Safety Challenges with Specimen Collection, Transport, Accessioning, and Storage

Transcript

Date of session: 08/29/2023

Facilitator

Aufra C. Araujo, PhD

Centers for Disease Control and Prevention

DLSbiosafety@cdc.gov

Didactic Speakers

Joey Stringer

General Laboratory Supervisor

Dallas County Health and Human Services

Joey.Stringer@dallascounty.org

Kayle Cirrincione

Health and Safety Manager

Dallas County Health and Human Services

Kayle.Cirrincione@dallascounty.org

Aufra Araujo: All right. Good afternoon, good morning, and good evening, everyone. My name is Aufra Araujo, and I want to extend a warm welcome from the Centers for Disease Control and Prevention in Atlanta, Georgia. I am a PhD Health Scientist in CDC's Division of Laboratory Systems. Thank you all for joining our eighth Extension for Community Healthcare Outcomes, ECHO, Biosafety session.

The topic for this interactive discussion is Safety Challenges with Specimen Collection, Transport, Accessioning, and Storage. Today's subject matter experts are Joey Stringer and Kayle Cirrincione from Dallas County Health and Human Services. To foster a strong sense of community and facilitate networking among biosafety professionals, we encourage everyone to turn on their cameras during today's session.

We understand that it may not be feasible for everyone, so please feel free to join with or without your camera. Our aim with the ECHO Biosafety project is to connect names with faces and view the community of practice. So I stopped sharing the slide here briefly so we can all see each other. And if you can and feel so inclined, please turn on your cameras so we can see you.

I would like to ask everyone a quick icebreaker question. What are everyone's plans for the upcoming Labor Day holiday on Monday, September 4? Are you traveling somewhere, firing up the grill, or relaxing at home? If you can, unmute and let us know. And if you do so, please say where you are calling from.

That would be great. Or if you cannot speak, put in the chat. Going to the lake for the weekend. Oh, I envy you.

Joey Stringer: Yeah. That's where I'll be as well. So I'll kind of break the ice, and yeah. So grill and lake.

Aufra Araujo: Oh, awesome. That sounds very relaxing. I love that. Beach and local festival. Love it.

Kayle Cirrincione: I'll probably just spend my time chasing my two children.

Aufra Araujo: Yeah! Well, that's fun too because when you are at work, Kayle, you can't chase them, so at least you'll be chasing them. That's fun. Oh, all right. A lot of action in the chat. That's good. Looking for moose in the mountains. Wow. I love it. That's so cool. His mother-in-law is taking my three-year-old. Wow. That's good.

All right. Anybody want to unmute besides Kayle and Joey? Anybody else? You don't have to. OK. All right. Let's get back to business. I will share the screen again. No, not yet. Before we continue, I'd like to address some technical aspects of our ECHO Biosafety sessions. Please use the video capabilities of your device for this session.

Currently all audience microphones are muted. When engaging in the discussion, please unmute yourself to speak. If you are experiencing technical difficulties during the session, please send a private chat message to George Xiang, who is labeled as CDC ECHO Tech. George will do his best to respond to your issue. If you are connecting to Zoom by phone only at the time of discussion, please introduce yourself by stating your name and institution before speaking.

How do these ECHO sessions differ from other presentations? These sessions are different from webinars in that the main feature is the discussion of cases or clinical laboratory challenges. Our subject matter experts aim to share some applicable solutions that can be implemented in your individual laboratories. We encourage your active participation by sharing your knowledge and experiences as well. Each laboratory is unique and your skill sets are unique, so your contributions to the discussion are valuable.

Here is a brief overview of today's session. Let me go back to the slides. I will introduce– here is the agenda. I'll introduce our subject matter experts, Joey Stringer and Kayle Cirrincione, who will provide a didactic presentation and real case discussion. Then my colleague, Sabrina DeBose, will summarize today's discussion. Closing comments and reminders will follow, and we will adjourn this session. Today's session is being recorded. If you prefer not to be recorded, please disconnect now.

Closed captioning is provided for this session, and you can find the link in the chat box. After today's session, the transcript, the audio recording, presentation slides, and other resources will be posted on the DLS ECHO Biosafety website. So now to the best part. It is my pleasure to introduce today's presenters.

Joey Stringer currently serves as the Technical and General Laboratory Supervisor for the Dallas County Laboratory Department. Joey has worked in public health for over 20 years and currently supervises the activities of various laboratory divisions, including serology, bacteriology, TB, and the short turnaround time, or STAT, lab at the Dallas County Health Department. He provides guidance and consultation to laboratory colleagues in biosafety, and currently serves as the Responsible Official for the Dallas County Select Agent program. Joey has served on various APHL committees and subcommittees, including the Biosafety and Biosecurity Committee, Public Health Preparedness and Response Committee, and currently the HIV Viral, Hepatitis, and STI Subcommittee.

Kayle Cirrincione is an experienced infectious disease microbiologist with a passion for biosafety and biosecurity. Kayle has worked with select agents and drug-resistant TB strains for 15 years and has developed expertise beyond the laboratory, which includes biosafety aspects as well. She currently serves as the Health and Safety Manager for Dallas County Health and Human Services. She also oversees clinical labs and serves as the alternate responsible official for their select agent program. Kayle has recently been accepted as a member of the APHL Biosafety and Biosecurity Committee forum that fosters collaboration among diverse backgrounds to drive impactful transformations in the field of biosafety and biosecurity.

Joey and Kayle, the floor is yours. I'll stop sharing so you can share your slides.

