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Interim Guidelines for Smallpox Response and Management in Scotland in the Post-Eradication era
Appendix 1: procedures for collecting and transporting diagnostic clinical specimens
Collecting specimens
Appropriate equipment for obtaining specimens would be:
Personal protective equipment - see
Appendix 7.
A 'tuberculin' syringe and needle for aspirating fluid from vesicles.
20ml syringe and hypodermic needle for taking blood specimens; standard EDTA- and heparin- containing tubes, and a tube without anticoagulant for serum collection.
A small scalpel blade for removing the roofs and upper tissue from lesions, and for lifting scabs.
Clean plastic microscope slides.
Eppendorf tube or bijou container for transporting crusts.
A sterile universal container for transporting scabs.
Tourniquet.
Cotton wool buds.
A permanent marker pen for writing the patient's identity and the date on the slides.
A slide container for the safe transfer of slides
A waterproof sharps container for needles, syringes, scalpels and unused slides.
Waterproof plasters.
A sealable plastic specimen bag, absorbent packaging material, and a strong metal outer container plus biohazard tape to seal it and 0.1% hypochlorite solution to clean the outside before transport to the laboratory.
High risk labels.
A clinical waste bag for the disposal of discarded dressings and personal protective equipment.
The procedure for collecting specimens of vesicle fluid is as follows:
Put on personal protective equipment.
Puncture a vesicle with the tuberculin' syringe, draw up fluid and express it onto a clean plastic microscope slide.
Cover the punctured vesicle with a waterproof plaster.
Allow the slide to air dry.
The slide must be clearly marked to indicate the surface used and the position of the sample.
The slide should be transferred to the laboratory in a plastic slide carrier.
Vesicle fluids should not be submitted to the laboratory in hypodermic syringes or in capillary tubes, as this could be hazardous to laboratory staff extracting the specimen.
Smears can be made by using a scalpel blade to scrape material from the base of the lesion, and to spread it onto a clean plastic microscope slide.
Vesicle crusts may be removed and sent for examination in a small sealed container (Eppendorf tube or bijou).
Swabs or specimens in transport medium are not suitable specimens for electron microscopy.
For the diagnosis of initial cases, the RSDRT should take a minimum of four specimens of vesicle fluid plus additional specimens (smears, crusts and blood) as available.
Transporting specimens to the laboratory
For the diagnosis of initial cases, the RSDRT should send specimens to the designated Category 3 laboratory in Scotland for EM (see
Appendix 2). The designated laboratory, on receipt of specimens, should immediately send at least two specimens of vesicle fluid plus additional specimens (smears, crusts and blood) if available to a UK Reference laboratory. Contact details for the UK Reference laboratories can be found in the Annex.
A 'High Risk' label should be affixed to both specimen and request form. The latter should include any other relevant information and include adequate clinical details. Depending on the level of suspicion, it may be appropriate to label the specimen and request form "suspected smallpox" or "suspected Hazard Group 4 agent"
.
Under no circumstances should the request form be placed in the same bag as the specimen.
The bag must be sealed using tape. Pins, staples and metal clips should
not be used. A separate bag should be used for each specimen.
Each specimen must then be placed in a leak-proof secondary container with sufficient absorbent material to absorb all the contents should leakage occur. Each specimen must be packaged individually - ie. four specimens, four separate containers.
When the specimen is secured inside, the secondary container should be externally disinfected - eg. by wiping with 0.1% hypochlorite (1,000ppm).
Specimens must be recorded, and provided with chain-of-evidence documentation.
All used blood and tissue samples should be discarded immediately into a clinical waste container.
Archiving of specimens should not be carried out unless:
Specimens are kept in a designated Containment Level 4 laboratory; and
They have been made safe by 'fixing' with formaldehyde solution (5%); and
They have been made safe by heat treatment or irradiation.
Secondary containers should be placed within a final outer tertiary packaging, complying to the UN 602 standard packaging for the transport of infectious substances by air, road or rail.
The package should be certified to this standard and carry the appropriate UN certification numbers on the tertiary packaging along with the following information:
BIOHAZARD - danger of infection symbol Class UN 6.2.
Instructions not to open if found.
Telephone number of a responsible person - eg. Consultant Microbiologist, Laboratory Manager.
Specimens for transport between the Scottish designated laboratory and the UK Reference laboratories should be sent by a courier approved for Hazard Group 4 pathogens. Contact details can be found in the Annex.
The UK Reference laboratory (CPHL or CAMR) must be contacted to confirm dispatch and receipt of a possible hazard group 4 organism.
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