover the two major areas of responsibility. The first is the support, development and maintenance of the LIS. This responsibility involves the integration of the technical aspects of the laboratory operation with our Laboratory Information Management System (LIMS) that collects, displays and reports the tests performed on all specimens. The second responsibility concerns the installation, maintenance and enhancement of the physical devices (workstation, server, firewall etc) that are required to support the operation of the LIS. The GPHL LIMS uses many technologies; the Web-based LIMS implementations require no special client-side installation, whereas the rich client LIMS requires implementation on a laboratory server. The Web-based technology includes multitier architecture which offers a high level of security (HTTPS, secured port) and privacy of laboratory data and users. It also offers users the opportunity to see the laboratory results in real time.
113

SCIENTIFIC SERVICES The Scientific Services Unit prepares microbiological culture media for the Central Laboratory in Decatur and Regional laboratories in Albany and Waycross. Sterilization and biohazardous waste disposal for the entire Decatur facility are handled through the Scientific Services area. Glassware is also cleaned, sterilized and delivered to the labs. On January 1, 2000, the Scientific Services Unit began fluoride proficiency testing for the DHR, Office of Oral Health. Each water system in Georgia that adjusts the fluoride level in drinking water is asked to participate in this proficiency testing. This work had previously been handled by the Environmental Protection Division of the Georgia Department of Natural Resources.
114

List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Abnormal Hemoglobin -see Hemoglobin screen, Hemoglobin screen - newborns

Abrine/ricinine

Urine

E

Acanthamoeba

Vitreous fluid

Actinomyces, thermophilic serology

Serum/blood3

(Farmer's Lung)

Acute Respiratory Disease (ARD) See Respiratory Virus

Adenovirus culture

Eye swab, feces, urine

Adenovirus PCR African trypanosomiasis serology African trypanosomiasis slide Amebiasis, extraintestinal, serology Amebiasis, intestinal

NP swab, Throat swab

D

Serum/blood3

Thick blood smear

Serum/blood3

Feces

Anthrax4 Antimicrobial susceptibility, bacterial

Pure culture/Suspicious

E

substance

Pure culture

E

Antimony Arbovirus serology

Urine

E

Serum/blood3

Arsenic

Urine

E

Aseptic Meningitis - See Meningitis, viral

Atypical pneumonia - see Pneumonia, viral

Babesiosis

Thin blood smear

outfit not provided/form 3600

Chemical Threat

sterile vial/not provided/CDC form Parasitology
50.34 serology/500/CDC form 50.34 Immunology

$8.00 $8.00 $8.00

viral culture/575/form 3595 viral culture/575/form 3595 serology/500/CDC form 50.34 blood smear/542/form 3415 serology/500/CDC form 50.34 IP & PVA/521/form 3414
outfit not provided/form 3409
culture referral/505/form 3410/CDC form 50.34 outfit not provided/form 3600 serology/500/form 3432 outfit not provided/form 3600

Virology Virology Immunology Parasitology Immunology Parasitology; Regional Lab Molecular Biology
Bacteriology
Chemical Threat Immunology Chemical Threat

$8.00

blood smear/542/form 3415

Parasitology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2















W













List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Bacillus cereus Bacillus cereus Bacillus cereus

Feces

E

Food (outbreaks only)

E

Pure culture

Bacterial culture for identification

Pure culture

Barium

Urine

E

Bartonella (cat scratch disease) culture Pure culture

Bartonella (cat scratch disease) serology Serum/blood3

Beryllium

Urine

E

Bioterrorism Agents4 Blastocystis hominis

Feces

Blood Lead - See Lead Testing

Blood Parasites

Thick & thin blood

smears Bordetella (B. pertussis, whopping cough) - See Pertussis

Bordetella spp PCR

Culture

E

Borrelliosis (Borrelia spp.)

Serum/blood3

Botulism culture/toxin (Clostridium

Feces-refrigerate

botulinum) Call Epidemiology 404-657-

E

2588 in advance Botulism culture/toxin (Clostridium

Food

botulinum) Call Epidemiology 404-657-

E

2588 in advance Botulism culture/toxin (Clostridium

Pure culture

botulinum) Call Epidemiology 404-657-

E

2588 in advance

Botulism serology (Clostridium botulinum). Serum/blood3

Call Epidemiology, 404-657-2588 in

E

advance

$8.00
$8.00 $8.00 $8.00

stool culture/sterile container not Bacteriology

provided/form 3410 outfit not provided/form 3410

Bacteriology

culture referral/505/form 3410 Bacteriology

culture referral/505/form 3410 Bacteriology

outfit not provided/form 3600

Chemical Threat

culture referral/505/form 3410 Bacteriology

serology/500/CDC form 50.34 Immunology

outfit not provided/form 3600

Chemical Threat

$8.00

IP & PVA/520/form 3414

$8.00

blood smear/542/form 3415

Parasitology, Regional Lab
Parasitology

outfit not provided/form 3409

Molecular Biology

serology/500/CDC form 50.34 Immunology

sterile container/not provided/form Bacteriology 3410/CDC form 50.34

outfit not provided/form 3410/ CDC form 50.34

Bacteriology

culture referral/505/form 3410/CDC form 50.34

Bacteriology

serology/500/CDC form 50.34 Immunology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2






W












List of Laboratory Services

Specimen Needed

Brucellosis (Brucella)4 PCR Brucellosis serology

Pure culture Serum/blood3

Cadmium

Urine/Blood

California encephalitis serology, IgG, IgM Serum/blood3

Campylobacter culture

Feces

Campylobacter culture

Food (outbreak only)

Campylobacter culture

Pure culture

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

E

outfit not provided/form 3409

Molecular Biology

serology/500/CDC form 50.34 Immunology

E

outfit not provided/form 3600

Chemical Threat

$8.00

serology/500/form 3432

Immunology

$8.00

stool culture/555/form 3410

Bacteriology

E

outfit not provided/form 3410

Bacteriology

$8.00

culture referral/505/form 3410 Bacteriology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2




Candidiasis serology (Candida albicans) Serum/blood3

Cat scratch fever - See Bartonella

Cesium

Urine

E

Chagas' disease serology (Trypanosoma
cruzi) Chagas' disease slide

Serum/blood3 Thick and thin blood

Chickenpox - See Varicella zoster

smears

Chlamydia pneumoniae PCR

Bronchoaveolar Lavage

(BAL), nasopharyngeal

or oropharyngeal swabs,

D

aspirates or washes,

sputum

Chlamydia trachomatis DNA amplified

Swab: cervix, male urethra, urine

D

Cholera - See Vibrio cholerae

Clonorchiasis

Feces

Clostridium botulinum - See Botulism

serology/500/CDC form 3410

Immunology



outfit not provided/form 3600

Chemical Threat



serology/500/CDC form 50.34 Immunology



$8.00

blood smear/542/form 3415

Parasitology



outfit not provided/form 3409

Molecular Biology



outfit available through STD program/form 3568

Bacteriology; Regional Lab



A

$8.00

IP & PVA/520/form 3414

Parasitology; Regional Lab



W

List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Clostridium perfringens Clostridium perfringens Clostridium perfringens

Feces

E

Food (outbreak only)

E

Pure culture

CMV - See Cytomegalovirus

Cobalt

Urine

E

Coccidioidomycosis serology

Serum/blood3

Congenital adrenal hyperplasia (CAH)

