RITM Training Manual for

Specimen
Collection, Transport
and Referral during
Infectious Disease
Outbreak Response

MODULE 1: INTRODUCTION

RITM Training Manual for Specimen Collection, Transport and Referral during
Infectious Disease Outbreak Response
Overview of the Course
Course Description: The course is designed to provide to all levels of surveillance
and field health care staff on how to collect, handle and transport specimens
including laboratory referral during Infectious Disease Outbreak Response

Course Goals:
• To influence in a positive way the attitudes of the participant toward the benefits
of using appropriate and standard principles and practices in Specimen
Collection, Transport and Referral During Infectious Disease Outbreak Response
• To provide the participant with training in simple, inexpensive epidemiologic and
laboratory investigation of infectious disease outbreak
• To provide participant with the knowledge and skills needed to implement and/or
improve Specimen Collection, Transport and Referral During Infectious Disease
Outbreak Response in his/her station/facility
Course Modules
Module 1: Introduction
Session 1: Welcome, introductions and expectations
Session 2: Administration, logistics, and house rules
Session 3: Rationale for the revised RITM Outbreak Manual and course
overview
Session 4: Review the role of the laboratory on outbreak response

Module 2: Planning an Outbreak Response

Session 1: Define the possible causes of the outbreak
Session 2: Decide which clinical specimens are required to confirm the cause
of the outbreak according to WHO Syndromic Surveillance
Course Modules
Module 3: Collection & Processing of Specimens
Session 1: General guidelines for outbreak specimen collection, handling &
storage
Session 2: Specifics on collection of outbreak specimen
Session 3: Collection, handling & storage per specimen type
Session 4: Specimen storage
Session 5: Specimen labeling
Session 6: Case Investigation Forms (CIFs)
Course Modules
Module 4: Specimen Packaging & Transport of Infectious Substances
Session 1: Objectives
Session 2: General guidelines
Session 3: Classification of infectious substances
Session 4: Specimen packaging and transport of infectious substances

Module 5: The Laboratory Referral System

Session 1: Objectives of an efficient laboratory referral system
Session 2: Laboratory roles by level of service
Session 3: Laboratory referral network
Session 4: Laboratory referral flow
Session 5: Requirements for specimen referral
Session 6: Rejection of outbreak specimen
Course Modules
Module 6: Biosafety & Biosecurity
Session 1: Definition of terms
Session 2: Principles of Biosafety
Session 3: Risk Group classification of microorganisms
Session 4: Laboratory Biosafety Level
Session 5: Infection control, disinfection & personal protection
Session 6: Sterilization, decontamination, waste management & disposal

Practicum: NPS/OPS Specimen Collection

Session 3: Rationale for the Revised
RITM Outbreak Manual
Rationale for the Revised RITM Outbreak Manual
• In many outbreaks, confusion regarding specimen collection, referral
and information flow resulted in non-laboratory confirmation of the
infectious agent.
Inappropriate specimens were sent for testing from suspected cases of
pertussis in 2007.
In 2009 a leptospirosis outbreak was hampered by confusion during sample
collection, transport and referral that resulted in the low detection rate of
Leptospira

• The misinterpretation of laboratory results and lack of compliance

with the recommended specimen transport guidelines happened
during a suspected Anthrax outbreak in 2010.
RITM Outbreak Manual, 2nd Ed
RITM has updated the manual to provide field health workers and staff in
laboratories a set of standard practices to follow in conducting disease
outbreak investigations. This is meant to:
• ensure that the correct specimens are collected, packaged and transported
in a safe and standardized manner during a field investigation of an
outbreak;
• make health personnel efficient and effective to contain, identify and treat
diseases when they cluster or break out—especially in areas that may not
have safe water supplies, electricity or good transport systems;
• assist leaders and members of a multidisciplinary outbreak investigative
team to plan and guide their specimen collection in the field, leading to
rapid diagnostic confirmation and control of the infectious agent causing
the outbreak.
Session 4: Role of the
Laboratory
 Laboratory and Disease Surveillance
Before the outbreak
• Early warning signals
• Outbreak detection
During the outbreak
• Outbreak response and management
In between outbreaks
• Trend monitoring
• Intervention evaluation
• Monitoring progress towards a control objective
 Outbreak Detection
1. Outbreak detection with lab support
Outbreak Investigation Team captures an increased incidence
Laboratory:
• Confirms the diagnosis
• Allows for a more specific case definition
• Detects a new pathogen
• Provides additional details on the pathogen (e.g., phage type)

Effective participation of the laboratory in surveillance requires good

communication between the OIT and the laboratories
 Outbreak detection

2. Outbreak detection by the laboratory

Identification of a cluster of:
• Infections with an unusual pathogen
• Specific subtype of a pathogen
Outbreak of antibiotic-resistant strains
Subtypes of a pathogen (e.g. Shigella dysenteriae type I)
Reference centers may capture outbreaks disseminated
over a large area
Laboratory Support to Outbreak Investigation

Successful laboratory confirmation of a disease depends on:

• Outbreak notification
• Advance planning
• Collection of appropriate and adequate specimens
• Correct packaging and rapid transport to an appropriate laboratory
• The ability of the laboratory to accurately perform the diagnostic
tests
• Proper biosafety and decontamination procedures to reduce the
risk of further spread of the disease
Laboratory Support to Outbreak Investigation
• Laboratory Diagnosis is an essential element of communicable disease
surveillance, both for routine confirmation of infections and for the rapid
identification of the cause of outbreaks and epidemics.
• Challenge to countries is to identify rapidly and correctly the microbial
cause of an outbreak which is of potential international public health
concern. To meet this challenge, the laboratory needs to be “in the loop,”
i.e.
Know that there is an outbreak
Receive appropriate specimens
Provide, or provide access to, reliable laboratory expertise and facilities
Communicate the laboratory findings to the appropriate persons dealing with the
outbreak.
Critical Elements of Laboratory Support
1. Communications – the laboratory must be informed when there is
suspected outbreak and the nature of that outbreak (hemorrhagic,
diarrheal, etc. The lab must also communicate results of
investigations promptly and accurately to the outbreak investigation
team
2. Collection and transport of specimens and accompanying data from
the outbreak to the laboratory
2.1. The laboratory needs to know:
• The nature of the outbreak (therefore type of specimens to be collected)
• Approximate number and types of specimens that the lab is expected to
receive
• Approximate timing of specimen collection and dispatch to laboratory
Critical Elements of Laboratory Support
2.2. The laboratory should provide:
• Materials for the safe collection and transport of specimens (including
laboratory request forms, case investigation forms, etc.)
• Guidance on:
What to collect, how to collect and how much, safe handling of
specimens
How to package and transport, and where to transport to
3. Specimen processing, identification of pathogens, interpretation of
results, data management