Joey Stringer: Righty. Well, thank you. Let me go ahead and share mine. All right, so I have a split screen. Are you able to see this, Kayle, and the rest of the attendees?

Kayle Cirrincione: It's in presenter view, so you'll need to switch it.

Joey Stringer: All right.

Kayle Cirrincione: There you go.

Joey Stringer: All righty. Well, let's go ahead and get started. But first I want to welcome everyone. Good morning, good afternoon, wherever you all are at. It's not quite afternoon yet here in Dallas. And thank you for joining and being a part of this talk. I want to first thank CDC and ECHO Biosafety for having myself, as well as Kayle, today to discuss some safety challenges with specimen collection, transport, accessioning.

We kind of inserted accessioning over processing, and we'll see we'll see how that goes and throw in some safety challenges that we may have that we'll see with accessioning and with us and with everybody else. So as we listen, I want to reiterate, again, I want everyone to keep in mind the ECHO model. That is everybody teaches, everybody learns, so I'd like everyone to kind of take part and be a part and provide your expertise.

There's no right or wrong answer. We're here. What you have in your lab is kind of different than what we have in our lab, so everyone's perspective here is definitely welcome and encouraged. And we'll have questions, some Q&A. We'll also have some breakout sessions, which will be kind of interesting to see how we can pull these off. So I think we have three or four breakout sessions that we're going to go out into a breakout with some questions, and then come back and hopefully have some good dialogue about it. So let's all learn from each other and let's go ahead and get started.

So for the objectives today, we're going to identify some safety challenges with, as I mentioned, handling, collection and transport, and then accessioning and storage. And myself and Kayle are going to dual-tag this presentation, and she's going to add some good knowledge and perspective as well as on my side as well. And we'll discuss some proper handling at every stage and some risks that go along with it, describe some alternative methods to safety concerns, and at the end we'll discuss a real-life incident and some cases related to specimen handling.

And as we made this last slide, I kind of thought before we started, maybe this last slide should have been the first slide because this is one of the– kind of just goes into everything from what went wrong from the collection to the transport to the accessioning. But we'll get to that at the end and we'll go over some incidents, and hopefully you will be able to provide some of your perspective as well.

So we're going to dive into the first question here, and keeping in mind with specimen collection, what are some of your safety challenges that you have in your lab? What are some challenges you see with specimen collection? You know, complacency, filling wrong tubes, PPE, lack of training. Or if there's something else, let's provide that at the end as well. But we'll give you a couple minutes.

All right. Well, good. We have kind of everybody all over. We had some complacency. It looks like filling the wrong tube was the number one that people suggested definitely is a safety challenge, as well as PPE. And saw some all the above. And I think for us it's kind of all the above. Definitely fill in the wrong specimen as well as complacency. That seems to be a problem as well, and then not having the PPE– not wearing the right PPE or not having any PPE at all. You feel like, well, I'm just going to do this really quick.

Let me just go in there without gloves on or a coat and something happens. But looks like– let's see. All right. There we go. So proper training personnel involved is a paramount of risk here. So proper training and specimen collection techniques is essential. Ensuring that collectors follow the standardized protocols in order to minimize any errors training is always important.

We always talk about training and BSL-3 or training how to work in a biological safety cabinet, but do we still do training– how are we training on specimen collection and how are we doing on transport? I think this was a perfect opportunity for us to do this talk. We're right in the middle of coordinating our own courier system here at Dallas County, and so this talk came up just at the right time. And how do we do that?

How do we do a courier system here in Dallas County that's safe, effective, and– I don't know too, too many other public health departments that kind of have their own courier system. But we're going to try. We're going to try. We're going to try to do this, and throughout the talk hopefully we'll be able to get some feedback from you all as well. And then safety challenges.

As I said, complacency. Doing the same thing repeatedly. And you forget one item and you kind of made a mistake there. Vigilance. Due to routine tasks could lead to lapses in following proper safety protocols. And so that was– for me, complacency is a safety challenge as well as some of the other items that you all have picked as well. Lack of training and collection techniques, which was what a lot of people picked in this first question.

Everyone needs training in collection techniques and proper selection and use of equipment and supplies. How do you use them in order to minimize the risk in your lab? And so we're going to not focus too many on 42 CFRs. I think we have two of them in the talk and we'll kind of leave it at that. These get kind of pretty lengthy, but this one here is just your standard specimen submission in handling and referral for CLIA and high-complexity laboratories.

Laboratories are required to establish and adhere to these SOPs, and again, SOPs are essential. Make sure we evaluated, validated, verify, and make sure that the SOP is workable, and it doesn't present any more risk than otherwise addressing these issues to ensure the consistent and standardized practices is important.

And components of the SOPs according to the 42 CFR is identification, labeling, collection techniques, proper PPE, packaging and transport, and we're going to dive into the transport in the next section, Kayle is, and is going to go into a lot of things for us trying to incorporate a courier system. How do we do that safely? How do we do it effectively? Considering now you have temperatures that hover around 100 degrees, so how do we transport a sample from point A to point B safely?

Documentation, safety measures, emergency procedures. What happens if your car breaks down? So that's something that we had to address. What do we do when you have a flat tire or something? How do you effectively and safely take care of the sample in your car as well as the personal safety? So it's just not biosafety hazard or safety, it's also personal safety. And then some of the unique safety challenges with specimen collections.

