Implementing lab-based influenza surveillance

The project in brief

The surveillance programme aims at describing influenza virus circulation in Pacific Island countries and territories (PICTs). It involves obtaining basic epidemiological data and respiratory specimens from both hospital and regional health care centre patients, along with laboratory testing of the samples.

Two tests will be evaluated in the laboratories for the detection of influenza in these clinical samples, mainly direct immunofluorescence (DIF) and additionally EIA rapid tests. Confirmatory testing will be performed at the Pasteur Institute of New Caledonia (IPNC) on ethanol-fixed nasal specimens using Real-Time PCR.

For more information on this project, see “Increasing influenza surveillance in the Pacific Island region”, published in Inform’ACTION 22, p. 27–28.

Initial in-country implementation and training

Country implementation of the PPHSN laboratory-based influenza surveillance project, coordinated by SPC and IPNC and funded by the Centers for Disease Control and Prevention (CDC), commenced in June 2006. Teams from SPC consisting of an epidemiologist (Dr Seini Kupu, Dr Justus Benzler or Dr Narendra Singh) and a laboratory specialist (Mr Albert Gurusamy or Ms Melissa Pontré) made in-country visits to Cook Islands, Tonga, Palau, Guam and Fiji Islands.

During each country visit the SPC teams made PowerPoint presentations to introduce and discuss the project implementation, including the selection of sentinel sites. Both the epidemiology and laboratory aspects of the project were presented. The meetings were attended by physicians, laboratory staff, nursing staff and ministry of health staff. Specimen collection was demonstrated and specimen transportation issues were discussed.

In Cook Islands, Tonga and Fiji Islands the media were invited to the launch of the new project. This helped in raising awareness of the availability of testing for human influenza in the local community.

Immunofluorescence microscopes (Leica DM 1000 model) were shipped to each PICT mentioned above, where they were unpacked and assembled by the laboratory project counterpart and the SPC/IPNC laboratory specialist. The counterpart was then shown the correct use and care of the new equipment.

A CD containing all relevant project documents, protocols and procedures was given to and discussed in detail with the counterpart.

All necessary reagents and supplies as well as a satisfactory dark room set-up were organised. The counterpart was then shown the various procedures involved for specimen collection, treatment, staining, microscopy, interpretation and reporting. At the end of the week an initial training checklist was ticked off and signed, showing the counterpart’s satisfactory completion of all these procedures.

Training course on immunofluorescence

Following the visit of the SPC teams, an intensive training course on DIF for influenza laboratory diagnosis was organised for one laboratory technician per participating country, in collaboration with two L3 laboratories (see below), the WHO National Influenza Centre (NIC) at the Institute of Environmental Science and Research (ESR) in New Zealand, and the WHO Collaborating Centre (WHO-CC) for Influenza in Melbourne, Australia.

Training at ESR, New Zealand

By Dr Sue Huang, Head of WHO NIC, ESR

Mr Albert Gurusamy approached me to train two senior medical laboratory scientists, Ms Theresa Tatuava from Cook Islands and Ms Latu Soakai from Tonga, on the immunofluorescence techniques for detecting influenza and other related respiratory viruses.

The course was held at ESR from 7 to 11 August 2006. The dates were chosen to coincide with the influenza season in New Zealand, so the trainees could get as much practical experience as possible in influenza-related clinical specimens. Latu and Theresa attended a half-day lecture covering IF theory, caveats, quality controls, differential diagnosis and relevant laboratory management issues. They observed ESR staff performing IF and then spent more than three days obtaining hands-on experience in processing clinical and cell culture specimens, fixing slides, conducting IF test procedures and reading slides for influenza viruses, respiratory syncytial virus (RSV), adenovirus and parainfluenza viruses.

The biggest challenge of the IF test is to be able to differentiate specific staining from non-specific staining and interpret the results correctly. Both Latu and Theresa spent a lot of time reading slides under the IF microscope to build up their experience. On the last day of their training, they conducted the IF test independently and their interpretations on the test samples were correct. Both Latu and Theresa have successfully completed the training course. Congratulations!

