Emerging Infectious Diseases Volume 17 Issue 6

2011·6 MB·English

by  CDC

Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 963–1160
EDITOR-IN-CHIEF
D. Peter Drotman
Managing Senior Editor EDITORIAL BOARD
Polyxeni Potter, Atlanta, Georgia, USA
Dennis Alexander, Addlestone Surrey, United Kingdom
Senior Associate Editor Timothy Barrett, Atlanta, GA, USA
Brian W.J. Mahy, Bury St. Edmunds, Suffolk, UK Barry J. Beaty, Ft. Collins, Colorado, USA
Martin J. Blaser, New York, New York, USA
Associate Editors
Christopher Braden, Atlanta, GA, USA
Paul Arguin, Atlanta, Georgia, USA
Arturo Casadevall, New York, New York, USA
Charles Ben Beard, Ft. Collins, Colorado, USA
Kenneth C. Castro, Atlanta, Georgia, USA
Ermias Belay, Atlanta, GA, USA
Louisa Chapman, Atlanta, GA, USA
David Bell, Atlanta, Georgia, USA
Thomas Cleary, Houston, Texas, USA
Corrie Brown, Athens, Georgia, USA
Vincent Deubel, Shanghai, China
Charles H. Calisher, Ft. Collins, Colorado, USA
Ed Eitzen, Washington, DC, USA
Michel Drancourt, Marseille, France
Daniel Feikin, Baltimore, MD, USA
Paul V. Effl er, Perth, Australia
Kathleen Gensheimer, Cambridge, MA, USA
David Freedman, Birmingham, AL, USA
Duane J. Gubler, Singapore
Peter Gerner-Smidt, Atlanta, GA, USA
Richard L. Guerrant, Charlottesville, Virginia, USA
Stephen Hadler, Atlanta, GA, USA
Scott Halstead, Arlington, Virginia, USA
Nina Marano, Atlanta, Georgia, USA
David L. Heymann, London, UK
Martin I. Meltzer, Atlanta, Georgia, USA
Charles King, Cleveland, Ohio, USA
David Morens, Bethesda, Maryland, USA
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J. Glenn Morris, Gainesville, Florida, USA
Takeshi Kurata, Tokyo, Japan
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S.K. Lam, Kuala Lumpur, Malaysia
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Stuart Levy, Boston, Massachusetts, USA
Didier Raoult, Marseille, France
John S. MacKenzie, Perth, Australia
Pierre Rollin, Atlanta, Georgia, USA
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Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011
June 2011
On the Cover Pandemic (H1N1) 2009 Risk
Max Weber (1881–1961) for Frontline Health Care Workers ..........1000
Figures (c. 1914) C. Marshall et al.
Pastel on paper (61 cm × 45.7 cm) Clinical workers did not have a substantially greater
High Museum of Art, Atlanta risk for infection.
Gift in memory of Louis Regenstein by
his wife Helen and sons Lewis and Kent
Campylobacteriosis Decline
after Interventions Aimed at
About the Cover p. 1156 Poultry, New Zealand ...............................1007
A. Sears et al.
A population-level food safety response successfully
reduced disease incidence.
Synopsis
Laboratory Service Effectiveness Wild Birds and Highly Pathogenic
during Pandemic (H1N1) 2009, Avian Infl uenza (H5N1) among
Victoria, Australia .......................................963 Poultry, Thailand .......................................1016
M. Catton et al. J. Keawcharoen et al.
The greatest challenges were insuffi cient staff and Wild birds are associated with increased virus
test reagents. transmission.
Research Methicillin-Resistant Staphylococcus
aureus, Samoa, 2007–2008 ......................1023
Multiple Introductions of J. Alesana-Slater et al.
Multidrug-Resistant Tuberculosis
A wide range of MRSA genotypes cause wound
into Households, Lima, Peru .....................969 p. 1024 infections.
T. Cohen et al.
Data on household transmission are needed to
develop optimal treatment.
Taenia solium Tapeworm Infection,
Binary Toxin and Death after Oregon, 2006–2009 ...................................1030
Clostridium diffi cile Infection ....................976 S. O’Neal et al.
