Appendix 1: Standard operating procedures (SOPs) for working on suspected Nipah virus infected premises
Appendix 2: Standard operating procedures (SOPs) for performing necropsies and collecting serum samples on Nipah virus infected premises
Appendix 3: Checklist of equipment and supplies for Nipah virus field investigations
Appendix 4: A guide to sampling tissues for Nipah virus diagnosis: samples from natural and experimental cases in which Nipah virus has been identified
Appendix 5: Laboratories with PC4 facilities and Nipah virus research programmes
Appendix 6: Packing infectious substances - International Air Transport Association (IATA) packaging instruction 602
Appendix 7: Packing diagnostic specimens with a low probability of being infectious - International Air Transport Association (IATA) packaging instruction 650
It is recommended that investigating teams take a laminated photocopy of these pages into the field for reference.
General SOPs for working on suspected Nipah virus infected premises:
On the infected farm, establish a base that may be considered “uninfected” for the purposes of operator safety from which to conduct the investigation.1. Mark the boundary of the clean area so it is easily identified.
2. Place buckets of disinfectant at the boundary of the clean area.
3. Before entering the infected area, put on appropriate protective clothing.
4. Organize all equipment to minimize returns to the clean area from the infected area.
5. Enter the infected area (animal pens) and conduct a visual examination of the disease situation. Note the health status of all animals, the distribution of any sick or dead animals, the location of any classes of animals to be sampled, and suitable locations to either establish a sampling coordination area or to conduct the post mortem examinations.
6. In the infected area, collect all rubbish into appropriate containers.
7. Place all needles or disposable scalpel blades into a “sharps” container.
8. Carry a spray bottle of viricidal disinfectant so that hands and equipment can be progressively washed and sterilized throughout the course of operations.
9. Before leaving the infected area, wash all visible contamination (blood, faeces, etc.) from equipment, boots, hands and clothing.
10. Disinfect boots and gloves in the buckets of disinfectant at the boundary every time before returning to the clean area.
11. Clean and spray with disinfectant the outside of sampling containers (blood tubes, tissue jars).
12. Secure the containers in a plastic bag then place them in a transport container (ideally a plastic or metal container, but at least a plastic bag).
13. Spray the outside of this extra container with disinfectant.
14. Spray all clothing, and wash all equipment in the disinfectant before taking them to the vehicles.
15. If waterproof overalls are to be reused, ensure that these have been completely sprayed with disinfectant.
16. After everything has been disinfected move to the vehicles, store samples and equipment and remove protective clothing.
17. Wet any cloth overalls in disinfectant and store in leak-proof plastic bags.
18. If disinfected waterproof overalls are to be reused, store these in clean plastic bags.
19. Spray face masks and safety glasses again with viricidal disinfectant, and store for reuse.
20. Discard items such as gloves and any other rubbish into biohazard or other strong plastic bags and tie the bag. It is good practice to leave removal of the inner pair of gloves to the last step in the undressing procedure. At the laboratory, burn or autoclave the bag.
It is recommended that investigating teams take a laminated photocopy of these pages into the field for reference.
Specific SOPs for performing necropsies:
1. Appropriate clothing:Specific SOPs for collecting blood samples:- Long sleeve overalls2. In the infected area, select a site where contamination of other animals can be minimized and which can be cleaned and sterilized after the job is done.- Rubber boots
- Gloves, taping these to the sleeves of the overalls, preferably two sets of gloves
- A plastic apron that can be disinfected or discarded
- A face shield or similar eye and mucous membrane protection
- A mask with a HEPA filter or a positive air pressure respirator (PAPR) is mandatory where Nipah virus infection is known to occur, and recommended where the disease is suspected
3. Plan carcass disposal in advance. To what extent will the necropsy increase the level of contamination at the premises? What protocol for disinfection should be followed? Will the carcass be burnt or buried?
4. Instruct personnel not involved in the post mortem examination (for example the farmers) to remain away from the work site.
5. Procedures that create aerosols should be done in such a way as to minimize the dispersal of aerosol particles.
6. Place all needles or disposable scalpel blades into a “sharps” container.
7. Place necropsied carcasses in a body bag ready for burial or burning. Spray the outside of the bag with disinfectant.
1. Appropriate clothing:- Long sleeve overalls2. In the infected area, establish a sampling coordination station where tubes can be labelled, recorded and prepared for removal from the infected area.- Rubber boots
- Gloves, taping these to the sleeves of the overalls, preferably two sets of gloves
- A plastic apron that can be disinfected or discarded
- A face shield or similar eye and mucous membrane protection
- A mask with a HEPA filter or a positive air pressure respirator (PAPR) is mandatory where Nipah virus infection is known to occur, and recommended where the disease is suspected.