Dried blood spot

Conjunctivitis, bacterial Conjunctivitis, viral Coxsackievirus Coxsackievirus

Pure culture
Eye swab
Cerebrospinal fluid, feces Throat swab, rectal swab

Cryptosporidium

Feces

Cryptosporidium Cyanide Cyclospora cayetanensis

Water

E

Whole blood (EDTA)

E

Feces

Cysticercosis serology (Cysticercus

Serum/blood3

cellulosae) Cytomegalic inclusion disease (CID) See Cytomegalovirus

Cytomegalovirus (CMV) serology, IgG, IgM Serum/blood3

Cytomegalovirus (CMV) Dengue fever serology

Urine, buffy coat,
bronchoalveolar Lavage
(BAL) Serum/blood3

$8.00

stool culture/sterile container/not Bacteriology

provided/form 3410 outfit not provided/form 3410

Bacteriology

culture referral/505/form 3410 Bacteriology

$8.00 $8.00 $8.00 $8.00 $8.00
$8.00

outfit not provided/form 3600

Chemical Threat

serology/500/CDC form 50.34 Immunology

metabolic disease test/535/form
3491 culture referral/505/form 3410

Newborn Screening Bacteriology

viral culture/575/form 3595

Virology

sterile container/not provided/form Virology

3595 viral culture/575/form 3595

Virology

IP & PVA/520/form 3414

Parasitology; Regional

Lab

sterile container/not provided/form Parasitology

3414

outfit not provided/form 3600

Chemical Threat

IP & PVA/520/form 3414 serology/500/CDC form 50.34

Parasitology; Regional
Lab Immunology

$8.00 $8.00

serology/500/form 3432

Immunology

sterile container/not provided/form Virology 3595

serology/500/CDC form 50.34 Immunology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2



















W







W






Lab Performing Test1

List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Decatur

Regional Labs

Sent to CDC2

Diarrhea, bacterial identification (Salmonella, Shigella, Campylobacter, Aeromonas,STEC, Yersinia enterocolitica) Diarrhea, bacterial (Salmonella, Shigella, Campylobacter, Aeromonas, STEC, Yersinia enterocolitica) Diarrhea, unknown etiology

Pure Culture Feces Feces

Diphtheria culture

Pure culture

$8.00 $8.00 $8.00
$8.00

culture referral/505/form 3410 Bacteriology


stool culture/555/form 3410

Bacteriology



stool culture/555/form 3410/and Bacteriology,

IP&PVA/0520/form 3414/and sterile container/not provided/

Parasitology and Virology



form 3595

culture referral/505/form 3410 Bacteriology



Diphtheria culture

Throat or naso-

pharyngeal swab

Dirofilariasis slide

Thick and thin blood

smears Dysentery, amoebic - See Amebiasis, intestinal

Eastern Equine encephalitis serology, IgG Serum/blood3

$8.00

Loeffler's slant/not provided/or strep outfit/560/form 3410

Bacteriology



$8.00

blood smear/542/form 3415

Parasitology



$8.00

serology/500/form 3432

Immunology



Eastern Equine encephalitis serology, IgM Serum/blood3

$8.00

serology/500/form 3432

Immunology



Echinococcosis serology (Echinococcus Serum/blood3 granulosus)

serology/500/CDC form 50.34 Immunology



Echovirus culture (serology not available) Cerebrospinal fluid, feces

$8.00

sterile container/not provided/form Virology 3595



Echovirus culture (serology not available) Throat swab, rectal swab

$8.00

viral culture/575/form 3595

Virology



Ectoparasites

Lice, mites, ticks, fly larvae, etc.

$8.00

70% alcohol/not provided/form 3414

Parasitology



Ehrlichiosis serology

Serum/blood3

serology/500/CDC form 50.34 Immunology



Encephalitis, viral culture

Cerebrospinal fluid, feces, CNS tissue

$8.00

sterile container/not provided/form Virology 3595



Encephalitis, viral culture

Throat swab, rectal swab

$8.00

viral culture/575/form 3595

Virology



Encephalomyocarditis culture

Cerebrospinal fluid, feces

$8.00

sterile container/not provided/form Virology 3595



Encephalomyocarditis culture

Throat swab, rectal swab

$8.00

viral culture/575/form 3595

Virology



List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Endocarditis, bacterial culture Entamoeba histolytica (amebiasis)

Pure culture Feces

Enterovirus culture Enterovirus culture

Cerebrospinal fluid,
feces Throat swab, rectal swab

Erysipelothrix rhusiopathiae Culture

Pure culture

Farmer's lung - See Actinomyces, thermophilic

Fascioliasis (Fasciola spp.)

Feces

Filariasis (Wuchereria bancrofti)

Thick blood smear

Fluorescent treponemal antibody (FTA-ABS) - See Syphilis, confirmation

Foodborne illness outbreak, bacterial:

Feces

Bacillus cereus, Campylobacter,

Clostridium botulinum, C. perfringens, E.

coli O157:H7, Salmonella, Shigella,

E

Staphylococcus aureus, S. aureus

enterotoxin, & Vibrio spp.): Contact Environ-

mental Health (404)657-6534 or

Epidemiology (404)657-2588 Foodborne illness outbreak, bacterial:

Food

Bacillus cereus, Campylobacter,

Clostridium botulinum, C. perfringens, E.

coli O157:H7, Salmonella, Shigella,

E

Staphylococcus aureus, S. aureus

enterotoxin, & Vibrio spp.): Contact

Environmental Health (404)657-6534 or

Epidemiology (404)657-2588 Foodborne illness outbreak- parasitic:

Feces

(Cryptosporidium, Cyclospora, Giardia,

Entamoeba histolytica) - contact

E

Environmental Health (404)657-6534 or

Epidemiology (404)657-2588 Foodborne illness outbreak- parasitic:

Food (tested only if

(Cryptosporidium, Cyclospora, Giardia, organism found in feces)

Entamoeba histolytica) - contact

E

Environmental Health (404)657-6534 or

Epidemiology (404)657-2588 Foodborne illness outbreak - viral

Feces

Francisella tularensis - See tularemia

$8.00 $8.00 $8.00 $8.00 $8.00

culture referral/505/form 3410 Bacteriology

IP & PVA/521/form 3414

Parasitology; Regional

Lab sterile container/not provided/form Virology

3595 viral culture/575/form 3595

Virology

culture referral/505/form 3410 Bacteriology

$8.00 $8.00

IP & PVA/520/form 3414 blood smear/542/form 3415

Parasitology; Regional
Lab Parasitology

stool culture/555/form 3410

Bacteriology

outfit not provided/form 3410

Bacteriology

IP & PVA/521/form 3414

Parasitology

outfit not provided/form 3415

Parasitology

sterile container/not provided/form Virology 3595

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2





W









W








List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Fungus serology Giardiasis