S. Bacci et al. Incidence was higher than expected.
Strains with this toxin and toxins A and B were
associated with high case-fatality rates. p. 1072
Cefepime-Resistant
Invasive Group A Streptococcal
Pseudomonas aeruginosa .......................1037
Infection and Vaccine Implications,
E. Akhabue et al.
Auckland, New Zealand .............................983
A. Safar et al. Of tested organisms, 8.4% were resistant to one of
the last effective drugs available.
The proposed 26-valent vaccine would provide limited
benefi t.
Historical Review
Antiviral Drugs to Reduce Household Refl ections on 30 Years of AIDS .............1044
Transmission of Pandemic (H1N1) 2009, K.M. De Cock et al.
United Kingdom ..........................................990 Although the end of the epidemic is not yet in sight,
R.G. Pebody et al. the remarkable response has improved health around
Early treatment of primary case-patients and the world.
prophylaxis of household contacts provide effective
protection.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011
Dispatches
1049 Reassortant Pandemic (H1N1) 2009 Virus June 2011
in Pigs, United Kingdom
W.A. Howard et al. 1116 Patients’ Geographic Origins and Viral
Hepatitis Co-infection Patterns, Spain
1053 Immunologic Changes during Pandemic
S. Pérez Cachafeiro et al.
(H1N1) 2009, China
H.-H. Shen et al. 1120 Possible Novel Nebovirus Genotype in
Cattle, France
1056 Human Infection with Avian Infl uenza
J. Kaplon et al.
Virus, Pakistan, 2007
M. Zaman et al.
Letters
1060 Novel Reassortant Highly Pathogenic
Avian Infl uenza (H5N5) Viruses in Domestic
1124 Vibrio cholerae in Traveler from Haiti to
Ducks, China
Canada
M. Gu et al.
1125 Easy Diagnosis of Invasive Pneumococcal
1064 Multidrug-Resistant Acinetobacter
Disease
baumannii Harboring OXA-24
Carbapenemase, Spain 1127 Mimivirus-like Particles in Acanthamoebae
J. Acosta et al. from Sewage Sludge
1068 Internet Queries and Methicillin-Resistant p. 1084 1129 Rabies Immunization Status of Dogs,
Staphylococcus aureus Surveillance Beijing, China
V.M. Dukic et al.
1131 Effect of Media Warnings on Rabies
1071 Porcine Reproductive and Respiratory Postexposure Prophylaxis, France
Syndrome in Hybrid Wild Boars, China
1132 Bedbugs as Vectors for Drug-Resistant
J. Wu et al.
Bacteria
1074 Hepatitis E Virus Seroprevalence and
1134 Community Vaccinators in the Workplace
Chronic Infections in Patients with HIV,
Switzerland 1135 MRSA in Retail Meat, Detroit, Michigan
A. Kenfak-Foguena et al. 1137 Suspected Horse-to-Human Transmission
1079 Macrolide Resistance in Mycoplasma of MRSA ST398
pneumoniae, Israel, 2010 1139 Screening for Pandemic (H1N1) 2009 Virus
D. Averbuch et al. among Hospital Staff, Spain
1083 Outcome Predictors in Treatment of Yaws p. 1145 1140 Pandemic (H1N1) 2009 and HIV Infection
O. Mitjà et al.
1143 Swine Infl uenza Virus A (H3N2) Infection in
1086 Increasing Ceftriaxone Resistance in Human, Kansas, 2009
Salmonellae, Taiwan
1145 Severe Leptospirosis Similar to Pandemic
L.-H. Su et al.
