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Laboratory Emergency Preparedness and Response to Mpox

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Winnie Agwang

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Session Objectives

The purpose of this session is to orient participants on laboratory preparedness and response to Mpox

By the end of this session, the participant should be able to;

• Provide an overview on the Mpox outbreak
• Describe quality and safety requirements when preparing and responding to Mpox
• Package, transport and store Mpox samples
• Manage Mpox test results

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Mpox Overview

• Mpox disease (Monkeypox) is a viral zoonotic disease.
• Caused by Monkeypox virus (MPXV), an enveloped double-stranded DNA virus
• Belongs to Orthopoxvirus genus of the Poxviridae family
• Occurs primarily in tropical rainforest areas of central and west Africa but has also been reported in other countries around the world.
• There are two known clades of MPXV, one endemic in Western Africa and one in the Congo Basin region.

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Mpox Detection

• Incubation period is 5-21 days (average 7-10 days).
• The confirmation of Mpox in persons who have not travelled to an endemic area is atypical, and even one case of monkeypox in a non-endemic country is considered an outbreak.
• Mpox is treated and usually resolves in 2-4weeks but can be severe and even cause death.

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Epidemiology of Mpox

From 1 January 2022 through 31 March 2024,

• 95,226 laboratory confirmed cases of monkeypox have been reported to or identified by WHO from 117 Member States across WHO regions.
• Uganda confirmed 2 imported Mpox cases in Kasese district from DRC on 24^th July 2024 as per MoH press release (02^nd August 2024)

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Transmission of Mpox

Anyone can get Mpox. It spreads from:

• Contact with infected materials, such as contaminated sheets, clothes or needles
• Infected pregnant women, who may pass the virus on to their unborn baby
• Inhaling contaminated particles or viruses
• Contact with infected animals (squirrels, rats, mice, and monkeys), when hunting, skinning, or cooking them.
• Contact with infected persons, through touch, kissing, or sexual intercourse.

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Signs and symptoms of Mpox

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• Skin rash
• Fever
• Sore throat
• Headache
• Body aches
• Backpain
• Body weakness)
• Swollen lymph nodes.

Types of Lesions

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Mpox in animals

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Role of laboratory in Mpox outbreak preparedness and response

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Morgan Otita

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Laboratory Preparatory Phase

• Determine type of test being requested and number of suspected cases to be sampled.
• Assemble laboratory rapid response team, and their logistics including Sample collection material, related to the investigation
• Notify testing laboratory and hub coordinator
• Testing laboratory may provide additional information including acceptance requirements

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Pathway of sample movement

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Note:

1. Not all samples will be referred.
2. Onsite testing from the facility where the cases are managed.

QMS approach to Mpox response

a). Pre-Examination:

• Alert verification made
• Suspect / patient identification
• Trained staff / HCWs
• Routinely serviced & certified equipment

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b). Examination:

• SOPs / protocol to be followed (read and understood by attestation)
• Internal Quality control (passed)
• Test performed by a trained and competent laboratory staff

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c). Post-Examination:

• Results relay through MoH outbreak protocol to PHEOC
• Result dispatched to relevant authorities, respective DHO and requester

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In accordance to ISO: 9001; 35001, 15189; 15190; 17025

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• Availability of required supplies
• Mpox case investigation form completely filled
• Biorisk assessment
• Test to be done

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• Laboratory test result verified against the controls
• Laboratory result signed by test performer
• Laboratory result verified by senior laboratory staff

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• Suspected case informed of laboratory findings

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Bio Risk Management

• Biosafety
• PPE utilization at all levels of sample handling
• Scrub suit
• Gum boots
• Disposable gloves
• Disposable gown
• Certified N95 masks
• Face shield / Goggles

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• Waste segregation and disposal
• Segregate waste at point of collection
• If waste is generated in the community/ field, transport it back to the facility for appropriate disposal

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• Infection Prevention and Control
• Hand hygiene using soap and water or an alcohol-based hand sanitizer
• Respiratory hygiene and cough etiquette patient placement
• Personal protective equipment
• Cleaning done with soap and water
• Common disinfectants are hypochlorite and alcohol solutions

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Note: Only Trained staff (HCWs) to handle Mpox samples

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Bio Risk Management

• Biosecurity
• Restricted access to laboratory
• Including sample security at the collection site
• Complete documentation of chain of custody
• Restricted access to the bio-repository
• Restricted access to sample and result related information
• All samples collected should be accounted for
• Always refer Mpox samples to designated laboratory for testing immediately

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Logistics requisition and reception

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Lab requirements before sample collection

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• Contact the DLFP and hub coordinator
• Trained Human resource to perform procedure
• Completely filled request form
• Sample collection materials
• Sample packaging materials
• Sample transportation materials

Laboratory investigation form�

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• This request form is filled by the requester

Prior to sample collection

• Safety precaution and risk assessment must be done to guide RRT team’s .
• Assemble all sample collection supplies
• Dacron or Rayon or Synthetic swabs
• Cryo-vials
• Preferably Viral Transport Media (VTM)
• Biohazard bags (Red in colour)
• Put on appropriate PPE
• Always endeavor to use the buddy system
• Verify request form for patient recognition, completeness and accuracy
• Inform the patient on the sample collection procedure