Serum/blood3 Feces

Giardiasis

Water

E

Gonorrhea culture screening

Culture

Gonorrhea DNA Amplified Gonorrhea identification

Swab: cervix, male

D

urethral, urine

Culture

Haemophilus influenzae, typing (types a-f) Pure culture

Hepatitis A serology, Total AB, IgM

Serum/blood3

Hepatitis B serology Hepatitis C serology Hepatitis, delta, serology

Serum/blood3

HD

Serum/blood3

D

Serum/blood3

Herpes simplex I serology

Serum/blood3

Herpes simplex II serology

Serum/blood3

Herpes simplex culture

Lesion swab

Herpes Simplex type I PCR

Scab, vesicular tissue, lesion scab

E

Herpes Simplex type II PCR

Scab, vesicular tissue,

E

lesion scab

Herpes zoster (shingles) - See Varicella zoster

Histoplasmosis serology - See Fungus serology

Histoplasmosis serology

Serum/blood3

Human Immunodeficiency Virus (HIV) serology

Serum/blood3

$8.00 $8.00
$8.00 $8.00
$10.00 $8.00 $8.00 $8.00

serology/500/CDC From 50.34 Immunology

IP & PVA/520/form 3414

Parasitology; Regional

Lab

sterile container/not provided/form Parasitology

3415

Martin Lewis or Thayer Martin Bacteriology

transport media not provided/form

3410 outfit and form available only

Bacteriology; Regional

through STD Program/form 3568 Lab

culture referral/505/form 3410 Bacteriology

culture referral/505/form 3410 Bacteriology

serology/500/form 3432

Immunology

serology/500/form 3432

Immunology

serology/500/form 3432

Immunology

serology/500/CDC form 53.2

Immunology

serology/500/form 3432

Immunology

serology/500/form 3432

Immunology

viral culture/575/form 3595

Virology

outfit not provided/form 3409

Molecular Biology

outfit not provided/form 3409

Molecular Biology

$10.00

serology/500/CDC form 50.34 HIV/515/form 3595

Immunology Virology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2





W







A,W

























List of Laboratory Services HIV-1 Viral Load (PCR) HIV 2 serology HTLV I/II serology Human metapneumovirus (hMPV) PCR Influenza A subtyping PCR
Influenza A/B typing PCR
Influenza culture Lead Lead testing Legionella spp. PCR
Legionella pneumophila PCR Legionnaires disease culture

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Plasma

D

Serum/blood3

Serum/blood3

NP swab, Throat swab

D

Nasopharyngeal or oropharyngeal (throat) swab, nasal or oral aspirate, tracheal aspirate, bronchoaveolar Lavage (BAL)

Nasopharyngeal or oropharyngeal (throat) swab, nasal or oral aspirate, tracheal aspirate, bronchoaveolar Lavage (BAL)

Throat swab

Urine Whole blood (EDTA)
Bronchoaveolar Lavage (BAL), nasopharyngeal or oropharyngeal swabs, aspirates or washes, sputum
Pure culture

E HD & Special Cases
D
D

HIV/565/form 3595 HIV/515/CDC form 50.34 HIV/515/CDC form 50.34 viral culture/575/form 3595 flu kit/n/a/form 3409

Virology Virology Virology Virology Molecular Biology

flu kit/n/a/form 3409

Molecular Biology

$8.00 $10.00

viral culture/575/form 3595 outfit not provided outfit components provided/Lead/form 3593
outfit not provided/form 3409

Virology Chemical Threat Regional Lab
Molecular Biology

$8.00

outfit not provided/form 3409
Buffered charcoal yeast extract (BCYE)/available commercially/ culture referral/505/form 3410

Molecular Biology Bacteriology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2








A


List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Legionnaires disease serology
Leishmaniasis, cutaneous or visceral, serology Leishmaniasis, cutaneous or visceral

Serum/blood3 Serum/blood3 Tissue smear

Leptospira culture Leptospira serology

Ellinhausen's media

inoculated with

E

blood/urine Serum/blood3

Listeria monocytogenes typing/subtyping by Pure culture

PFGE Lyme disease serology (Borrelia
burgdorferi) Lymphocytic choriomeningitis (LCM)
serology

Serum/blood3 Serum/blood3

Lymphogranuloma venereum (LGV)

Rectal swabs

Malaria serology Malaria slide Measles serology Melioidosis culture (B. pseudomallei)

Serum/blood3
Thick and thin blood smears Serum/blood3
Pure culture

Melioidosis serology (Burkholderia pseudomallei) Meningitis, bacterial
Meningitis, bacterial, culture
Meningitis, viral, culture
Meningitis, viral, culture

Serum/blood3

Cerebrospinal fluid

E

Pure culture

Cerebrospinal fluid,
feces Throat swab, rectal swab

Meningitis, viral, serology

Serum/blood3

$8.00
$8.00
$8.00 $8.00 $8.00
$8.00 $8.00 $8.00

serology/500/CDC form 50.34 Immunology

serology/500/CDC form 50.34 Immunology

blood smear/542/form 3415

Parasitology

Ellinhausen's medium/available Bacteriology

commercially/form 3410/CDC form

50.34 serology/500

Immunology

culture referral/505/form 3410 Bacteriology

serology/500/CDC form 50.34 Immunology

serology/500/CDC form 50.34 Immunology

form 3410/CDC form 50.34

Bacteriology

serology/500/CDC form 50.34 Immunology

blood smear/542/form 3415

Parasitology

serology/500/form 3432

Immunology

culture referral/505/form 3410 Bacteriology

serology/500/CDC form 50.34 Immunology

outfit not provided/form 3410/
CDC form 50.34 culture referral/505/form 3410

Bacteriology Bacteriology

sterile container/not provided/form Virology

3595

viral culture/575/form 3595

Virology

serology/500/form 3432

Immunology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2







List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Meningoencephalitis, amoebic, serology Cerebrospinal fluid,

Mercury

feces

Blood

E

Metabolic toxins panel (MTP)

Urine

E

Microfilaria

Thick blood smear

Microsporidia spp.

Feces

Mites

Mite

Molybdenum Mumps culture

Urine

E

Throat swab

Mumps PCR Mumps serology

Oral/biccal swab

E

Serum/blood3

Murine typhus serology

Serum/blood3

Mycobacteria culture (includes M. tuberculosis and other Mycobacteria sp.). Drug sensitivity testing done on when M. tuberculosis is isolated for the first time.

Sputum, specimens from respiratory sources, gastric washings, urine, body fluids, exudates, bronchial wash-ings, tissue samples

Mycobacteria cultures for identification

Pure culture on media

(Drug-sensitivity testing will be done

slant or AFB positive

automatically when M.tuberculosis is

MGIT tubes

isolated for the first time.) Mycobacterium tuberculosis drug

Pure culture on media

susceptibility testing

slant

Mycoplasma pneumoniae PCR

Nasopharyngeal or

oropharyngeal (throat)

swab, nasal or oral

aspirate, tracheal

D

aspirate, bronchoaveolar

Lavage (BAL)

$8.00 $8.00 $8.00
$8.00
$8.00 $8.00 $8.00

serology/500/CDC form 50.34
outfit not provided/form 3600 outfit not provided/form 3600 blood smear/542/form 3415 IP & PVA/520/form 3414 70% alcohol/not provided/form 3415 outfit not provided/form 3600 viral culture/575/form 3595 outfit not provided/form 3409 serology/500/form 3432 serology/500/form 3432 sputum/550/form 3412

Immunology Chemical Threat Chemical Threat Parasitology Parasitology Parasitology Chemical Threat Virology Molecular Biology Immunology Immunology Mycobacteriology

$8.00

outfit not provided/form 3412

Mycobacteriology

$8.00

outfit not provided/form 3412 outfit not provided/form 3409

Mycobacteriology Molecular Biology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2









List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Neisseria meningitidis grouping

Pure culture

Newborn Screening Panel

Dried blood spot

Organophosphate nerve agent metabolites Urine

E

(OPNA)

Paragonimiasis (Paragonimus westermani) Feces, NP swab, Throat

swab

Parainfluenza 1,2,3 RVP RT-PCR

NP swab, Throat swab

D

Parasites, intestinal (helminths & protozoa) Feces

Parasites, serology
Pertussis culture(B.pertussis & B.parapertussis)
Pertussis, smears for FA (Bordetella pertussis & B. parapertussis) Pinworm