(H1N1) 2009, Florida and Missouri
1091 Salmonella enterica Serotype Typhi and
1147 HKU1 Coronavirus in Children, Brazil, 1995
Quinolone Resistance Phenotype
M. Accou-Demartin et al. 1148 Macrolide Resistance–associated Mutation
in Mycoplasma genitalium
1095 Ciprofl oxacin-Resistant Salmonella
enterica Serotype Typhi, United States, 1150 Saffold Cardioviruses in Children with
1999–2008 Diarrhea, Thailand
F. Medalla et al. 1152 Lethal Necrotizing Pneumonia and ST398
1099 High Vancomycin MIC and Complicated Staphylococcus aureus (response)
MSSA Bacteremia 1153 ESBL-producing Escherichia coli in
J.M. Aguado et al. Neonatal Care Unit (response)
1103 New Porcine Calicivirus in Swine, United
States Book Review
Q. Wang et al.
1107 Invasive Streptococcus pneumoniae in 1155 Emerging Infections 9
Children, Malawi, 2004–2006

J.E. Cornick et al.
About the Cover
1110 Worldwide Distribution of Major Clones of
Listeria monocytogenes
1156 The only emperor is the emperor
V. Chenal-Francisque et al. of ice-cream
1113 Klebsiella pneumoniae Bacteremia and
Etymologia
Capsular Serotypes, Taiwan
1082 Yaws
C.-H. Liao et al.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011
Reality Check of Laboratory Service
Effectiveness during Pandemic
(H1N1) 2009, Victoria, Australia
Michael Catton, Julian Druce, Georgina Papadakis, Thomas Tran, and Christopher Birch
No campaign plan survives fi rst contact with the severe outcomes), and protect (identify and manage those
enemy.—Helmuth Graf von Moltke at risk for severe illness and those in vulnerable settings
such as aged-care facilities). The pandemic plan envisaged
In Australia, the outbreak of pandemic (H1N1) 2009
all Australian states moving together through the pandemic
began in Melbourne, Victoria; in the fi rst 17 days, the
phases. In practice, however, Victoria implemented the
Victorian Infectious Diseases Reference Laboratory
sustain phase, referred to as modifi ed-sustain, sooner than
detected 977 cases. Although the laboratory had a
other states.
pandemic plan in place, a retrospective evaluation found
The fi rst 3 case-patients were siblings who had recently
3 major variations from plan assumptions: 1) higher peak
demand not limited by a case defi nition, 2) prolonged returned from the United States (Figure 1). When the
peak demand because containment attempts continued outbreak began, Victorian health authorities implemented
despite widespread infl uenza, and 3) unexpected infl uence the contain phase (3), and laboratory confi rmation of
of negative test results on public health actions. Although cases was conducted by the Victorian Infectious Diseases
implementation of the plan was generally successful, the Reference Laboratory (VIDRL). Attempted containment
greatest challenges were limited availability of skilled staff ceased on June 3 when confi rmed cases totaled 977,
and test reagents. Despite peak demand of 1,401 tests
at which time laboratory testing was restricted to that
per day, results were provided within the usual 24 hours
appropriate under a modifi ed-sustain phase. By June 23,
of specimen receipt; however, turnaround time seemed
when the modifi ed-sustain phase ended, 1,406 cases had
slower because of slow transport times (>3 days for 45%
been laboratory confi rmed and 1 patient had died. Testing
of specimens). Hence, effective laboratory capability might
efforts subsequently moved to those required under the
be enhanced by speeding transport of specimens and
improving transmission of clinical data. protect phase. By September 27, a total of 6,895 cases in
Victoria had been reported, 24 of them fatal (3), although
the true number of cases is probably greater.
The pandemic (H1N1) 2009 outbreak in Australia was
We describe VIDRL provision of laboratory support for
detected in Victoria on May 18, 2009, and during
the pandemic (H1N1) 2009 outbreak response in Victoria.
the following weeks spread to other states. Pandemic
We critically appraise the effectiveness of this laboratory’s
planning guidelines for Australia consist of 4 phases (1):
pandemic planning from 3 perspectives: 1) how the reality
delay (identify and test persons who meet a clinical case
of the pandemic matched planning assumptions, 2) how
defi nition), contain (home quarantine laboratory-confi rmed
successfully this planning facilitated workfl ow in practice,
case-patients and give antiviral prophylaxis to their
and 3) how successfully the laboratory delivered the
contacts), sustain (restrict laboratory testing to persons
required testing.