3. Place all needles or broken blood tubes into a “sharps” container.
4. Pack and unpack samples as described above.
1. Protective clothing:
- overalls (long sleeved disposable or non-disposable)2. Necropsy kit- plastic aprons (minimum 3)
- gumboots
- goggles or face shields (minimum 3)
- disposable breathing masks, incorporating a HEPA filter (one for each person)
- positive air pressure respirators (PAPRs) (minimum 3)
- waterproof disposable gloves
- rough textured rubber kitchen gloves (minimum 3)
- wide packing tape
- tranquilizers appropriate for each species to be examined3. Specimen collection- specialized restraint equipment for each species (for example, pig snares)
- euthanasia solution
- knives - skinning and boning
- steel
- scalpel handle and blades
- “sharps” container
- scissors - several pairs, various sizes and types
- large rat-toothed forceps
- butcher’s saw, tomahawk, bone cutters
- ruler
- string
- plastic sheeting
- plastic waste disposal bags
- 2 buckets - able to accommodate a gum boot
- plastic scrubbing brush
- towels
- detergent, soap
- disinfectant (for example, Virkon diluted at 20 g/litre)
- supply of 10 percent formalin- plain blood tubes for serum collection and blood tubes with anticoagulant
- disposable needles and syringes, “sharps” container
- venoject holder and needles if venoject tubes are to be used
- sample containers for tissues - various sizes including one for fixing brain
- labels and permanent markers for sample ID
- sterile swabs, transport media and sample tubes for attempted virus isolation
- selection of sealable plastic bags in various sizes
- appropriate boxes for use as outer containers for transport of samples to the lab
- biosecure consignment boxes to comply with IATA packing instructions 602 or 650; if samples are to be consigned, plus all necessary documentation for consignment of specimens such as relevant import permits and dangerous goods forms
|
Sample |
Virus |
Immunohistochemistry |
PCR |
|
Nasal swabs |
Pig |
|
|
|
Throat swabs |
Pig |
|
|
|
Urine |
Human |
|
|
|
Serum/blood |
Pig |
|
|
|
CSF |
Human |
|
Human |
|
CNS (including meninges) |
Cat |
Pig |
Human |
|
Lung |
Pig |
Pig |
|
|
Spleen |
Pig |
Human |
|
|
Lymph node |
Cat |
|
|
|
Kidney |
Cat |
Pig |
Dog |
|
Other organs |
Pig tonsil |
Human heart |
Human |
Note: Adapted from Daniels et al.2001
1. CSIRO AUSTRALIAN ANIMAL HEALTH LABORATORY
Contact details:
Project Leader, Diagnosis and Epidemiology2. CENTERS FOR DISEASE CONTROL AND PREVENTION
CSIRO Australian Animal Health Laboratory
Private Bag 24 (5 Portarlington Road)
Geelong 3220
Australia
Phone: +61 3 5227 5000
Fax: +61 3 5227 5555
E-mail: Peter.Daniels@csiro.au
Website:
http://www.csiro.au/index.asp?type=faq&id=Australian%20Animal%20Health% 20Laboratory
Contact details:
Special Pathogens Branch3. LABORATOIRE P4 JEAN MERIUEX
Mail Stop G14, DVRD/NCID
Centers for Disease Control and Prevention
1600 Clifton Rd Atlanta, GA 30333
USA
Phone: +1-40 4 639 1115
Fax: +1-40 4 639 1118
E-mail: TKsiazek@cdc.gov or PRollin@cdc.gov
Website: http://www.cdc.gov/ncidod/dvrd/spb/index.htm
Contact details:
Laboratoire P4 Jean Meriuex
Centre de Recherche Mérieux Pasteur à Lyon
21 av. Tony Garnier, 69007 Lyon
France
Phone: +33 4 3728 2440
Fax: +33 4 3728 2441
E-mail: web@cervi-lyon.inserm.fr
Website: http://www.cervi-lyon.inserm.fr
The following is taken from the IATA Dangerous Goods Regulations (42nd edition, CD-rom version 42.01).
Please refer to the IATA internet site (http://www.iata.org) for further information.