For us, one of the things that we do here in the local public health department, we do outreach. Point of care testing in the field. So what's the safety issues that you have here conducting point of testing in remote areas or remote settings where access to resources in your infrastructure is limited. You don't really have a roof over your head, so to speak. Point of care, it can present hazards in adverse weather conditions. Now in Dallas, as I mentioned, it's 100 degrees outside. What if it's raining?

How do you circumvent all of that, those issues, and still try to be safe in collecting samples and safe in trying to transport samples? You have resource limitations, waste disposal. How do you get rid of the waste safely? And also something we do here in detention centers and specimen collections, and this is important for us. We do a lot of collection at the juvenile detention and county jail.

During the pandemic we did site visits through our county jail and detention centers to make sure that they were doing things safe and properly, and I think that was something that's important for us to still maintain as a local health department. You need to discuss the specific challenges of collecting specimens in detention centers where safety protocols can be influenced by security concerns or legal restrictions, especially in juvenile detention centers, what you can and can't do.

You need to highlight the importance of training staff and the centers in the Dallas County jails or just jails in general on proper collection techniques, safety, and security measures. And as mentioned, it's not just about just about safety hazard. It's safety on the personnel as well, and how do they do things safely.

All right. So here we're going to go to our first breakout session and keeping in mind specimen collection. What are some safety challenges you see within your laboratory? One question that we always get is about these prepackaged kits. Specifically a lot of times for us, TB, we have these prepared kits that go out into the field. We do a collection on homeless.

How do you manage this? What additional instructions should accompany the kits? What would you all have in your lab as far as a specimen collection? What are some of the challenges that you see with your laboratory? And we'll go ahead and breakout. I don't know how– George, how would we do this? See if we can get this working here.

George Xiang: Yeah, I'll set up the rooms with four to five people per room and give everyone four to five minutes. Is that right, Joey?

Joey Stringer: All right. Yeah, that's fine. And I think what we'll do is everybody kind of grab their thoughts, and if one person in the group can come back and be the presenter and give your little talk and what you all come up with, and we'll hopefully get into some good dialogue. And so we'll go ahead– and George, if you want to go ahead and separate them into two groups, that would be good.

George Xiang: I'll do that. And I'll share the slide with the question in the breakout rooms, too.

Joey Stringer: OK, and that'll take about five minutes and have some fun with it and see how it works.

[No audio available for breakout room session #1]

Aufra Araujo: I'm going to volunteer John Laurance even though– John, you mind sharing what you were just discussing in the group even though you said you don't do specimen collection? But I think you share good points that would be interesting to discuss as well.

John Laurance: Not at all. I'm happy to share. So all our group, none of us did primary sample collection. We're mostly diagnostic laboratories, so we work with facilities that do collections. One of the concerns was laboratory consolidation. So fewer facilities that are collecting samples, but that also means that there are fewer facilities that students can go and get practical training at.

So there's going to be, in the future, a lack of– I guess a diversity in training for new students who are coming into the system and going to be working in laboratories. All of our laboratories send out kits, collection kits to some degree. We didn't really dive into what those kits were. My lab sends out Hologic Panther collection kits, so that's not typically, I would say, a huge biosafety concern, just because it's a simple swab into the transport system.

I think that's probably similar to maybe what a lot of facilities end up sending out. And then discussions about couriers and how we receive samples. So who's bringing samples to our facilities or transporting in between? And there's a lot of contract career systems that are moving that material back and forth. So that was kind of the focus of our discussion.

Joey Stringer: Yeah, thank you. And I definitely see those, especially the transport and the couriers for us, and being so hot outside and how do we address that. And we're going to dive into that in the next section. And I think for us, we used to do– we're a local public health department, so the state health departments are a lot different than us.

We do do outreach, and sometimes we'll go out and to the community with these TB collection kits. How do you really maintain that, considering the organism you're submitting is sputum for TB? How do we do that really safely? And what do you do if they collect the wrong specimen? That happens many times.

They're supposed to be sputum, and they come back with urine in a 50 mL conical tube. Some people use metal containers as well as– in placement of the sputum– the plastic conical tubes. And so that's some of the safety issues that we see in outreach and specimen collection for us. Does anybody else– go ahead, Kayle.

Kayle Cirrincione: So even in the early days when we were putting together COVID collection samples, it was ensuring that we were including the right viral medium that was compatible with our extraction methods so there wasn't hazardous off-gassing. So that was one of our issues for COVID.

Joey Stringer: Yeah. Definitely remember that. What about group two or group three or group four? Do you all have anything differently that you would like to provide? And like I said, any information would be good? All here is on our side. So if anybody has anything they'd like to add, we appreciate it.

Luke Short: I'll speak up for group three. We had a very interesting discussion that went on about issues with turnover and training. And it's funny because not only is it something that we're facing currently in our lab, but in previous labs I've worked at, same issue. And we had people in our group talking about different things with TB collections, as well as with IGRA tubes. All these issues of new staff coming in and completely botching specimens coming in, and then you have to quickly monitor it, monitor your onset rate to see whether or not things go awry as quickly as you can. So we had a lot of fun talking about that. So I'll vanish again.

Joey Stringer: Yeah, turnover rate. Yeah. Nothing more frustrating than really training people on safety and how to do things, and then they leave and you get this kind of a cycle. And IGRA tubes, yeah, definitely. Those are really temperature dependent, and you have to really make sure you do those correctly in the field. Are you doing one tube or three tubes? But thank you for that. But I think we'll go ahead and move on. And thanks for everybody who provided their insights, and hopefully we'll get some more discussion in some of these breakout sessions. I think we got two or three more, so we'll see how they go. But Kayle, I'll turn it over to you.