Serum/blood3
NP swab in ReganLowe (RL) transport medium Nasopharyngeal (NP) smear Tape slide

Platinum Pneumocystis carinii
Pneumonia, bacterial, culture Pneumonia, viral culture

Urine

E

Tissue smear, bronchoalveolar lavage (BAL) Pure culture

Throat swab

Pneumonia, viral culture

Tissue

Poliomyelitis (Polio) culture Poliomyelitis (Polio) culture

Cerebrospinal fluid,
feces Throat swab, rectal swab

$50.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.00

culture referral/505/form 3410 form 3409 with filter paper

Bacteriology Newborn Screening

outfit not provided/form 3600

Chemical Threat

IP & PVA/520/form 3414 viral culture/575/form 3595

Parasitology; Regional
Lab Virology

IP & PVA/520/form 3414 serology/500/CDC From 50.34

Parasitology; Regional
Lab Immunology

Regan-Lowe transport medium Bacteriology

available commercially/0525/ form

3410 pertussis slide/545/form 3410

Bacteriology

pinworm/520/form 3414 outfit not provided/form 3600 blood smear/542/form 3414

Parasitology; Regional Lab Chemical Threat
Parasitology

$8.00 $8.00 $8.00 $8.00 $8.00

culture referral/505/form 3410 Bacteriology

viral culture/575/form 3595

Virology

sterile container/not provided/form Virology

3595

sterile container/not provided/form Virology

3595

viral culture/575/ form 3595

Virology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2









W





W









W







Lab Performing Test1

List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Decatur

Regional Labs

Sent to CDC2

Pox viruses PCR Psittacosis serology

Scab, vesicular tissue,
scab Serum/blood3

Q fever serology

Serum/blood3

Rabies

Animal head or brain,

whole bat Rapid Plasma Reagin (RPR) See Syphilis serology

Rapid Toxic Screen (Chemical Threat

Blood (EDTA & Hep),

E

agents)

urine

Rat-bite fever culture (Streptobacillus

Pure culture

moniliformis)

Respiratory syncytial virus (RSV) serology Serum/blood3

E

Respiratory virus culture (panel) Respiratory virus serology

Throat swab,
Nasopharyngeal
washing Serum/blood3

Rhinovirus PCR Ricin RMSF

NP swab, Throat swab

D

Environmental Specimen

E

Serum/blood3

Rotavirus detection

Feces

RPR (Rapid plasma reagin) - See Syphilis serology

RSV PCR

NP swab, Throat swab

D

Rubella, diagnostic

Serum/blood3

Rubeola - See Measles Saint Louis encephalitis serology

Serum/blood3

outfit not provided/form 3409

Molecular Biology



serology/500/CDC form 50.34 Immunology



serology/500/form 3432

Immunology



rabies/form 3062

Virology/ Regional Lab/ Epidemiology



A,W

outfit not provided/form 3600

Chemical Threat



$8.00

culture referral/505/form 3410 Bacteriology



serology/500/CDC form 50.34 Immunology



viral culture/575/form 3595

Virology



$8.00

serology/500/CDC form 50.34 viral culture/575/form 3595 outfit not provided/form 3409

Immunology Virology Molecular Biology Immunology







W

$8.00

sterile container/not provided/form Virology 3595



viral culture/575/form 3595

Virology



$8.00

serology/500/form 3432

Immunology



$8.00

serology/500/form 3432

Immunology



List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Salmonellosis culture (Salmonella)

Feces

Salmonellosis culture (Salmonella)

Food (outbreak only)

E

Salmonella serotyping and subtyping

Pure culture

(PFGE)

Schistosomiasis (Schistosoma

Feces

haematobium, manson, japonicum,

mekongi) Schistosomiasis serology (Schistosoma
spp.)

Serum/blood3

Selenium

Urine

E

Septicemia culture

Pure culture

Shiga Toxin PCR

Pure culture/food

E

Shigella serotyping and subtyping (PFGE) Pure culture

Shigellosis culture (Shigella)

Feces

Shigellosis culture (Shigella)

Food (outbreak only)

E

Shingles - See Varicella zoster

Sickle cell anemia, adult - See Hemoglobin Screen, non-neonatal

Staphylococcus aureus

Feces

E

Staphylococcus aureus

Food (outbreak only)

E

Staphylococcus aureus

Pure culture

Staphylococcus aureus enterotoxin

Food

E

STEC and shiga-like toxin (SLT)

Feces

STEC and shiga-like toxin (SLT) STEC and shiga-like toxin (SLT)

Food (outbreaks only)

E

Pure culture

Streptobacillus moniliformis See Rat-bite fever

$8.00
$8.00
$8.00 $8.00 $8.00

stool culture/505/form 3410 outfit not provided/form 3410 culture referral/505/form 3410 IP & PVA/520/form 3414
serology/500/CDC form 50.34 outfit not provided/form 3600 culture referral/505/form 3410 form 3409 culture referral/505/form 3410 stool culture/555/form 3410 outfit not provided/form 3410

Bacteriology Bacteriology Bacteriology Parasitology; Regional Lab Immunology Chemical Threat Bacteriology Molecular Biology Bacteriology Bacteriology Bacteriology

$8.00 $8.00 $8.00

stool culture/555/form 3410 outfit not provided/form 3410 culture referral/505/form 3410 outfit not provided/form 3410 stool culture/555/form 3410 outfit not provided/form 3410 culture referral/505/form 3410

Bacteriology Bacteriology Bacteriology Bacteriology Bacteriology Bacteriology Bacteriology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2





W






List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Streptococcus Group A Streptococcus Group A

Pure culture Throat swab

Streptococcus, Group B

Vaginal

E

Strongyloides

Feces

E

Subacute sclerosing panencephalitis (SSPE) serology (Measles complication)
Syphilis serology screening

Both serum or
blood3and
Cerebrospinal fluid,
feces Serum/blood3

Syphilis serology (EIA) confirmation

Serum/blood3

Syphilis serology (FTA) confirmation

Tetramine

Urine

E

Thallium

Urine

E

ToRCH serology (toxo-plasmosis, rubella, Serum/blood3

cyto-megalovirus, herpes simplex virus)

Toxocariasis (Toxocara spp.)

Feces

Toxoplasmosis serology IgG (Toxoplasmia Serum/blood3

gondii)

Toxoplasmosis serology IgM (Toxoplasma Serum/blood3

gondii)

Trace metals panel (cadmium, mercury, Blood

E

and lead)

Trace metals panel (12 metals)

Urine

E

Tuberculosis and other Mycobacterial diseases See Mycobacterial diseases

Tularemia culture4 (Francisella tularensis) Pure culture

E

Tularemia FA4 (Francisella tularensis)

Tissue

$8.00 $8.00
$8.00

culture referral/505/form 3410
Streptococcus culture/560/form 3410 Amies or Stuart transport media/not provided/form 3410 IP & PVA/520/form 3414
serology/500/CDC form 50.34

Bacteriology
Bacteriology
Bacteriology
Parasitology; Regional Lab Immunology

$10.00

syphilis/500/form 3432 syphilis/500/form 3432

Immunology; Regional Labs Immunology; Regional Labs

$8.00 $8.00 $8.00 $8.00

outfit not provided/form 3600 outfit not provided/form 3600 serology/500/form 3432 IP & PVA/520/form 3414 serology/500/form 3432 serology/500/form 3432 outfit not provided/form 3600 outfit not provided/form 3600

Chemical Threat Chemical Threat Immunology
Parasitology; Regional Lab Immunology
Immunology
Chemical Threat
Chemical Threat

outfit not provided/form 3409

Molecular Biology

sterile container/not provided/CDC Molecular Biology

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2









W





A,W



A,W











W











List of Laboratory Services

Specimen Needed

Tularemia FA (Francisella tularensis)

Tungsten

Urine

Typhoid Fever culture (Salmonella ser. Feces

Typhi)

Typhoid Fever culture (Salmonella ser. Pure culture

Typhi) Typhus - See Murine typhus

Undulant fever - See Brucellosis

Upper respiratory infection (URI) See Respiratory virus

Uranium

Urine

Varicella zoster (Chickenpox) culture

Lesion swab

Varicella zoster (Chickenpox) culture

Vesicle fluid

Varicella zoster serology (Chickenpox) VDRL serology
Venezuelan encephalitis serology Vibrio spp.