with clinically defi ned cases who are at increased risk for
Pandemic Planning
Author affi liation: Victorian Infectious Diseases Reference Our planned algorithm for infl uenza A virus testing
Laboratory, North Melbourne, Victoria, Australia involved extraction of RNA from clinical specimens
by using QIAxtractor or BioRobot Universal System
DOI: 10.3201/eid1706.101747
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011 963
SYNOPSIS
PCRs being conducted each day for 2 weeks. Second, a
step-down in demand with a focus on severe or atypical
cases that needed testing for clinical management would
result in ≈200 tests being conducted each day for several
months. Implicit in the latter phase was that a clinical case
defi nition would suffi ce for most uncomplicated infl uenza
cases and that dominant circulation of the pandemic strain
would enable a test result of “infl uenza A detected” from
many laboratories to be a de facto diagnosis of pandemic
(H1N1) 2009 infection. Some laboratory capacity would be
reserved for outbreak monitoring by sentinel surveillance
and detailed strain characterization. All routine diagnostic
laboratory activity (≈1,000 tests/day) for diseases other than
infl uenza would proceed routinely, but elective activities
Figure 1. Number of patients with infl uenza-like illness and numbers
of laboratory detections of pandemic (H1N1) 2009 derived from such as research would be delayed as needed.
primary care physician infl uenza surveillance together with the To realize this pandemic plan, certain measures
phases of the outbreak in Victoria (VIC). The phases are as follows: were undertaken at VIDRL. They were 1) assembly of
delay (conduct active surveillance and border control measures),
enough nucleic acid extraction robotics and real-time PCR
contain (restrict establishment of the pandemic), modifi ed-sustain
analyzers for >500 daily PCRs, 2) recruitment and training
(minimize transmission and maintain health services), and protect
(focus on those at risk for severe outcomes). Modifi ed from (1,2), of 2 additional scientists who could work in the testing
laboratory during a major outbreak, 3) planning for the
temporary reassignment of scientifi c staff with appropriate
extraction robots (each from QIAGEN, Valencia, CA, skills from other laboratory areas during an outbreak, 4)
USA), followed by reverse transcription with random cross-training of secretarial and clerical staff to enter
hexamers. cDNA was amplifi ed in parallel assays by using patient and specimen data into the laboratory information
an Applied Biosystems 7500 Fast Real-Time PCR System system, 5) manning of the laboratory telephone switchboard
(Foster City, CA, USA) and incorporating primers and by clerical staff, and 6) creation of a small stockpile of
probes selective for the matrix gene of infl uenza A viruses, essential laboratory reagents.
including that of the pandemic (H1N1) 2009 virus, and for
the hemagglutinin (HA) gene of that virus. (Sequences of Effectiveness of Testing
all primers and probes used in these assays are available During the initial contain phase, the number of tests
upon request to M.C.). run was high. On June 1, the day of peak testing, 1,401
Our model of anticipated pandemic infl uenza testing PCRs for infl uenza were performed, this being the sum of
comprised 2 phases. First, an initial peak of intense testing the matrix gene PCRs performed on each referred specimen
needed to identify early cases would result in >500 additional and HA gene PCRs performed on matrix gene PCR-positive
Figure 2. Number of diagnostic
specimens received at the Victorian
Infectious Diseases Reference
Laboratory and laboratory detections
of pandemic (H1N1) 2009 virus,
Victoria, Australia, 2009.
964 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011
Laboratory Service during Pandemic (H1N1) 2009
samples (Figure 2). In contrast, a typical daily peak number
in winter would be ≈100. However, the laboratory was able
to sustain peak levels of infl uenza testing and provision
of results within typical turnaround times. The times
from specimen data entry into the laboratory information
system to result reporting were calculated by extracting
data from the Laboratory Information System (Medipath,
LRS Health; Melbourne, Victoria, Australia) with an
integral analytic software module. Because the actual time
of specimen arrival is not searchable on our system, the
representativeness of this electronic data as a proxy for
total test turnaround time was verifi ed by a manual audit of
200 Medipath fi les. This procedure compared the manually
stamped arrival time and date on scanned digital images
of specimen request forms received on June 1, the busiest
day of the outbreak, with the corresponding time and date
Figure 3. Mean turnaround times for Victorian Infectious Diseases
recorded electronically for result reporting. This manual Reference Laboratory detection of infl uenza, Victoria, Australia,
audit gave a faster estimate for turnaround time than the 2008 and 2009.
electronic search, probably because the latter includes data
from weekends (data not shown).