Kayle Cirrincione: Perfect. So now that we've kind of gone over specimen collection, let's dive in the territory of transportation. It is one thing that I actually have quite a bit of interest in, so. So just kind of a little pop-up questions. What kind of issues do you guys have with transporting specimens?

Any spills or how they're packaged, lack of communication between submitting labs and receiving labs, or just lack of coordination in general between submitting labs and receiving labs? Or just kind of a little bit of all of above? And if you have anything else, please feel free to drop it in the chat. OK, so yeah. Kind of a little bit of all above. We definitely see sometimes where specimens aren't secured in the bags.

Lack of communication between the submitting lab and receiving lab is a big one here, and the coordination, especially between some of our bigger labs and the sentinel labs around us. And, Natasha, specimen transport and temperature ranges. We have a huge issue with that. Here in Dallas I think we're at 40 days of over 100, and we are definitely trying to keep a tight eye on those temperatures to make sure that they come in at the correct temperature so we can still run them.

Perfect. So I think we're going to jump into another breakout session. Yep. OK. Within your groups, it's talking about, do you guys have safety concerns about transporting these specimens? What is needed for the different types of specimens that you use? Are you sending exempt? Are you sending Category A, Category B? Are you sending them via– there we go. Hold on just a second. It went back. Are you sending them through a FedEx or a courier? Joey, I think you're– are you moving the slides?

Joey Stringer: No. You need me to move them?

Kayle Cirrincione: Yeah. It's not wanting to go for me. Just the different challenges. So let's kind of break out. We'll have a few minutes. Discuss your issues with transportation that you see within your laboratories.

[No audio available for breakout room session #2]

John Laurance: I can speak for my group again. Perfect. So we discussed leaking specimens. So specimens that were not necessarily closed or loads tightened or sealed correctly and so they end up leaking in transport. Not having a quality shipping manifest or documentation of what specimens were supposed to arrive. And so we've got a mismatch between what our submitter facilities expected us to receive and then what we actually received.

And then there's also been issues with being able to supply our submitters with the correct packaging. So Category A shippers for facilities and kind of like a lack of funding to have those supplied to them when they need it, or certain shippers not being available to accept those packages, which is an issue. U.S. Postal Service can't accept Cat As. And so if that's all you have available in certain communities, that becomes an issue.

Kayle Cirrincione: Perfect. Yeah. During the COVID era we saw some very interesting scenarios in transportation. We have seen a nasal swab dropped off in Kroger bags. So yeah, transportation and what's needed has definitely lacked a little bit with the COVID era. Anyone else?

Had a rabies sample delivered to the lab for testing that was improperly packaged. It was not contained in any type of biohazard bag, and blood started to leak through the box onto the transport vehicle, from Kayla. Oh. Yeah. That would be a big one. That's kind of also where you want to make sure your receiving lab has all of your spill precautions and contact information along with those.

Luke Short: I'll speak for group three. We had a very lively chat and a lot of fun. And Kayle, it was really funny you mentioned about bad packaging. During COVID back in DC, I remember we had once where we had a whole trash bag– literal trash bag filled with just random swabs and said, here, test. And it was, no. No. So in our group we had some very interesting discussions. Natasha from Tennessee was saying that they had something like what we went through up in Dallas– down in Dallas?

Dealing with temperature monitoring issues where CLIA comes by and says you have to monitor temperature and so all the cooler packs and everything have to be monitored. Macey from Oregon was saying that they had some challenges with educating submitters about how to package things, Cat A packaging, and all the nuances of that.

And also agreeing that temperatures were an issue. And Takisha, I didn't catch where your lab was from, but you mentioned about issues with getting specimen vials all wrapped in cellophane and just big messes where you run the risk of– I mean, you mentioned losing the sample. I would personally be worried about hurting myself with potentially breaking it in sharps. But that was group three.

Kayle Cirrincione: Perfect. Yeah those are definitely, I think, examples that we're all kind of seeing. Perfect. So we can move on. Let's see the slides. Joey, did you stop sharing your screen?

Joey Stringer: No, I did not. Let me go–

Kayle Cirrincione: Or did I just not–

Joey Stringer: Hold on.

Kayle Cirrincione: OK, perfect.

Joey Stringer: All right. Got it now?

Kayle Cirrincione: OK. Yeah. Let me request remote so I can– OK. Let's see. Did that work? OK. So specimen transport. So when you're talking about specimen transport, it's going to include your pickup, your loading, your movement, and unloading. Challenges that we receive to transportation includes potential hazards during transit, leaks, breakage, temperature fluctuations, all of those.

Proper packaging, label, and documentation is a must when it comes to specimen transportation, and that's going to depend on what method you use for transportation. Are you sending it by air? Are you sending it by ground? Are you sending it by private courier? That's all going to be kind of wrapped around 6.2 hazardous shipping. So for air you're going to be following the IATA regulations. For ground you're going to be following DOT.

And private courier, depending on what you're doing and how it's sending, there's going to have some exemptions there that you may not have to follow those packaging as stringent. And then CLIA's favorite topic at the moment is maintaining that cold chain specimen transport to preserve that sample integrity. Are you needing to send that sample 2 to 8 degrees? So is it just going to be just regular cold packs? Is it needing to be under dry ice? If you're sending it dry ice, you're possibly going to need additional training with that.