Serum/blood3
Cerebrospinal fluid, feces only (must be clear) Serum/blood3
Feces

Vibrio spp.

Food (outbreaks only)

Vibrio spp.

Pure culture

Viral Meningitis See Meningitis, viral Viral pneumonia See Pneumonia, viral Viral culture (must specify virus suspected) Cerebrospinal fluid,
feces, urine, blood, feces, tissue, Serum/blood3 Viral culture (must specify virus suspected) Throat swab, lesion swab, rectal swab

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

form 50.34 outfit not provided

Laboratory Unit to Contact
gy
Chemical Threat

stool culture/555/form 3410

Bacteriology

$8.00

culture referral/505/form 3410 Bacteriology

E

outfit not provided/form 3600

Chemical Threat

$8.00

viral culture/575/form 3595

Virology

$8.00 $8.00

sterile container or syringe/not
provided/ form 3595 serology/500/form 3432

Virology Immunology

$8.00

sterile tube/not provided/ form 3432

Immunology

serology/500/CDC form 50.34 Immunology

$8.00

stool culture/555/form 3410

Bacteriology

E

outfit not provided/form 3410

Bacteriology

$8.00

culture referral/505/form 3410 Bacteriology

$8.00

sterile container/not provided/form Virology 3595R

$8.00

viral culture/575/form 3595

Virology

Lab Performing Test1

Decatur


Regional Labs

Sent to CDC2







List of Laboratory Services

Specimen Needed

COMMENT CODE*

Fee Amount**

Submission Outfit Name/Order Number/form Number

Laboratory Unit to Contact

Viral serology (specific virus must be indicated): cytomegalovirus, herpes virus, mumps, rubeola, rubella, varicella zoster Visceral larva migrans serology

Serum/blood3 Serum/blood3

Volatile organic compound panel

Grey or Green top tube

E

VZV PCR

Serum, scab, vesicular lesion swab

E

West Nile Virus serology

Serum/blood3,

Western Equine encephalitis serology

Cerebrospinal fluid, Serum/blood3

Whooping cough see Pertussis Worm identification

Worms or segments

Yersinia enterocolitica culture &/or typing
(O:3) Yersinia enterocolitica culture &/or typing
(O:3) Yersinia pestis culture4

Feces Pure culture Pure culture

$8.00

serology/500/form 3432

Immunology

$8.00 $8.00

serology/500/CDC form 50.34 outfit not provided/form 3600 outfit not provided/form 3409 serology/500/form 3432 serology/500/form 3432

Immunology Chemical Threat Molecular Biology Immunology Immunology

$8.00 $8.00 $8.00

bottle containing 70% alcohol/not Parasitology; Regional

provided/ form 3414

Lab

stool culture/555/form 3416

Bacteriology

culture referral/505/form 3410 Bacteriology

outfit not provided/form 3409

Molecular Biology

Tests performed are subject to change at any time without prior notice. This list will be updated when changes are made.

Lab Performing Test1

Decatur

Regional Labs

Sent to CDC2






W







References: 1. If the testing is performed in more than one of the Public Health Laboratories, refer to the related section for each laboratory you use. A= Albany, W= Waycross 2. All specimens designated for testing at CDC must first come through the GPHL (Decatur, Albany, or Waycross Lab). 3. 2-5ml blood or 1ml serum (minimum).
4. If a bioterrorist threat is suspected, see Section on "Agents of bio and chemical threats" for protocol to follow.
* Comment Codes: D = Restricted availability - Selected submitters only. E = Prior arrangements must be made, call lab unit listed. HD = Only Health Departments can use the service

** Refer to "Laboratory Fees" Section of this manual

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
BACTERIOLOGY SUBMISSION FORM

Acc # (Lab use only)

SUBMITTER INFORMATION SUBMITTER CODE:

PATIENT ID:

PATIENT INFORMATION

DOB:

/

/

NAME: _____________________________________________________________

Last

First

Middle

CLINIC NAME: _____________________________________ STREET: _________________________________________ CITY: ____________________________________________

RESIDENCE: Street
County

City PHONE:
Home

State Work

Zip Cell/other

STATE & ZIP CODE: _______________________________ PHONE NO: ______________________________________ FAX NO: _________________________________________ CONTACT NAME: _________________________________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown White

ETHNICITY:

GENDER:

Hispanic or Latino

Non-Hispanic or Latino

Unknown

Male Female Unknown

Date of Collection: _____/______/___________
Source: Blood Cervix CSF Nasopharyngeal Skin Sputum Stool/Feces First Repeat Throat Urethra Urine Wound Other: ___________________

SPECIMEN INFORMATION Type:
Isolated organism Culture Slide/ Smear Other: ___________________
Special instructions:
____________________________________
____________________________________
____________________________________
Forward to CDC* *Special arrangement required CALL 404-327-7997

Clinical Information:
Date of Onset: _____________________________
Incubation period: __________________________
Antibiotics: ________________________________
Collected before antibiotic Rx Yes No
Outbreak related: Yes No If Yes, name of outbreak: _________________________________________ Travel outside US: Yes No If Yes, where? : _________________________________________

Symptoms: Diarrhea

Vomiting

Blood/mucus Not Ill

Other: ________________________

ENVIRONMENTAL/FOOD (Epidemiology use only)
Source: ___________________________

Please select ONLY one TEST per SPECIMEN per FORM
BACTERIOLOGY
Enteric Bacteriology Suspected Agent: _________________________________________________ Isolation & Identification Confirmation Serotyping

Type:
___________________________
Shipped: Refrigerated Frozen Room Temperature
Test requested: B. cereus Campylobacter C. perfringens / Toxin EC0157:H7 / SLT Salmonella Shigella S. aureus / Toxin Other: ____________________

Referred Culture / Special Bacteriology Suspected Agent: _________________________________________________ Aerobic Anaerobic
Pertussis (Whooping cough) DFA Culture
Stool Culture Suspected Agent: _________________________________________________ Preserved stool (Para-Pak C&S, Room Temp) Routine (Salmonella, Shigella, Campylobacter, Aeromonas, EC0157:H7 & Yersinia) S. aureus (Submit within 24h after onset)** Fresh stool (Refrigerated) B. cereus (Submit within 48h after onset)** C. perfringens (Submit within 48h after onset)** C. botulinum**
Group A Streptococcus LGV * Other (Please specify): __________________________________________________________

Form # 3410 (Rev. 1/22/2010)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
BLOOD LEAD SUBMISSION FORM

Acc. #
(Lab use only)

SUBMITTER INFORMATION
SUBMITTER CODE:

PATIENT INFORMATION

PATIENT ID # ______________________

DATE OF BIRTH: _____/_____/_____

SUBMITTER NAME:

NAME: ________________________________________________________________________

Last

First

Middle Initial

___________________________________________ SUBMITTER ADDRESS & PHONE:

STREET: ___________________________________

CITY: ______________________________________

STATE: _____

ZIP CODE: _________-_______

PHONE NO: ________________________________

ADDRESS: ____________________________________________________________________ CITY: _______________________________________ STATE: _______________

COUNTY: ____________________________________ ZIP CODE: ___________-________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown
White
SPECIMEN INFORMATION

ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Unknown

GENDER: Male Female Unknown

DATE COLLECTED: ______/______/______

COLLECTION METHOD: CAPILLARY

VENOUS

REASON FOR TEST:

SCREEN

CONFIRMATION

FOLLOW-UP

OTHER: ______________________

Form 3583 (Rev. 8-01)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
CHEMICAL THREAT SUBMISSION FORM

Accessioning number (Lab use only)
Received date stamp

SUBMITTER INFORMATION
SUBMITTER CODE:

PATIENT ID:

PATIENT INFORMATION
CTS#:

NAME: ____________________________________________

NAME: Last

First

Middle

STREET: ___________________________________________ CITY: _____________________________________________

RESIDENCE: Street
County

City PHONE:
Home

State Work

Zip Cell/other

STATE & ZIP CODE: __________________________________

DOB: _____/______/______

Medicaid #___________________

PHONE NO: _________________________________________ FAX NO: ___________________________________________ CONTACT NAME: ____________________________________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown White

ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Unknown

GENDER: Male Female Unknown

Date of collection: ___/_____/______

SPECIMEN/CLINICAL INFORMATION

Clinical information

Symptoms:

Patient location at time of collection:

(check all that apply)

Time of collection: ____________
Total urine volume __________mL Urine creatinine (if applicable)_______

Inpatient Hospital name ____________________ Outpatient Long term care

Blood Number of tubes w/ EDTA : ________ Number of tubes w/ Heparin: ________
Shipped: Frozen (urine only) Refrigerated (blood only)

Illness related to chemical exposure: Yes No
Name/ID number of event: __________________

Backache Blurred vision Chest pain Constipation Cough Diarrhea Difficulty swallowing Disordered speech Fatigue Fever Headache Hemorrhage

Joint pain Myalgia Nausea Necrosis Vomiting Rash Sore throat Stiff neck Swollen lymph nodes Watery/red/itchy eyes Weight loss Other______________

Test requested

Please select ONLY one TEST per SPECIMEN per FORM
Results

Rapid toxic screen **

Trace metals (urine) *

Arsenic and selenium (urine) *

Cyanide (blood)*

Volatile organic compounds (VOC) (blood)*

Organophosphate nerve agent metabolites (OPNA) (urine)*

Metabolic toxins panel (MTP) (urine)*

Abrine and ricinine (urine)*

Hold for testing*

Date reported: ________________

**performed at the Centers for Disease Control (CDC) *consultation with GPHL Emergency Response Coordinator required

Reported by: _____________________

Received in CT Unit:

(Rev. 01/2010)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
IMMUNOLOGY SUBMISSION FORM

Accessioning Number (Lab use only)

SUBMITTER INFORMATION
SUBMITTER CODE:

PATIENT ID:

PATIENT INFORMATION
CTS#:

NAME:

CLINIC NAME: ______________________________________

Last

First

Middle

STREET: ___________________________________________ CITY: _____________________________________________

RESIDENCE: Street
County

City PHONE:
Home

State Work

Zip Cell/other

STATE & ZIP CODE: __________________________________ DOB: _____/______/______

Medicaid #___________________

PHONE NO: _________________________________________
FAX NO: ___________________________________________
CONTACT NAME: ____________________________________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown White

ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Unknown

GENDER: Male Female Unknown

Date of Collection: _____/______/___________
Source/Type: Blood CSF Plasma Serum Serum/Acute Serum/Convalescent Other: ___________________

SPECIMEN INFORMATION

Reason for Testing:

Clinical Information:

Contact to STD Court Ordered

Date of Onset: _______________________________

Diagnosis

Previous Lab Results, if any: _____________________

Repeat testing

Other: ___________________

Travel outside US: Yes No

Shipped:

If Yes, where? : ____________________________

Refrigerated Room Temperature

Symptoms: (check all that apply) fever

Please complete: Pregnant Yes No Unknown

rash stiff neck headache

Prenatal (Hepatitis B) EDC date__________

other____________

Routine Syphilis

Please submit a separate form and specimen for each Test Panel Arbovirus/WNV panel

Routine RPR VDRL(spinal fluid)

Arbo IgG & IgM panel WNV IgG & IgM WNV IgM (CSF)

Special RPR testing request:

Hepatitis Testing

Quantitative(Titer) and Confirmatory even if screening test (RPR) negative No Confirmatory Test needed even if screening test (RPR) is positive Quantitative (Titer) RPR

Hep B (Prenatal) Hep B (Routine Screen) Anti-HAV Total Antibody Anti-HAV-IgM Anti-HCV
Miscellaneous Serology

List test for CDC referrals _______________________ Special test requests____________________________

Toxoplasmosis IgG Toxoplasmosis IgM Rubella IgG Rubella IgM CMV IgG CMV IgM

HSV1/HSV2

Murine Typhus

Rubeola IgG

Torch Panel**

Rubeola IgM

Other __________

Mumps

Varicella Zoster

Rocky Mountain Spotted Fever

** TORCH panel includes Toxoplasmosis, Rubella, CMV, HSV1/2

Form 3432 (Rev. 06/2010)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
MOLECULAR BIOLOGY SUBMISSION FORM

Accessioning number (Lab use only)
Received date stamp

SUBMITTER INFORMATION
SUBMITTER CODE:

PATIENT ID:

PATIENT INFORMATION
CTS#:

NAME:

NAME:_____________________________________________

Last

First

Middle

STREET: ___________________________________________ CITY: _____________________________________________

RESIDENCE: Street
County

City PHONE:
Home

State Work

Zip Cell/Other

STATE & ZIP CODE: __________________________________ DOB: _____/______/______

Medicaid #___________________

PHONE NO: _________________________________________
FAX NO: ___________________________________________
CONTACT NAME: ____________________________________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown White

ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Unknown

GENDER: Male Female Unknown

Date of collection: ___/_____/______ Time of collection: ____________
Source: _____________
Specimen type: Clinical ______________________ Culture Other
Specimen shipped: Frozen Refrigerated Room Temperature

SPECIMEN/CLINICAL INFORMATION

Clinical information:

Symptoms:

Date of onset: ____/____/_______

(check all that apply):

Patient location at time of collection:
Inpatient Hospital name ____________________ Outpatient Long term care Patient receiving antivirals: Yes No
Patient receiving antibiotics: Yes No
Outbreak related: Yes No If Yes, Name/ID# of outbreak: ____________________

Backache Blurred vision Chest pain Constipation Cough Diarrhea Difficulty swallowing Disordered speech Fatigue Fever Headache Hemorrhage

Joint pain Myalgia Nausea Necrosis Vomiting Rash Sore throat Stiff neck Swollen lymph nodes Watery/red/itchy eyes Weight loss Other______________

Special instructions (if any): ________________________________

Travel outside US (within last 10 days): Yes No
If yes, where? _______________________

