from the bench
Florida Responds to the Challenges
of Zika Surge Testing
By Jessica Brown, Medical Laboratory Scientist III, Bureau of Public Health Laboratories-Jacksonville;
Andrew Cannons, PhD, HCLD(ABB), laboratory director, Florida Bureau of Public Health Laboratories-
Tampa; Amanda Davis, NT(ABB), MLT(ASCP), Medical Laboratory Scientist III, Florida Bureau of Public
Health Laboratories-Jacksonville; Lea Heberlein-Larson, MPH, SM(ASCP), virology administrator, Florida
Bureau of Public Health Laboratories; and Marie-Claire Rowlinson, PhD, D(ABMM), assistant laboratory
director, Florida Bureau of Public Health Laboratories-Jacksonville
The Florida Department of Health’s
Bureau of Public Health Laboratories
(BPHL) detected the first cases of travel-
associated Zika virus infection in Florida
in January 2016 and the number of
cases steadily increased over the next
several months. Approximately seven
months later, as many scientists had
predicted, the Florida Department of
Health (DOH) confirmed the first case
of local transmission of Zika in the
US when the virus was detected in a
Miami-Dade area resident. The BPHL was
well-prepared for such an event, having
implemented the laboratory-developed
tests for Zika (RT-PCR and IgM MAC-ELISA)
in BPHL-Jacksonville and BPHL-Tampa
in late 2015. However, the detection of
locally-acquired Zika cases led to an
immediate increase in test volume and
some unprecedented challenges.
Adapting to Surge Testing
The first was triaging of specimens, which
proved to be a formidable experience
throughout the surge. Since dengue
and chikungunya virus–diseases with
very similar symptoms to the Zika
virus–were circulating in South America,
it was essential to have background
information such as travel history,
pregnancy status and exposure in order
to test for the appropriate arboviral
diseases. Oftentimes, this information
was not supplied or was incomplete,
and obtaining it post-sampling was
very challenging because direct contact
information for the provider was not
available. An unfortunate consequence
could be that the testing process and
the release of test results to providers
was delayed. Education to providers
was key in improving the submission of
appropriate information with samples.
Amanda Davis (left) works in the BSC processing samples for Zika testing, while Jessica Brown (right) performs ELISA testing. Photo
courtesy of Florida Department of Health, Bureau of Public Health Laboratories
26
LAB MATTERS Summer 2017
Incorrect packaging and shipping of
specimens was the second challenge.
On average, each patient had at least
two specimens (serum and urine) from
potentially nine different specimen
types. With the overwhelming number
of specimens and the lack of experience
with this virus, many providers sent
the wrong specimen types or shipped
them incorrectly. Urine collection cups
would often leak during transport
requiring technicians unpacking the
shipments to use extreme caution.
BPHL developed guidance documents
in an educational campaign to help
health departments, clinics and other
agencies understand what sample types
to submit, how to package and where
to ship. These documents were updated
as necessary, for example, following
an update to the testing algorithm.
BPHL also developed and distributed
a frequently asked questions (FAQ)
document based on commonly asked
and anticipated questions. Following
the release of these documents by
the Florida virology laboratories and
epidemiology department, most urine
samples arrived in collection tubes
rather than cups, greatly reducing the
likelihood of leakage and biorisk.
A third challenge was limited testing
capacity, involving both instrumentation
and personnel. To help alleviate this, BPHL
purchased additional equipment which
was quickly deployed to augment Zika
PCR and ELISA testing capacity. Among
the purchases were high-throughput
nucleic acid extraction instruments to
increase PCR testing capability, plate
washers/readers for ELISA testing and
other automated instrumentation. Even
with equipped laboratories, there was a
bottleneck effect with simply not enough
staff to triage and test specimens. During
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