The mean turnaround time from specimen data data from patient to testing site and provision of results
acquisition to result reporting for the 4 peak months of the back to the patients’ caregivers must also be optimal. To do
2009 outbreak was <24 hours (Figure 3). For all except a so required a systemwide planning approach that was less
2-week period in June, this turnaround time was faster than than complete at the onset of the pandemic. More planning
the equivalent turnaround time for the winter of 2008. The will be needed for optimal functioning under the pressures
main contributors to this outcome were longer than usual imposed by a future large outbreak (Table).
working hours for scientifi c and support staff, coupled with
high levels of automation. Effectiveness of Pandemic Planning
Specimens were transported by courier to VIDRL During the pandemic, 3 key elements differed
from Melbourne hospitals, other laboratories, and general substantially from our planning assumptions: 1) we did
practitioners on behalf of Victorian health authorities. The not predict the expectation that all community respiratory
duration of time from specimen collection to arrival at disease would be tested, 2) we did not plan for testing
VIDRL varied. Transport times for all pandemic (H1N1) to continue long after widespread community spread of
2009–positive samples were calculated by comparing the infl uenza was evident, and 3) we had not considered that
interval between the laboratory receipt time and date stamp negative test results would be so infl uential to the public
and the recorded collection time and date on digital images health response. This outbreak was the fi rst infl uenza
of specimen request cards. Positive samples were chosen pandemic during which provision of real-time diagnostic
for analysis because of the relative ease with which this
dataset could be collated from the laboratory information
system. The positive samples were representative of the
total sample group from which they came; ≈15% of positive
specimens arrived on the day of collection, 40% arrived the
next day, and ≈30% arrived over the next 2 days (Figure 4).
Despite maintenance of typical test turnaround times, these
transport times contributed to clinicians’ perception of slow
turnaround times (4), for which VIDRL received numerous
complaints. During the pandemic, it was common to
receive telephone inquiries for results for specimens that
had arrived only hours earlier or had yet to arrive.
Our pandemic planning had focused primarily on
resources and processes under our control within the
Figure 4. Timing of receipt of pandemic (H1N1) 2009 virus–
laboratory. However, for optimal functioning of the whole
positive specimens by the Victorian Infectious Diseases Reference
testing cycle, the movement of specimens and accompanying Laboratory, Australia, 2009.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011 965
SYNOPSIS
Table. Summary of laboratory effectiveness during pandemic (H1N1) 2009, Victoria, Australia, 2009
Challenge Potential solution
Data management
Pressure on specimen data entry into laboratory information Direct electronic communications of specimen data from
system referring source to laboratory
Missing telephone, fax, address details on request forms Direct electronic communication of results from laboratory to
referring source
Volume of negative results precluding telephone contact with Direct electronic communication of results from laboratory to
referring source referring source
Specimen transport
Slow Multi-institution planning of efficient emergency specimen
transport
Poor interfacing with test start times in laboratory Multi-institution planning of efficient emergency specimen
transport
Staff
Finite laboratory staff resources Further minimization of manual steps for specimen processing
and additional staff cross-training
Telephone inquiries
Difficulty manning switchboard over extended laboratory hours Planning for additional agency staff during emergencies
High call volume to laboratory taking scientific staff away from Minimization of inquiries through improved specimen transport
testing and data management
Reagents
Shortages threatening test capacity Expansion of reagent stockpile and use of validated test
protocols using reduced reagent volumes
Communication
Misunderstandings regarding scope and objectives of Strengthened lines of communication between laboratories,
laboratory testing clinicians, and health authorities
Pandemic planning
Lack of flexibility to accommodate verging levels of influenza Adapted pandemic plan
activity at state jurisdiction level
virologic testing on large numbers of specimens had been network within the fi rst week of the outbreak (3). Unlimited
a practical possibility. This testing capability created high testing as infl uenza spread rapidly in the community drove
expectations among users of our service. Our pandemic testing demand to extremely high levels. The reasons for
planning had sought to provide a realistic volume of testing continuation of the contain phase are complex but were
