North Carolina lab-oratory.

              http://slph.state.nc.us/
I N S I D E
t h i s i s s u e
PAGE 3
Cytyc ThinPrep® Imaging System
Exciting new technology for better
cytology results
PAGE 4
First Laboratory Confirmed Rabid
Opossum in N.C.
PAGE 5
Summary report on Arboviral Agents
PAGE 6
New Lab Information Management
System brings the NCSLPH further
into the information age
PAGE 7
Microscope Tips
Tips to help you decide what
microscope is best for your lab
PAGE 8
A case of congenitally acquired malaria
PAGE 9 / EDITORIAL
Needle Points
Ensure your facility is “in step” with
current regulations
PAGE 10
The Safety Corner
Information on creating an Exposure
Control Plan
Instructions on filling out the Newborn
Screening Form
From the Directors Chair
Greetings from the Director’s Offi ce at the North Carolina State Labora-tory
of Public Health (NCSLPH)! It has been quite a while since we last
published an issue of LabOratory. We hope that other venues have been sources of
critical information in the interim, such as numerous electronic list servs,
health alerts, weekly arboviral and infl uenza reports, and quarterly EpiNotes
publications. Recognizing the dynamic nature of the public health laboratory fi eld and
thanks to the infusion of fresh faces at NCSLPH, we decided it was time to revive
Lab-Oratory and fi ll an empty niche.
Many changes have taken place at NCSLPH while Lab-Oratory was on hiatus. In
November 2004, we established and fi lled two new Quality Assurance (QA)
positions to allow us to focus on quality assessment and improvement of both clinical
laboratory testing processes and environmental laboratory testing. Vickie Whitaker,
formerly Laboratory Improvement Unit Supervisor, was promoted to QA Manager, and
Tony Ivosic was hired as the Clinical QA Coordinator. Th eir exceptional leadership
has allowed us to move toward greater standardization and consistency in QA
throughout the laboratory.
Other organizational changes included the addition of a new Laboratory Preparedness
Unit that includes 18 new staff members, 14 in Bioterrorism and Emerging Pathogens
(BTEP) and four in Chemical Terrorism (CT). Th e BTEP Coordinator is Royden Saah,
and the CT Coordinator is Kaye Flood. Th e BTEP Unit has not only developed a
well-trained, dedicated staff here in Raleigh, but has also seen the completion of three
Regional Response Laboratories in Buncombe, Mecklenburg and Pitt counties. We are
very proud of our increased capacity to respond to threats of bioterrorism and other
public health emergencies across the state. Th e CT Unit staff has been installing
sophisticated instrumentation, attending and providing training, and validating
methods for heavy metals and other chemical agents of concern. Th e increased
capacity to respond to chemical events by testing exposed individuals for levels and
metabolites of chemicals of concern is a great step forward in the preparedness eff orts in
North Carolina.
Lab-Oratory, March 2006 Number 83
Cont. on page 2
Lab-Oratory / March 2006
2
Our management team has undergone
changes in personnel in recent months,
besides adding the QA Offi ce and Labora-tory
Preparedness coordinators. After lead-ing
the Organic Chemistry Laboratory for
many years, John Neal was promoted to Unit
Supervisor of Environmental Sciences. When
Vickie Whitaker became QA Manager, Kristy
Osterhout was promoted to Laboratory
Improvement Coordinator. Th e retirement
of Gwen Brown after 30 years of dedicated
service to the Cancer Cytology Unit led to
the promotion of Marjorie Lavender to the
Unit Supervisor position in November 2005.
Myra Brinson became Unit Supervisor of
Virology/Serology following the departure
of Todd McPherson in July 2005. While we
miss the staff members who have moved on to
enjoy retirement or pursue other career paths,
we are excited about the chance to have new
ideas brought forward by the fresh faces on
our management team.
Beyond the dramatic changes in labora-tory
staff leadership, we have undergone tre-mendous
advances in technology that have
allowed us to provide better laboratory tests
to meet the needs of local health depart-ments
and hospitals and their patients. In
November 2004, our Newborn Screen-ing
laboratory added a new test to
detect biotinidase defi ciency in newborns.
In December 2005, our Cancer Cytol-ogy
Unit began screening 100 percent of
Th inPrep slides using the Cytyc Corporation’s
Imager Plus System, making NCSLPH the
fi rst state public health laboratory to use this
technology. Th is system allows for high-er
sensitivity of potentially abnormal cells
and higher productivity among cytotech-nologists.
Th e Environmental Sciences Unit
recently incorporated a new state-of-the-art
Fourier-Transformed InfraRed (FTIR)
Microscope into its already sophisticated
arsenal of laboratory instrumentation. Th e
FTIR microscope enables us to rapidly
identify a number of chemical compounds, whether they are part of a routine
request for identifi cation or are part of a suspect white powder investigation.
One of the more prominent changes is the addition of a number of
molecular tests to allow for better detection of Chlamydia trachomatis and
Neisseria gonorrheoea, Bordetella pertussis, norovirus and infl uenza viruses,
and earlier detection of HIV infection. In fact, North Carolina was the fi rst
state to institute a comprehensive acute HIV detection and followup program
with our partners at UNC-Chapel Hill and the N.C. HIV/STD Prevention and
Care Branch. As part of the national Laboratory Response Network (LRN),
the BTEP routinely uses real-time PCR assays to rule out or confi rm agents of
bioterrorism, such as Bacillus anthracis, Francisella tularensis, Yersinia pestis
and ricin, and also, when required, for emerging pathogens such as SARS
coronavirus, monkeypox and avian infl uenza. Th e use of 16S ribosomal DNA
sequencing to aid in identifi cation of atypical bacteria (such as fastidious
gram negative rods) has been incorporated into the Microbiology Unit. By
comparing batteries of biochemical test results with sequence results from
national DNA databases, the identifi cation of rare and unusual bacterial
species is much improved. We expect molecular diagnostics to be incorporated
into routine laboratory testing in the future.