(STATE VARIATIONS: AUG-03, CAG-04, USG-13, VUG-02 OPERATOR VARIATIONS: AF-04, AS-02/08, CI-01, CO-07/08, CS-07, FX-09, SW-01, US-08)
The General Packing Requirements of Subsection 5.0.2 must also be met.
General Requirements
Shippers of infectious substances must comply with these Regulations and must ensure that shipments are prepared in such a manner that they arrive at their destination in good condition and that they present no hazard to persons or animals during shipment. The packaging must include:
(a) inner packagings comprising:Note: Packagings of the type known as a “dry shipper” when used to ship infectious substances must meet the testing requirements of Subsection 6.5 and the marking requirements of 6.0.6.
- a watertight primary receptacle(s);
- a watertight secondary packaging;
- other than for large body parts and whole organs which require special packaging, an absorbent material which must be placed between the primary receptacle(s) and the secondary packaging. Absorbent material is not required for solid substances.
Multiple primary receptacles placed in a single secondary packaging must be wrapped individually or for infectious substances transported in liquid nitrogen, separated and supported to ensure that contact between them is prevented.
The absorbing material, for example cotton wool, must be sufficient to absorb the entire contents of all primary receptacles.
(b) an outer packaging of sufficient strength meeting the design type tests found in Subsection 6.5 and bearing the Specification Markings as required by 6.0.6 for shipments of infectious substances other than those containing large body parts and whole organs which require special packaging. Also infectious substances shipped on liquid nitrogen in packagings that meet the requirements of Packing Instruction 202 are excluded from the testing requirements of Subsection 6.5 and the marking requirements of 6.0.6.
Packages must be at least 100 mm (4 in) in the smallest overall external dimension.
For all packages containing infectious substances other than those containing large body parts or whole organs which require special packaging, an itemized list of contents must be enclosed between the secondary packaging and the outer packaging.
The primary receptacle or the secondary packaging used for infectious substances must be capable of withstanding, without leakage, an internal pressure which produces a pressure differential of not less than 95 kPa (0.95 bar, 13.8 lb/in2) in the range of -40°C to +55°C (-40°F to 130°F).
All packages containing infectious substances must be marked durably and legibly on the outside of the package with the NAME and TELEPHONE NUMBER OF A PERSON RESPONSIBLE FOR THE SHIPMENT.
Shipments of Infectious Substances of Division 6.2 require the shipper to make advance arrangements with the consignee and the operator to ensure that the shipment can be transported and delivered without unnecessary delay. The following statement required by 8.1.6.11.3 must be included in the Additional Handling Information area of the Shipper’s Declaration: “Prior arrangements as required by the IATA Dangerous Goods Regulations 1.3.3.1 have been made.”
Specific Requirements
Although in exceptional cases, for example, the shipment of large body parts and whole organs, may require special packaging, the great majority of infectious substances can and must be packed according the following requirements:
- Substances shipped at ambient or higher temperatures: Primary receptacles may only be of glass, metal or plastic. Positive means of ensuring a leak-proof seal must be provided, such as heat seal, skirted stopper or metal crimp seal. If screw caps are used, these must be reinforced with adhesive tape.- Substances shipped refrigerated or frozen (wet ice, prefrozen packs, Carbon dioxide, solid [dry ice]): Ice, Carbon dioxide, solid (dry ice) or other refrigerant must be placed outside the secondary packaging(s) or alternatively in an overpack with one or more complete packages marked in accordance with 6.0.6. Interior support must be provided to secure the secondary packaging(s) in the original position after the ice or Carbon dioxide, solid (dry ice) has been dissipated. If ice is used, the packaging must be leak-proof. If Carbon dioxide, solid (dry ice) is used, the outer packaging must permit the release of carbon-dioxide gas. The primary receptacle and the secondary packaging must maintain their containment integrity at the temperature of the refrigerant used as well as at the temperatures and pressure(s) of air transport to which the receptacle could be subjected if refrigeration were to be lost.
- Substances shipped in liquid nitrogen: Plastic primary receptacles capable of withstanding very low temperatures must be used. Secondary packaging must also withstand very low temperatures and in most cases will need to be fitted over individual primary receptacles. Requirements for shipment of liquid nitrogen must also be observed. The primary receptacle must maintain its containment integrity at the temperature of the refrigerant used as well as at the temperatures and pressure(s) of air transport to which the receptacle could be subjected if refrigeration were to be lost. Where multiple primary receptacles are contained in a single secondary packaging, they must be separated and supported to ensure that contact between them is prevented.