Feedback from participants

Ms Theresa Tatuava from Cook Islands was very pleased with the training. “We gained much confidence and experience from this short visit … We got the opportunity to set up slides for other viruses apart for influenza A and B and RSV (i.e. adenovirus and parainfluenzae viruses), which we thought was great. We departed feeling confident in ourselves to be able to perform IF testing to ensure that the influenza surveillance programmes in our respective country laboratories continue. I also hope that from this training my experience and the expertise gained will encourage clinicians to cooperate so that this surveillance programme is successful.”

Ms Latu Soakai had a good experience and was very impressed with the work at ESR. “The “safety procedure” carried out in the laboratory was impressive. Congratulations to the management for making sure that safety regulations are carried out to the last detail. I think one week was a bit too short to really have a good experience with the reading of the slides. However, being alone in reading the slides in Tonga, I am glad the control slides are still working properly.”

Training at WHO-CC, Melbourne

By Dr Ian Barr, Deputy Director, WHO-CC for Influenza, Melbourne

Three scientists, Ms Claire Baradi from Guam, Mr Uraia Rabuatoka from Fiji Islands and Mr March Kloulubak from Palau, visited the WHO-CC for Influenza in Melbourne from 21 to 25 August to undertake training in the detection of influenza virus in clinical samples. The technique they learned is known as immunofluorescence – a rapid and sensitive technique that can be used to detect other respiratory pathogens, such as RSV, as well as influenza. Part of the training was performed at the Royal Children’s Hospital, a large hospital near the Centre, under the guidance of the virologist-in-charge, Dr Robert Alexander. The trainees were shown how to prepare slides and also looked at a number of clinical samples at the hospital laboratory. Following the training, the participants are fully capable of performing the tests independently in their own laboratories and will be able to add their information to the worldwide surveillance of influenza.

Feedback from participants

Mr March Kloulubak from Palau was very enthusiastic after the training: “This has got to be the best training I have gone on so far. The training went great and we learned a lot in a short period of time that should prove to be beneficial for our knowledge in dealing with influenza testing.”

Mr Uraia Rabuatoka from Fiji Islands sent us a detailed report on the proceedings of the training. He believes that after the training, “participants should be able to perform immunofluorescence procedure and provide quality results for the detection of influenza viruses. They should also be consistent with influenza surveillance testing and data compilation”.

Ms Claire M. Baradi from Guam said, “The secondary training received in Australia gave all the participants further opportunity to hone their skills and develop individual technique.”

Claire was very keen to share her “fruitful experience”: “Our training began at WHO-CC by detailing their procedural principles on immunofluorescence and viral tissue cell culture. We observed techniques in the staining method that would yield improved results. Training also included an overview and testing of several rapid diagnostic test kits for influenza, giving us the opportunity to distinguish which manufacturer’s kit would be most suitable for each laboratory. Instruction was delivered by Chris Durant and Aeron Hurt, supported by Dr Ian Barr.

“In addition, we were taken for instruction to the Royal Children’s Hospital Department of Microbiology and Virology, to further develop our IF staining technique. An incredibly informative lecture was given by Dr Robert Alexander on the theory and principle of IF staining and viral tissue cell culturing.

“Undoubtedly, the training will help provide definitive advancement for the PPHSN Influenza Surveillance Project, and the skills acquired will aid in laboratory testing for the Guam Pandemic Influenza Plan and ultimately the Government of Guam, Department of Public Health and Social Services test menu. Being that our islands are isolated, these types of training also pave the opportunity to build improved communications and develop relationships with other laboratories. If given the opportunity, I encourage all laboratories of the Pacific outlying islands to participate.”

Next steps

The implementation of the project in the sixth participating PICT, Wallis and Futuna, will be done at the end of this year or early next year, as the laboratory is being rehabilitated. The project will be extended to three or four more PICTs in 2007.