Note: Do not use physiological saline or water

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Rogers Michael Eilu

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Sample collection

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Sample collection material

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Dacron / Rayon swabs with plastic shaft with VTM / UTM

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Dry swab used with or with out transport media

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Sample collection procedure

1. Gather necessary sample collection supplies
2. Conduct procedure for donning of appropriate PPE.
3. Enter patient area and identify by calling out name on request form
4. Explain procedure to patient
5. Collect sample using a sterile Dacron / rayon / synthetic swab by attaching on the lesion.
6. Rotate swab in circular motion to enhance the harvest on the lesion
7. Insert swab into vial containing VTM and cut or break to fit into the vial
8. Repeat the procedures above (5,6,7) on another lesion from another part of the body.
9. For patients with lesion crust, pick lesion crust using a pair of forceps.
10. Insert in a separate VTM vial
11. Label the VTN vials with unique patient identification number
12. Attached the same identification number on the request form
13. Safely package using the triple packaging procedures as per shipping instruction for category B (UN3373)
14. Handover to buddy for cold chain (2–8°C) or freeze (-20°C or lower) specimens within an hour after collection and transportation

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Sample collection procedure

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Note:

1. The most recommended specimen is the swabs of lesion exudate, or lesion crusts.

2. Refrigerate or freeze the specimen within one hour of sample collection.

Swabbing the lesion

Oropharyngeal sample collection

Sample storage and transportation

• Send refrigerated specimens within 7 days of collection; ship frozen specimens within 60 days of collection.
• Specimens that are greater than 8°C upon receipt will be rejected.
• Transport in cool box with icepacks as category B UN3373 infectious substance
• Send both swabs to NHLDS or UVRI via the sample transport network
• Results will be emailed to the requesting clinician/laboratory, ensure to have all contact details clearly filled in.

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Examples sample acceptance criteria

1. Completely filled request form accompanying referred sample
2. Adequate sample volume
3. Correct sample type
4. Correct sample container

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5. Correct transport conditions (time of collection, media, nonleaking sample container and temperature)
6. Correct addresses and sample labelling

Sample packaging

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Triple packaging

Packaging and Transportation

• Monkey Pox virus is a Category B substance under infectious agent classification

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National Integrated Hub System

• NSRTN is based on hubs (100 hubs)

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• Motorbikes collect samples from peripheral facilities to hubs and vehicles from hubs to testing labs

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• The NSTRN transports ALL routine, outbreak/ surveillance and animal samples.( HIV VL, EID, TB, HEP B, Measles, Polio, Rubella, EVD, COVID 19, Anthrax, rabies, blood for transfusion)

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• It also transports sample collection materials, EQA panels, equipment for calibration, repair.

Vehicle Routing Including Veterinary Labs - (red stars)

NSTRN operations during Mpox response

Biosafety Precautions

Sample tracking

Note: Despite supporting the outbreak, there should be minimum or no distortion to other hub functions such as transporting surveillance and routine samples e.g. VL, EID

Sample Transportation and Result pathway

Points to note while preparing samples for referral

• Use suitable temperature (room temperature) conditions while referring samples
• 2-8°C for samples to be tested between 1 hour and 7 days
• -20°C for samples to be tested after 7 days

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• Samples under transit should be captured in RESTRACK
• https://play.google.com/store/apps/details?id=com.unhls.restrack&hl=en&pli=1 – For capturing the barcodes
• https://tracker.cphluganda.org- For tracking samples in transit
• Barcodes, chain of custody forms

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Nucleic Acid Amplification Testing (NAAT)

• Currently using conventional PCR and GeneXpert PCR
• Nucleic Acid Amplification Test (NAATs) most recommended test and only method in use in country
• NAAT can be generic to orthopoxvirus (OPXV) or specific to monkeypoxvirus (MPXV,preferable)
• Current probes can also test for other orthopox viruses
• In addition to NAAT, sequencing is useful to determine virus clade and to understand epidemiology.
• MPXV genetic sequence data is available on publicly accessible databases.

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Result verification & dispatch

• Result verification by laboratory management
• Results uploaded to laboratory’s information management system
• This is linked to the result dispatch system (RDS)
• The cycle is complete when the requester gets the test results
• Laboratory does not declare outbreaks
• Its Director General for Health Services-MOH role

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Waste segregation

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Proper waste segregation

Poor waste segregation

The waste segregation chart

Ethical Considerations

• Do not share patient results on social media.
• Information (Identification, Result etc.) concerning the patient or client is classified (confidential).
• Only approved or authorized systems are used for information sharing such as the RDS.
• Laboratory outcomes only shared to authorized personnel using authorized channels of reporting.
• Do not share the RDS password to unauthorized persons.

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Reference

• https://iris.who.int/bitstream/handle/10665/354488/WHO-MPX-Laboratory-2022.1-eng.pdf
• https://www.cdc.gov/poxvirus/Mpox/clinicians/prep-collection-specimens.html#:~:text=Place%20swabs%20from%20lesions%2C%20crusts,determine%20the%20specimen%20types%20accepted.
• https://www.cdc.gov/poxvirus/Mpox/lab-personnel/lab-procedures.html
• https://www.gov.uk/guidance/monkeypox-diagnostic-testing
• https://netec.org/2022/07/26/how-to-collect-a-monkeypox-specimen-for-diagnostic-testing/
• https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON390

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Acknowledgement

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