Safety challenges. So what training is needed? So obviously you need your 6.2 training if you are sending any specimens, and that's about every two years. Materials needed for correct packaging. Are you doing exempt? Are you doing Category A, which has its own full setup from all of the layers of packaging that you need?

Category B you can kind of mix and match your own packaging as long as you have all of those triple packaging, absorbance, everything that you need is there. Vehicle and driver safety. Are you the courier that is driving samples from point A to point B or are you just putting it in your lobby for FedEx to come pick up? And when you're just putting it in your lobby, are you making sure it's secure, that no one can come and just pick it up? Do you have those confirmations that's been picked up by FedEx, has been delivered by FedEx?

Just kind of all of that tracking so you see every step that you need. The documentation. If you were doing IATA for Category A, you're going to need a shipper's declaration. DOT you're just going to need a simple DOT declaration. And courier, it's always nice just to have some sort of inventory so you can manage and you know that all of the samples got from point A to point B, and your communications.

You want to make sure that you have someone in your point of contact that knows about those samples. You don't want to have a spill and have someone called and they're like, what samples are you talking about again? So for Cat A you need to have someone that is available to pick up 24/7 while those specimens are in transport. Category B, the only requirement is that the phone needs to be picked up at least during business hours. And then for us, we do the outreach specimen collection. So it's safety challenges on collecting in the field and transporting.

You want to make sure that you're able to get those samples that you're collecting down to the correct temperature and they're being transported and maintained safely. Next slide.

Additional training. So like Joey had mentioned earlier, we are working on getting our own courier system off the ground to support some of our sentinel labs around us. And so that's going to need additional training.

Familiarizing the personnel with relevant regulations and guidelines for the hazardous materials. Not just shipping, but any DOT regulations that actually talks about driving the specimens. Training on the movement of these specimens and make sure that they're securing and unloading. And in case that there is a spill, that it's not going to impact them immediately in terms of you want to make sure that those samples are transported in the back and they're secured.

They're not just kind of rolling around in the trunk. You want to make sure that you have those emergency response protocols available and they're knowledgeable about them. You want to make sure they're trained, and not just the initial training that you're going to give them, but you want to make sure that you are doing the occasional drills and you're doing refreshers. You want to keep that information fresh. And again, they know all of their points of contact.

So if they do have an issue, it's just one phone call away and they can get the help that they need. So training. We've talked about this a little bit. So if you're doing ground, it's the DOT CFR 49, and that regulates the transportation of hazardous materials in the US. And this pretty much covers ground, motor, and then IATA will cover air. Pretty much everything defaults to the IATA regulations because they are the most stringent, and so if you cover those, you're pretty golden.

You start getting into some exceptions and exemptions when you start transporting by private carriers. So according to CFR 173 134, exempt patient specimens or even Category B are exempt from the requirements and regulations when a private courier is used exclusively to transport this material. However, there is a caveat that this courier needs to be using that vehicle only for transporting. They can't be stopping. They can't be picking up Uber Eats or doing anything like that.

It has to be exclusively for transport of specimens. So additional training. So we have put together checklists. So our couriers, when they start, or before they start their routes, they have that checklist. They're checking the tires, the turn signals, the headlights, all of these little issues to see if they can catch any troublesome spots before they even get on the road.

And then, of course, they're going to have additional training for regulations and movement that is required by our specific Dallas County policies. So they're going to be learning on loading the samples, securing that material in transport. Like you said before, stick it in the back seat, secure it down. Make sure that the samples, if they need, are chilled to the correct temperature.

And then unloading. The courier's responsible, once he picks up the sample, to unload it and drop it off at its destination. And it needs to be a secure handoff. You don't want just them leaving it in a random lobby and walking away. And when they unload the package from outside, you want to make sure that they're handling it securely. You don't want them dropping the package, trying to carry it with one hand or anything like that.

So the emergency response procedures. How are you training these individuals for these emergencies? So we will be doing drills and we will be having them– sorry. Blank. Reading SOPs. They are required for any transportation, required to carry this little book. It's called the DOT ERG. It's their emergency response guidebook, and it is a great reference for any spills for that necessity.

So spill kits. They are required to have a spill kit, and ideally it needs to be for biological specimens, especially for bloodborne pathogens. So I think the next breakout session is what's included. So let's do a breakout, and what would you include in a spill kit for clinical specimens? Take into account that it needs to be applicable to bloodborne pathogens as well. So I think we'll break out.

[No audio available for breakout room session #3]

Joey Stringer: Kayle? I think you're muted, Kayle.

Kayle Cirrincione: Can you hear me now?

Joey Stringer: Yes.

Kayle Cirrincione: Perfect. OK. Now that everyone's come back, does anyone want to come on mic and let me know what they talked about about their vehicle spill kit?

Joey Stringer: Could be just a couple of things, but I think there's some important things you need in a vehicle spill kit. What did some of you all come up with?

Macey Henning: Yeah. I can add for group three. I mean, we named most of the standard absorbent decontaminate PPE. Biohazard waste bags, things to contain, whatnot. But also brought up was some way for that courier to cleanse their hands afterwards. We're used to being in a lab and there's sinks everywhere, but a disinfectant or something like that for actual skin contact. And then also enough spill kits that they feel like they can practice with them.

Kayle Cirrincione: Oh, yeah. For sure. OK.

Joey Stringer: Yeah, and that's a good point about the hand sanitizer as well.

Kayle Cirrincione: Yeah. So it's making sure that you have a complete kit that is all together. You made some excellent points. So having those protocols, one of the things that we like to do in our spill kits is have those protocols laminated. It makes for a quick decon. They can pull them out, reference them. So it's not just they get wet and they just start to disintegrate.