Influenza rapid test results (if performed): ______________________

Test requested

Please select ONLY one TEST per SPECIMEN per FORM
Results

BT agent rule out*_____________________________

Influenza panel (rRT-PCR)*

Mumps (PCR)*

Norovirus (rRT-PCR)*

Rash panel (rRT-PCR)*

Respiratory panel (rRT-PCR)*

VZV (PCR)*

Refer to CDC*

Other: ________________

Date reported: ________________

* Research use only procedure- requires epidemiology consultation

Reported by: _____________________

Form 3409 (Rev. 01/2010) Received in MB lab:

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
MYCOBACTERIOLOGY SUBMISSION FORM

Acc. #
(Lab use only)

SUBMITTER INFORMATION
SUBMITTER CODE, NAME AND ADDRESS:

PATIENT INFORMATION
Submitter's Patient ID # _____________________________________

NAME: ________________________________________________________________________

Last

First

Middle Initial

ADDRESS: ____________________________________________ CITY: ___________________

ZIP CODE: ____________________ COUNTY: __________________________ STATE: _GA__

DATE OF BIRTH: ____________/____________/______________

CONTACT PERSON: ___________________________________________ PHONE #: __________________________________ FAX #: _____________________________________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown White

ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Unknown

GENDER: Male Female Unknown

SPECIMEN INFORMATION

Specimen Source:

Sputum Other: _________________________________________________________________________________________

Date Collected: ______________________________________________________________________________________________________________

TEST REQUEST FOR MYCOBACTERIOLOGY
Check appropriate box(es)

Known TB patient? Yes, current patient Yes, former patient No

Have TB meds been given in the last 12 months? Yes, start date ___________/___________/____________ Yes, start date unknown No

Clinical specimens (sputum, BW, body fluids, tissues, abscesses, stool):

Smear, culture & susceptibility testing

MTD Testing (Nucleic Acid Amplification Test). This test is intended for use only with specimens from newly infected patients showing signs and symptoms of active pulmonary tuberculosis.

Check all symptoms that are present: Positive PPD Chest X-ray suggestive of TB Coughing Night sweats Weight loss

Chest pain when breathing or coughing Exposure to person who has active TB Malaise Fever

Cultures or Isolates:
Identification Susceptibility testing (MTB only) Genotyping Other _______________________________________________________________________

SPECIAL INSTRUCTIONS FOR MYCOBACTERIOLOGY TESTING
_______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________
Form 3412 (Rev. 01-11)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
PARASITOLOGY SUBMISSION FORM

Acc # (Lab use only)

SUBMITTER INFORMATION SUBMITTER CODE:

PATIENT INFORMATION PATIENT ID:__________________________________ DOB:______/____/____

CLINIC NAME ____________________________
STREET: ________________________________
_________________________________
CITY: ___________________________________

NAME:

____________________________________________________

Last

First

Middle

RESIDENCE:______________________________________________

__

Street

City

State

Zip

______________________

PHONE:__________________________________

County

Home

Work

Cell/other

STATE & ZIP CODE: _______________________
PHONE NO: ______________________________
FAX NO: _________________________________
CONTACT NAME: __________________________

RACE:

ETHNICITY:

American Indian/Alaska Native Hispanic or Latino

GENDER:
Male

Asian

Non-Hispanic or Latino Female

Black/African-American

Unknown

Unknown

Native Hawaiian/Pacific Islander

Other

Unknown

White

Date of Collection: _____/______/______
Source:
Feces Pinworm Urine Blood Tissue Arthropod
Other:___________________
Collected before Rx? Yes No

SPECIMEN INFORMATION

Test Requested:

Clinical Information:

Formalin Feces PVA Feces Pinworm slide

Symptoms: Date of Onset:_______________________

Worm identification

Abdominal pain

Headache

PCR

Watery diarrhea

Vomiting

Whole blood/blood smear for parasites

Nausea

Chills

Tissue/tissue smear for parasites

Eosinophilia

Fever

Urine for Schistosoma haematobium

Increased gas

Other____________

Miscellaneous identification____________

Purpose of Exam:
Diagnosis Test of Cure Outbreak

Confirmation Reference

Outbreak related: Yes No If Yes, name of outbreak:_____________________________
Travel outside US: Yes No
If Yes, where? : _______________________

Form #3414 (Rev. 1/7/2010

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
RABIES SUBMISSION FORM

Accessioning Number (Lab use only)
Received Date Stamp

SUBMITTER INFORMATION SUBMITTER CODE:

PATIENT INFORMATION CASE/BITE number: _________________________________________________

Name and Address of Person Exposed/Owner of Animal/Submitter (circle one)

CLINIC NAME: ______________________________________ STREET: ___________________________________________ CITY: _____________________________________________

NAME: Last
RESIDENCE: Street

First City

Middle

State

Zip

STATE & ZIP CODE: __________________________________ CLINIC NO: __________________________________ CONTACT NAME: ___________________________________ CONTACT NO: ________________________________

County

______/_________/_____________ DOB

Other Persons Exposed:

NAME_______________________________________ DOB ______/________/_______

NAME_______________________________________ DOB ______/________/_______

NAME_______________________________________ DOB ______/________/_______

Date of Collection: _____/______/___________

SPECIMEN INFORMATION

Date Killed:

County of Animal _______________

_____/______/___________

Species of Animal Submitted: Bat Cat Dog "Breed"_______________ Fox Raccoon Skunk Other _____________
Animal Classification: Pet Wild Stray

Reason for Testing: (mandatory, check all that apply)
Human exposure Domestic animal exposure Epidemiological Reasons Other _________________
Exposure Type: Bite Contact Saliva Scratch Unknown Other _________________

Clinical Information:
Domesticated animal vaccination status: Current None Expired Unknown
Veterinarian who observed animal/phone number
__________________________________
Has animal recently fought with a suspected rabid
animal? Yes No Unknown
If Yes, date: ____________________________

Form 3062 (Rev. 01/2010)

GEORGIA DEPARTMENT OF COMMUNITY HEALTH PUBLIC HEALTH LABORATORY
VIROLOGY SUBMISSION FORM

Accessioning Number (Lab use only)
Received Date Stamp

SUBMITTER INFORMATION SUBMITTER CODE:

PATIENT ID:

PATIENT INFORMATION CTS#:

NAME:

CLINIC NAME: ______________________________________

Last

First

Middle

STREET: ___________________________________________ CITY: _____________________________________________

RESIDENCE: Street
County

City PHONE:
Home

State Work

Zip Cell/other

STATE & ZIP CODE: __________________________________ DOB: _____/______/______

Medicaid #___________________

PHONE NO: _________________________________________
FAX NO: ___________________________________________
CONTACT NAME: ____________________________________

RACE: American Indian/Alaska Native Asian Black/African-American Native Hawaiian/Pacific Islander Other Unknown White

ETHNICITY: Hispanic or Latino Non-Hispanic or Latino Unknown

GENDER: Male Female Unknown

Date of Collection: _____/______/___________
Source/Type: Blood CSF Lesion/General Swab Lesion/Genital Swab Nasopharyngeal Aspirate Nasopharyngeal Swab Plasma Rectal Swab Serum Stool Throat Swab Urine Other: ___________________

SPECIMEN INFORMATION

Reason for Testing: Court Ordered Diagnosis

Clinical Information: Date of Onset: _______________________________

Outbreak Rapid Test Confirmation Routine Screening Other: ___________________

Previous Lab Results, if any: _____________________
Outbreak related: Yes No If Yes, Name/ID# of outbreak: __________________________________________

Shipped: Frozen

Travel outside US: Yes No If Yes, where? : ____________________________

Refrigerated Room Temperature

Symptoms: (check all that apply)

chills/body aches

cough

Special instructions:

diarrhea headache

fever rash

_______________________________

stiff neck watery/red/itchy eyes

vomiting other__________

____________________________________

Forward to CDC**
Please select ONLY one TEST per SPECIMEN per FORM

HIV

VIRAL CULTURE

Test requested:

Test requested:

HIV 1/2 plus O EIA HIV-1 Ab WB HIV-2 Ab
Ryan White Care Act Clients Only HIV-1 Viral Load (bDNA)
Other: ________________

CMV Culture/IFA Enterovirus Culture/IFA Gastrointestinal Outbreak Investigation
Norovirus Panel (EM/PCR) Rotavirus EIA Herpes Culture/ELVIS Respiratory Panel/IFA/PCR Adenovirus Culture/IFA/PCR Influenza Culture/IFA/PCR Parainfluenza Culture/IFA/PCR RSV Culture/IFA/PCR Other respiratory__________/IFA/PCR VZV Culture/IFA Viral Culture/Identification (Please specify): _________________________________________________

Form 3595 (Rev. 01/2010)

GEORGIA PUBLIC HEALTH LABORATORY SPECIMEN COLLECTION OUTFIT ORDER FORM
DECATUR, GA

DATE: ________________________
NAME OF COMPANY _______________
ADDRESS: ___________________________________________ _____________________________________________________ _____________________________________________________
ORDERS ARE SHIPPED UPS PLEASE INDICATE STREET ADDRESS

ORDER FR0M:

GA Public Health Laboratory Laboratory Services & Supply 1749 Clairmont Road Decatur, GA 30033-4050 (404) 327-7920 FAX (404) 327-7922

PERSON ORDERING: ___________________________ PHONE #: _____________________________________

SEROLOGY OUTFITS

BACTERIOLOGY OUTFITS

ITEM 0500
0501

QT/EA

DESCRIPTION
MICROBIAL IMMUNOLOGY WITH BLOOD TUBE
MICROBIAL IMMUNOLOGY WITHOUT BLOOD TUBE

VIROLOGY OUTFITS

0515

HIV (AIDS)

ITEM QT/EA

DESCRIPTION

0505

CULTURAL REFERRAL/ISOLATION FOR IDENTIFICATION

0525

PERTUSSIS SLIDE

0555 0560

STOOL CULTURE (PARA-PAK) STREPTOCOCCUS

0565
0575
*0520 *0521

VIRAL LOAD VIRAL CULTURE
PARASITOLOGY OUTFITS INTESTINAL PARASITES/PVA AMEBIASIS/E. HISTOLYTICA PCR

3491

NEWBORN SCREENING METABOLIC DISEASE

3603

MAILING ENVELOPE

MYCOBACTERIOLOGY (TB) OUTFITS

0550

TB SPUTUM

0585

TB CULTURE FOR IDENTIFICATION

*0530

PINWORMS

0542

BLOOD SMEAR

*AVAILABLE TO COUNTY HEALTH DEPARTMENTS ONLY

FOR LAB USE ONLY
DATE FILLED: __________________# BOXES: ________ BY:_______________________________

MAILING CANS/LIDS AND INDIVIDUAL COMPONENTS
(If a complete outfit is not needed, please order individual components)

ITEM

QT/EA

DESCRIPTION

0800

Specimen Bags

0804

White Tyvek Envelope

0801

Fiberboard Cans/Lids

0802

Lids Only

0803

Kyfax Wrapping Paper

0805

Clear plastic bags for Dekalb & Fulton Co.

0507

6 ml red top blood tube

.

ALBANY REGIONAL PUBLIC HEALTH LABORATORY
1109 NORTH JACKSON ST --- ALBANY, GA 31701
PHONE: (229)-430-4122 FAX: (229) 430-2997
ORDER FORM
****NOTE**** Most supplies are shipped UPS, indicate Street Address NOT P.O. Box
SUBMITTER NAME:
ADDRESS:

PERSON ORDERING:

PHONE:

ITEM 0507 3432

SEROLOGY SUPPLIES QT.EA DESCRIPTION
6 ML VACUTAINER TUBES,
SYPHILIS/EIA FORMS

ITEM 0605 0604 3583

LEAD SUPPLIES QT EA DESCRIPTION
CAPILLARY BLOOD TUBE EDTA PURPLE TOP 5 ML VACTAINER TUBE EDTA, PURPLE TOP LEAD SCREEN FORM
SMALL LABELS

GENERAL SHIPPING SUPPLIES

ITEM

QT. EA DESCRIPTION

3596 0801 0800

GOLD MAILING LABELS/ALBANY ADDRESS TALL CARDBOARD CANS/ALBANY ADDRESS
BIOHAZARD BAGS

0203

KYFAX WRAPPING PAPER

FOR ALBANY LAB USE ONLY
DATE RECEIVED:
FILLED BY:
DATE SHIPPED:
For those clients with Internet access, many of the GPHL submission forms are also available on the Division of Public Health Web Site at http://health.state.ga.us/programs/lab/manual.asp under Publications/Manuals & Guidelines/Laboratory Services Manual/Forms. As new forms are updated, they will be added to the web site.

WAYCROSS PUBLIC HEALTH LABORATORY SPECIMEN COLLECTION OUTFIT ORDER FORM

SUBMITTER CODE_________________________________________ FACILITY_________________________________________________ ADDRESS_________________________________________________

ORDER FROM:
WAYCROSS PUBLIC HEALTH LABORATORY 1751 GUS KARLE PARKWAY WAYCROSS, GA 31503
(912) 338-7050 FAX (912) 338-7061

CITY STATE ZIP____________________________________________

ORDERS ARE USUALLY SHIPPED BY U.P.S. STREET ADDRESS IS REQUIRED, NOT P.O. BOX

PERSON ORDERING____________________________________________PHONE (REQUIRED) ______________________ FAX_______________

SEROLOGY AND GONORRHEA/CHLAMYDIA INDIVIDUAL OUTFITS COMPONENTS

MISCELLANEOUS FORMS-
http://health.state.ga.us/programs/lab/manual.asp

ITEM

QTY

UNIT

DESCRIPTION

ITEM

QTY

UNIT

DESCRIPTION

0500

EACH

OUTFIT: SYPHILIS

0501

EACH

SYPHILIS OUTFIT WITHOUT 6 ML BLOOD TUBE

507

EACH

6 ML RED TOP BLOOD TUBE:

PARASITOLOGY OUTFITS

SYPHILIS

AVAILABLE ONLY TO COUNTY HEALTH DEPARTMENTS

0526 0527

EACH EACH

URINE OUTFIT: (GC/CT) SWAB OUTFIT: (GC/CT)

0520

BOX

INTESTINAL PARASITE OUTFIT IP/PVA (10 /BOX)

530

EACH

PINWORM OUTFIT

0900

RABIES INDIVIDUAL COMPONENTS

EACH

SHIPPING CONTAINER

MAILING CANS AND INDIVIDUAL COMPONENTS

3597

EACH

GREEN MAILING LABEL

0800

EACH

INSIDE CONTAINER (BIOHAZARD BAG)

081

EACH

TALL DOUBLE SHIPPING

CONTAINER

FOR LAB USE ONLY
DATED FILLED_____________________________________ # OF BOXES ________________ BY ________________ TRANSPORT BY: MAIL FEDEX UPS
DATE PICKED UP _______________________________________________________________ BY _______________________________________________
COMMENTS______________________________________________________________________________________________________________________
For those clients with Internet access, many of the GPHL submission forms are also available on the Division of Public Health
Web Site under http://health.state.ga.us/programs/lab/manual.asp