capacity for anticipated public health and clinical needs. in part a consequence of the pandemic plan’s treatment of
However, the initial expectation from the community and the country as a homogeneous whole, although in reality
many clinicians during the contain phases was that all the Victoria outbreak occurred several weeks sooner than
cases of respiratory disease in the community would be outbreaks in other Australian states (5). In contrast to
tested. This expectation is not unusual in highly publicized the higher than expected peak, testing levels during the
infectious disease outbreaks, but because the at-risk subsequent step-down phase were lower than provided for
population was effectively unlimited in this outbreak, the in our plan (Figure 2). This fi nding is consistent with the
demand was extreme. Most samples received were from relative clinical mildness of the pandemic (H1N1) 2009
persons who were relatively healthy, as evidenced by virus strain; in Victoria, only 0.3% of infected patients
telephone conversations between our medical staff and were hospitalized in the fi rst 10 weeks of the outbreak (6).
patients, clinical details when provided on request forms, In past outbreaks, we focused on urgent and accurate
and by the dramatic drop in demand later during the sustain communication of positive laboratory results that identifi ed
phase when testing was focused on those truly at risk for cases, and we communicated negative results en masse
serious illness (Figure 2). by routine systems, including electronic links to major
Our planning model of a 2-week initial surge followed health care institutions. However, during pandemic
by a step-down to clinically focused testing proved correct. (H1N1) 2009, major public health actions were triggered
However, the contain phase of high-demand testing by negative results, including cessation of quarantine
continued well beyond the point at which it was fi rst evident restrictions and decisions about antiviral prophylaxis.
that community transmission was widespread. Only 9 of While communication of large numbers of positive results
the fi rst 978 case-patients had a history of overseas travel to clinicians and public health authorities challenged
(3), and pandemic (H1N1) 2009 began to be detected from resources, urgent and personalized transmission of a much
our sentinel general practitioner infl uenza surveillance larger number of negative results was not possible. This
966 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011
Laboratory Service during Pandemic (H1N1) 2009
limitation was further compounded by the frequency with of our testing algorithm (from an initial test algorithm
which telephone or fax numbers of primary care physicians involving infl uenza A matrix gene PCR primers and H1
were missing on request forms; hence, laboratory reporting HA gene primers run in parallel to an algorithm involving
depended on postal addresses, which were also frequently the matrix gene alone with subsequent HA subtyping of
incomplete or missing. Spot checks of request forms positive samples on the same day); and, immediately
performed several times during the outbreak found this after introduction of the modifi ed-sustain phase, adhering
problem on up to 10% of request forms. rigidly to the criteria for test eligibility circulated by health
authorities. Adhering to these criteria included storing, but
Implementation of Planning not testing, samples from persons determined to not be at
Many aspects of our laboratory pandemic planning substantial clinical risk. This practice caused unhappiness
worked well in practice; outbreak testing facilities and among some clinical colleagues but preserved suffi cient
equipment platforms provided the required test capacity capacity to guarantee testing for patients in clinical need.
(as many as 1,400 extra PCRs in 1 day). Employment of
additional scientists before the outbreak also provided Outbreak Monitoring
considerable benefi ts. In other areas, a great deal of As described elsewhere (2,3), a network of 80 general
commitment and hard work from staff compensated for practitioners in metropolitan Melbourne and rural Victoria
planning shortcomings. Notably, preparations for surge conducted infl uenza surveillance, coordinated by VIDRL,
capacity in several support areas, including patient data from May through October 2009. Laboratory testing for
entry and dealing with telephone inquiries, could not infl uenza was conducted for a subset of these cases, and
match demand and required additional effort to resolve test results were made available online (7). This testing
bottlenecks. Because our system of data entry requires activity was maintained during the time of heavy laboratory
specifi c skills, we could not use temporary agency staff for demand because of the perceived need to collect unbiased
data entry. In practice, cross-trained secretarial staff and data on infl uenza activity comparable to data collected
volunteers proved too slow for the demand, and their needs during the previous 10 years of infl uenza surveillance.