Having that PPE, but it's also training your couriers to don and doff and use that PPE correctly and safely. Using absorbent pads and solidifiers at different abilities to absorb it and contain those spills depending on what exactly it is. And again, hand disinfectant is a great one to have after you're done. And again, maybe including a waste bag so that they can tie up the waste and then have a plan on how they're going to dispose of the waste or who they need to contact to make sure that waste is disposed of properly.

So one last question for transport. If an accident were to happen while you're transporting, what is the best scenario? Do you leave your vehicle and go for help? Attempt to move the vehicle to a safe place? Assess the situation and ensure specimen integrity and follow your established emergency protocols? Or a combination thereof?

Perfect. So C and D is what we're looking for, especially here in the Metroplex. I wouldn't want you to get out of your vehicle. That could put you at greater risk, especially if you are in the middle of our interstates here. People drive crazy. And you could possibly attempt to move the vehicle to a safer place if it doesn't put you at any risk, or are you able to?

Is your courier van that you're using, is it movable? So just kind of assesses the situation, reach out to your point of contacts, and start establishing your emergency protocols. That's excellent. And I think I'm going to hand you back over to Joey for accessioning.

Joey Stringer: All right. Well, good. Well, thanks. And we spoke a couple of times about communication and coordination, and these two things, communication and coordination, they go a long way in preventing safety issues. And so we've kind of mentioned it throughout, and we're going to continue to mention how important communication and coordination is regarding safety. Not just transporting safety, but just safety in general. And so now we'll move on to specimen accessioning.

All right. Kayle, go ahead and submit to forward the slide. And so we'll just go into this question here. So what safety concerns do you see with accessioning of samples? As we mentioned earlier, lack of communication of high-risk samples, inadequate size of accessioning room. How big are your accessioning rooms? How small are your accessioning rooms? Lack of a biosafety cabinet. Do you have a biosafety cabinet? Is it all the above, or is there another one that someone wants to drop in the chat that we didn't mention here?

Yeah. Lack of communication of high-risk samples is always an issue. And this seems to be a– it was really a problem with us during the COVID, and I'm sure it was a problem with everybody else. You get all these COVID samples and all of a sudden you have this little plate stuck in between everything else and you're like, well, what is this? Or you have some other meningitidis sample and an IGRA plate pass through your BSL-2 lab. What are some of the safety concerns here? You got possible exposure.

And inadequate size of accessioning room. I don't know how big everyone's accessioning room is. Is it adequate size? Do you think you need a bigger room? Too small of a room for accessioning examples, you get all of this clutter. Clutter makes it more difficult to kind of focus on your task. And the funny thing is, as I sit here and talk about clutter, I have 1, 2, 3, 4, 5, 6 stacks of paper on my desk. But anyway, so having too small of a size of a room can be an issue.

We're in the middle of creating– building a new laboratory and accessioning part of the lab had really a big focus on how do you really build a proper accessioning room. It's going to be a lot bigger. It's going to have a lot of other things in it. What are your safety concerns here for this scenario when you have too much clutter? Could you spill something when you have too much on your desk? Possible exposure. And then lack of biosafety cabinet accessioning room.

Processed samples on a benchtop. How do you accessioning samples, loading and unloading centrifuge on benchtops? Is your centrifuge small enough to go into the BSC? Do you have a BSC? What are some safety concerns here? You have possible spill. If it was in the BSC you can kind of contain it a little better.

Possible exposure if it was done on the benchtop. And so this is something else that we're considering in our new laboratory. Biosafety cabinets. And so here for question five– and just kind of a simple yes or no question. Do you all have a BSC in your accessioning room? And for those of you who don't, we'd like to discuss a little more about it. But we'll wait to see what everyone– how everyone responds to this one.

I'm kind of interested to see how many of you all actually have a BSC in your accessioning department laboratory. Wow. So everyone has a safety cabinet? Interesting. We do not, and so that's kind of– well, it's great that you all have a BSC. For the 27% of the labs that don't, including Dallas, how do you all accession your samples? I'm kind of interesting to know that.

For us, we have a very small accession, and there is no BSC. It just wouldn't fit in it. We have training that we do, but there's always that possibility of an accident. But for those labs that do not have a BSC, can someone kind of give their idea, their thoughts, their perspective on how they're accessioning samples?

Do you do it on the– well, obviously you do it on the benchtop because you don't have a BSC, but how does it–

Shawna Baumeister: In Stillwater, Oklahoma we take it to the micro department to open it. And either they open it, or I'm trained to open it so I'll open it. But we don't have one in our accessioning room. We have actually two separate accessioning rooms that are just small offices that we share the samples between. So it's really kind of inconvenient, but we don't have a safety cabinet that we get to use just for a accessioning.

Joey Stringer: OK, so you bring your samples back to the micro lab where there is a BSC, and that's where it's opened.

Shawna Baumeister: Yes. If it's a Cat A, yes. That's where we open it. Otherwise, just regular samples that come from the county health departments, we just open them in the accessioning room.

Joey Stringer: OK, that's what we do. So blood samples that– 90% of the samples that we get are blood samples for STIs, being a local health department. So we receive a lot a lot of blood samples. But even though they're plastic tubes, they're capped, they're in racks, and so we have a pretty good process. But you know, it's always nicer to have a safety cabinet in your accessioning room. But that's engineering.