- Lyophilized substances: Primary receptacles must be either flame-sealed glass ampoules or rubber-stoppered glass vials with metal seals.
The following is taken from the IATA Dangerous Goods Regulations (42nd edition, CD-rom version 42.01).
Please refer to the IATA internet site (http://www.iata.org) for further information.
OPERATOR VARIATIONS: AS-02, CO-07/08, CS-07, FX-09, QF-05
The General Packing Requirements of Subsection 5.0.2 must also be met.
General Requirements
Shippers of diagnostic specimens where a relatively low probability exists that infectious substances are present must comply with Packing Instruction 650 of these Regulations. Diagnostic specimens being transported to undergo routine screening tests or for the purpose of initial diagnosis may be considered to fall under the category of those specimens where a low probability exists that infectious substances are present. The shipper must also ensure that shipments are prepared in such a manner that they arrive at their destination in good condition and that they present no hazard to persons or animals during shipment. In the absence of other dangerous goods, no requirements other than those identified in Packing Instruction 650 are deemed to apply to such shipments. Packages prepared under this Packing Instruction must include:
(a) inner packagings comprising:The primary receptacle or the secondary packaging used for liquid diagnostic specimens must be capable of withstanding, without leakage, an internal pressure which produces a pressure differential of not less than 95 kPa (0.95 bar, 13.8 lb/in2) in the range of -40°C to +55°C (-40°F to 130°F). It is not necessary for the primary or secondary packaging to be capable of withstanding 95 kPa pressure differential when solid diagnostic specimens are being shipped.
- a watertight primary receptacle(s) - for diagnostic specimens the maximum quantity must not exceed 500 ml;
- a watertight secondary packaging - the maximum quantity per outer packaging for diagnostic specimens must not exceed 4 litres;
- an absorbent material - must be placed between the primary receptacle and the secondary packaging. No absorbent material is required when shipping solid substances.
If multiple primary receptacles are placed in a single secondary packaging they must be wrapped individually or for those transported in liquid nitrogen, separated and supported to ensure that contact between them is prevented.
The absorbing material, for example cotton wool, must be sufficient to absorb the entire contents of all primary receptacles.
(b) an outer packaging of adequate strength for its capacity, weight and intended use.
However, each completed package must be capable of successfully passing the drop test described in 6.5.1 except that the height of the drop must not be less than 1.2 m.
Packages consigned as freight must be at least 100 mm (4 in) in the smallest overall external dimension.
An itemized list of contents must be enclosed between the secondary packaging and the outer packaging.
Each package and the “Nature and Quantity of Goods” box of the air waybill must show the text - “DIAGNOSTIC SPECIMEN PACKED IN COMPLIANCE WITH IATA PACKING INSTRUCTION 650”.
A Shipper’s Declaration for Dangerous Goods is not required.
Specific Requirements
Although exceptional cases, (for example, the shipment of whole organs) may require special packaging, the great majority of diagnostic specimens can and must be packaged according to the following guidelines:
- Substances shipped at ambient temperatures or higher: Primary receptacles include those of glass, metal or plastic. Positive means of ensuring a leak-proof seal, such as heat seal, skirted stopper or metal crimp seal must be provided. If screw caps are used these must be reinforced with adhesive tape.- Substances shipped refrigerated or frozen (wet ice, pre-frozen packs, Carbon dioxide, solid [dry ice]) or other refrigerant must be placed outside the secondary packaging(s) or alternatively in an overpack with one or more completed packagings. Interior support must be provided to secure the secondary packaging(s) in the original position after the ice or Carbon dioxide, solid (dry ice) has been dissipated. If ice is used the packaging must be leak-proof. If Carbon dioxide, solid (dry ice) is used the outer packaging must permit the release of carbon-dioxide gas. The primary receptacle must maintain its containment integrity at the temperature of the refrigerant as well as at the temperatures and pressure of air transport to which the receptacle could be subjected if refrigeration were to be lost.
- Substances shipped in liquid nitrogen: Plastic capable of withstanding very low temperatures must be used instead of glass receptacles. Secondary packaging must also withstand very low temperatures and in most cases will need to be fitted over individual primary receptacles. Requirements for shipment of liquid nitrogen must also be observed. The primary receptacle must maintain its containment integrity at the temperature of the refrigerant used as well as at the temperatures and pressure of air transport to which the receptacle could be subjected if refrigeration were to be lost.
- Lyophilized substances: Primary receptacles must be either flame-sealed glass ampoules or rubber-stoppered glass vials with metal seals.