for support impeded the work of skilled staff. Particularly The number of laboratory-confi rmed cases of pandemic
after hours, laboratory test results were often available infl uenza (3) was heavily infl uenced by community testing
before complete data entry had been performed, delaying behavior and by guidelines for testing promulgated by
release of hard-copy laboratory reports. A technical health authorities. This infl uence is shown clearly in the
solution involving electronic upload of test requests from abrupt reductions in testing and detections of infl uenza in
clinicians seems the best future approach to this problem. Victoria after June 3, when the pandemic response phase
Scientists in our organization who were not involved changed from contain to modifi ed-sustain (Figure 2).
in infl uenza testing, envisaged as providing a pool of Hence, the number and timing of laboratory-confi rmed
supplementary staff with PCR or virology skills, were cases were unrepresentative of the wider outbreak. In
rarely able to perform this function during the outbreak. The contrast, laboratory-supported infl uenza surveillance
capacity of support staff who were performing functions undertaken in parallel with diagnostic testing provided
such as specimen reception was almost entirely consumed monitoring of the course of the outbreak relatively free
by the demands of receiving infl uenza specimens. Staff of these effects (Figure 1) and, as described elsewhere,
in other laboratory areas helped absorb demand by taking enabled direct comparison of the outbreak with >10 years
over these functions for their own specimens but then of seasonal infl uenza (3,7,8).
could not reasonably release scientifi c staff to supplement
infl uenza testing. As a result, those involved in infl uenza Conclusions
testing worked long hours, supported by scientists from Operationally, the pandemic (H1N1) 2009 outbreak
other laboratory areas who were also working overtime. tested our laboratory preparedness in ways that no exercise
Although this approach was sustainable for weeks, it could could; yet some of the potential pressures were limited
not have continued through the outbreak. by the relatively low clinical severity of the virus. The
Lastly, the small stockpile of PCR reagents proved numbers, speed, and accuracy of tests conducted, along
insuffi cient. The high demand for testing during the contain with real-time tracking of the outbreak through laboratory-
phase required a commensurate amount of reagents. supported infl uenza surveillance, were unimaginable less
Suppliers in Australia were initially unable to keep up than a decade ago. Facilities, equipment, and PCR-based
with our rapidly escalated demand. This limitation was testing performed extremely well. Limits to the available
successfully managed by using reduced reaction volumes pool of skilled staff and the threat of reagent shortages
(because of a shortage of random hexamers, the volume of provided challenges where contingency plans had only
reverse-transcribed cDNA was halved); changing aspects been partly successful. Staff performed admirably in the
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011 967
SYNOPSIS
face of these challenges, but in the future, more effective 3. Fielding J, Higgins N, Gregory J, Grant K, Catton M, Bergerei I,
solutions will be required. The greatest improvements in et al. Pandemic H1N1 infl uenza surveillance in Victoria, Australia,
April–September, 2009. Euro Surveill. 2009;14:pii:19368.
overall performance of the laboratory testing cycle will
4. Jardine A, Conaty SJ, Cretikos MA, Su WY, Gosbell IA, van Hal
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We thank Kristina Grant for reproduction of infl uenza-like 6. Lum ME, McMillan AJ, Brook CW, Lester R, Piers LS. Impact of
pandemic (H1N1) 2009 infl uenza on critical care capacity in Victo-
illness data shown in Figure 1.
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Dr Catton is director and head of virology at VIDRL in 7. Victorian Infectious Diseases Reference Laboratory. Sentinel infl u-
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Melbourne, Australia. His professional interests are molecular
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Diseases Reference Laboratory, Locked Bag 815, Carlton South, Victoria
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(Australia): The Department; 2008. p. 20–2. 3053, Australia; email: [email protected]
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968 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 6, June 2011