That's cost. That's a–

Shawna Baumeister: It would be nice to have.

Joey Stringer: Yeah, no. Hey, I'm right with you on that one. I think it's great to have. And for the 73% people that do have it, I think it's fantastic. But that's one of the focus that we are doing in our new lab is how big to make our accessioning room. And we'll have two biosafety cabinets. For those that do have a safety cabinet, do you have one or do you have two? Are there hard ducted or are there– or is it a class II A2 with a thimble? Meaning recirculated back into the room. Just curious. Anybody who has a safety cabinet, do y'all have a B2 or an A2?

Kayle Cirrincione: John Lawrence says that they have a Class II A2 with the thimble.

Joey Stringer: With a thimble? OK, so it's recirculated. So we're thinking of both, the hard ducted and the thimble. But for us it's the same. When we get the Cat A samples from our select agent rollouts, those are pre-notified and communicated to us, and then those go back to our LRN lab and they're not accessioned in that room. So interesting. OK, well thank you all for that information. So that's good. So Sean, I think you and I– your lab in Dallas kind of do the same thing. All righty. And then we'll move on to specimen storage.

Kayle Cirrincione: Perfect. That's me again. OK, so we've collected it, we've shipped it. It's gone through our accessioning. You've ideally ran your sampling, so how are you going to store this? Let's see. Can I move the slide? So a couple different things you need to consider when you're talking about storage. Do you have adequate refrigerator and freezer space?

I know during the outbreaks of COVID and mpox we ran out of storage space extremely quickly, especially in the early days when they wanted us to keep every sample. And then the importance of proper storage. Are you freezing it at minus 20, or can you hold it at 2 to 8 degrees? Risks of contamination. Are you separating out your higher– your higher level consequence from your lower?

You don't want to be diving into a minus 80 where you can pull out a possible anthrax sample or a COVID sample at the same time and possibly mix those up. Planning. How, in the grand scheme of things, are you planning the storage? Do you have maps? Do you have some sort of computer that you can assign different spots within?

And then maintenance. Are your freezers thawed at a regular interval, or you just kind of– they get defrosted when they kind of hit that point where they can no longer run and they start auto defrosting themselves? Which we've had a couple of those happen. And then expandable solutions. Is it just kind of a free for all where you're sticking everything in there, or is it really nicely organized with all of the shelves you can pull out with all of the little boxes?

And temperature monitoring. I know that has been a really big one for CLIA. We have been working over this last year and a half on getting all of our specimen storage monitored. So if it starts to dip and goes out of range, we can catch it before it causes an issue for the actual sample integrity. And then the inventory control is a really big one, especially for your high-risk samples. Covers risk mitigation, properly labeled.

Do you have those labels where they can easily be read if they are in deep cryo or minus 80? If they've been pulled out and wiped down with disinfectant, is it going to wipe off of your tube? Is the label going to fall off in minus 80? So you may want to consider some of those tough tags or cryolabels. Do you have restricted access, especially with those select agents? That is critical that you have restricted access and documented access. So that's going to be your chain of custody audits. And then training on how to use and access those samples. And then emergency protocols.

What are you going to do if you go and you open up your box and one of the cryotubes was filled way too high and it expanded and cracked the tube? And now you're dealing with some sort of frozen spillage? We have had that happen here in Dallas. So kind of to wrap this all up, one of our real-life case scenarios, it talks about a little bit of everything. So we had a specimen delivered here without knowledge. No communication. No contact.

This was early in our COVID days. We had just opened our accessioning department, and at the moment, to quickly get people in, we were using temps and we were training them as needed. But we were so concentrated on the mass amount of samples that we were getting from COVID, we really weren't getting any high consequence rule out. And all of a sudden this wonderful package came and got delivered, and it got delivered around lunchtime so there was limited people here.

The person that accepted it didn't quite know what they were dealing with. The courier that delivered it didn't quite know what they were dealing with. Came with absolutely no document or paperwork, just a sticky note with a name. And so it was an agar plate in one of those 95 KPA packages which wasn't actually sealed correctly because if you squeezed it, you could hear the air hissing out. And because this individual didn't quite know what to do, they found the name on the sticky note and went and placed it on our BSO's desk.

And so everyone got back from lunch, and all of a sudden there was this agar plate sitting on a personal desk in the office area, not in laboratory. And so it's one of those failed points. We very quickly put together an incident response. We put together trainings for all of our accessioning, what to do. We put together service manuals for our clients so they know the correct steps to take when they have these specimens.

Unfortunately, with COVID we have just seen such a high turnover rate that even someone that you had talked to and given instructions six months prior may not have had to have this knowledge. So we were able to give reference material that they had access to. Anything to add, Joey, on that one?

Joey Stringer: No. No. That was it. And needless to say the BSO was not happy. But we took everything that happened and made the situation a lot better and trained the hospital that submitted the sample as well, and they were a big part of the training. And so it wasn't just the accessioning area, it was also the hospital lab, retraining them.

And it was, from what I can remember, was someone that was not familiar with the protocol and what to do with the sample and how to package it correctly. Packaging the sample correctly, as well as not understanding the communication that needed to be to us regarding this type of high consequence sample.

Kayle Cirrincione: And as a biosafety person, you can plan all you want and you can try and come up with all of the scenarios, but someone is always going to find a loophole. So it is taking those in strides and going back and documenting it as incidents, and then going back and revising and doing training and trying to close up those loopholes as much as possible.

Joey Stringer: Yeah. Sometimes the training– or the real-life events are the best trainings to have because obviously, they're real. It happened, and you kind of focus a lot more heavily on it. But again, it goes back to what I said earlier about the communication and the coordination, just how important those two aspects are in preventing safety and preventing the risk and the hazard that comes with laboratory work.

Did anybody else have anything to add to this? Did you all ever have a scenario like this during COVID where you had all of these samples come in for COVID testing, and lo and behold, you see this slant or this plate that doesn't really look like it needs to be here? Did anybody else have a situation like that?

Macey Henning: Certainly not quite like this, but we definitely received the tubes and trash bags and all of the adventures of the pandemic.

Joey Stringer: Yeah. Trash bags, shoe boxes. You know? I think we all had sort of the same problem. But we took the mistakes and made everything better because of it.

Macey Henning: Absolutely.

Joey Stringer: Yeah. All right. All right. Go to last slide, Kayle.

Kayle Cirrincione: OK. I think you have control.

Joey Stringer: All right. And, well, that closes everything up. As I said before in closing, remember the laboratory safety and collection transport accessioning storage. It's important to have an effective safety program, and that's essential to preventing mistakes and spills and accidents, and also having someone dedicated to safety in your laboratory is essential.

I know sometimes that's easier said than done. Not all labs have a safety officer, and we certainly didn't have one. Kayle and her position are fairly new, but it's so important to have someone in your laboratory that's dedicated to safety and all of this, having good and proper leadership as well. All that goes into preventing risk and preventing mistakes and things of that sort. And anything you want to add in closing too, Kayle?

Kayle Cirrincione: No. It's a lot of– mitigating these risks and closing is a lot of coordination and communication. When people are open and honest and say, hey, I need help or, hey, this doesn't look right, and really reaching out for guidance on shipping or just sample doesn't look right before I open it, Kayle, guarantee this is what I should be using. That really goes a long way in minimizing the risks for any of these topics.

Joey Stringer: Well, we want to thank everyone for your participation and listening, and we really appreciate it, and it was good feedback. The breakout sessions were good and informative, and thanks again CDC and ECHO for your allowing us to be a part of this. This was a great for us, and thanks again to all the participants. I appreciate your listening as well as questions and providing some of your perspective on specimen collection and safety.

Kayle Cirrincione: Yes, thank you.

Aufra Araujo: Thank you. Thank you both, Joey and Kayle, for your excellent and informative presentation. Thank you everyone for participating. Now I will invite my colleague, Commander Sabrina DeBose, who is the Safety Team Lead in the CDC Division of Laboratory Systems, to provide a summary of the discussion from today's session. Sabrina, over to you.

Sabrina DeBose: Yes. Thank you Aufra. We want to thank you, participants, for a robust discussion that took place via the chat, the poll questions, and the breakout rooms. I have the discussion broken into the sections how it was presented. Specimen collection challenges that you see in your laboratory. Someone commented, well, we discussed the turnover and training of staff, and the importance of processing samples correctly.

Some of the discussion during the transportation that addressed safety concerns. It was a lack of communication between sending and receiving labs, transporting and maintaining the correct temperature to ensure that samples are usable once they were received, understanding how FedEx requirements may differ from federal requirements, and also stand on top of training to ensure that staff were aware of the differences.

Someone also discussed the issues with the courier maintaining the correct temperatures for samples. During the accessioning portion we discussed– let's see. Discussed the following safety concerns that were identified. During the poll question about sample challenges during accessioning, majority of the participants selected lack of communication about high-risk or select agent samples, lack of biosafety cabinets, and inadequate sizes of the accessioning room.

Majority of the participants reported having a biosafety cabinet in their laboratory, and the ones that did not have access to a cabinet share that they may take the samples to another location if it was a Category A, or open the samples on the benchtop in the accessioning area. During the specimen storage section, individuals shared experiences of receiving samples that were not packaged correctly and learning from their experiences. Once again, we want to thank you for the robust discussion, and I'll turn it back over to you, Aufra.

Aufra Araujo: Thank you so much, Sabrina. Thank you for your terrific presentation, Joey and Kayle. I would also like to thank all of our participants for taking part in our discussion today. Thank you. You know I'm going to talk about surveys Thank you for filling out our ECHO Biosafety surveys. We appreciate your feedback and have used your suggestions to improve our ECHO sessions.

We are using two types of surveys to collect data on– to collect your feedback on the sessions. We have the monthly surveys. So you can expect shortly to receive a survey about today's sessions. Today's session. Sorry. That we'll be sending out shortly. We also are sending a six-month survey. If you have attended any of the first five ECHO sessions from January to May, you should have received a six-month follow-up survey.

This survey, as I mentioned, is different from the monthly surveys because it focuses on gauging the use of the information from previous sessions and identifies factors that helped or hindered the use of the information you've learned during these ECHO sessions. If you have not already, please complete the six-month follow-up survey by August 31. Your responses are vital in ensuring the content of the sessions meets your needs. We appreciate your time and attention to completing these surveys. If you have any questions, please reach out to us at dlsbiosafety@cdc.gov.

Now let me share the screen again really briefly. We are excited to have our next session in September. It will be on Tuesday, September 26 at noon Eastern Time. The topic will be Medical Waste Management, presented by Dr. Nikki Parrish from Johns Hopkins University School of Medicine. Please visit the ECHO Biosafety website to view all upcoming sessions. Now we will adjourn. Thank you for attending, and I hope you were intentional about having a fantastic day. Thank you very much. Have a nice rest of your day.