Finally, NCSLPH is fortunate to have one of the strongest and most active
training and consultation teams in the nation. Our Laboratory Improvement
Unit has many new faces, and you will be experiencing a number of new
initiatives from this group in the coming year. Not only has Laboratory
Improvement held more workshops than ever before, including packaging
and shipping and the basics of molecular biology, but also held its fi rst annual
Clinical Laboratory Tech Day in August 2005. It was an overwhelming
success, thanks to the vision of Lisa Ballance, one of our Regional Laboratory
Improvement Consultants, and the hard work of the entire team. As a
direct result of the positive response to the phlebotomy lectures by Dennis
Ernst, an expert in the fi eld, a phlebotomy initiative is being rolled out in
2006 to emphasize the important safety issues associated with venipuncture.
Th ese are just a few of the examples of changes coming from our training and
consultation group.
Th anks to Laboratory Improvement staff , Lab-Oratory is revived, and we
hope you fi nd the articles interesting, practical, and even enlightening! As
always, we welcome your comments and feedback about Lab-Oratory.
Leslie A. Wolf, PhD, HCLD (ABB)
Acting Laboratory Director
Director’s Chair cont. from page 1
Lab-Oratory / March 2006
3
Cytyc ThinPrep® Imaging System
(previously published in EpiNotes)
Prepared by Cytology Unit Supervisor, Gwen Brown, CT-ASCP, NCSLPH, Retired
NCSLPH decided to move forward
with a six month study to demonstrate
performance of the Th inPrep® Imaging
System.
A new stain was developed by Cytyc
Corporation to enhance the amount
of DNA in the nuclei, necessary for
the algorithms of the imaging system.
NCSLPH began using this new stain in
July of 2004 to address problems with
unsatisfactory specimens. An adjust-ment
period was needed for the cyto-technologists
and pathologists to become
comfortable with the darker stain and
increased nuclear detail. Using man-ual
screening, the unsatisfactory rate
dropped and the abnormal (dysplasia/SIL)
detection rate increased after two
months with the new stain. Th is prior
conversion to the new stain allowed the
training segment of the Imager study to
proceed ahead of schedule.
Two screening cytotechs, the Chief Cy-totech
and a Quality Control Cytotech,
were selected for Imager training. A
senior cytotech with 31 years experience
Th e Cytology Unit at the North
Carolina State Laboratory of Pub-lic
Health (NCSLPH) has undergone
many improvements over the years,
changing technologies to better meet
customer needs. One challenge has been
to maintain an acceptable turnaround
time for PAP smears. Vacancies due to
cytotechnologist shortages and salary
discrepancies with competing cytology
labs have been contributing factors.
In March 2004, the Cytyc Corporation
asked the NCSLPH to take part in a
six-month study to evaluate an FDA-approved
Th inPrep® Imaging System.
Th is system consists of an imaging unit
that scans each slide and locates twenty-two
fi elds of interest. Th e Imager uses
optical cellular selection algorithms
to select these fi elds. Abnormal cells
have larger, darker nuclei, and are easily
identifi ed by the Imager. Additional
algorithms look for clusters of cells that
may represent endocervical cells. Th e
algorithm analyzes all objects on the
slide, discards objects that aren’t likely
nuclei, and sorts the remaining objects by
integrated density. Two automated
review scopes are provided that are
attached by Ethernet cable to the Imager.
Th e cytotechnologist reviews the 22
fi elds on each slide and quickly evaluates
the negatives based on these fi elds. Th e
slides with detected abnormalities in the
selected fi eld of view are completely
screened. Many cytology labs in the
country are already using the new
system and report an increased cytotech
productivity and disease detection. For
these reasons, and because many of the
specimens received from local health de-partments
are from high risk patients,
and one of the newest cytotechs on staff
with only three years experience were
selected as the primary screeners. Based
on volume and demographics, eight
health departments were chosen to
participate in the study. A validation
study was conducted and the pilot
project went live on March 1, 2005.
Historical manual screening data
was collected on the two screening
cytotechs from the same six-month
period in 2004 to compare with the
statistics gathered during this study.
An increase in sensitivity was noticed
immediately and was sustained during
the entire study. Th ere was a signifi cant
increase in HSIL (high grade squamous
intraepithelial lesions). An increase in
LSIL (low grade squamous intraepithelial
lesions) and a decrease in the ASC-US
(equivocal atypical cells) were also noted.
A considerable decrease in the unsatis-factory
rate was also an unexpected, but
positive outcome. Th e chart below shows
the increase in disease detection realized
during the study.
Negatives -4% Decrease
Atypical glandular &
squamous cells
-4% Decrease
LSIL 32% Increase
HSIL 144% Increase
AIS 0 0
Cancers 0 0
Unsatisfactory -34% Decrease
Imager vs. Historical Manual Screening
Cont. on page 4
Lab-Oratory / March 2006
4
First Laboratory-Confirmed
Rabid Opossum in N.C.
bats (1,862), raccoons (1,435), dogs
(1,510), foxes (334), and skunks (240).
Of these animals, the three groups with
the highest positivity rate were skunks
(73%), raccoons (43%) and foxes (41%).
All positive specimens, except for bats
and raccoons, are typed using monoclo-nal
antibodies for strain identifi cation.
Th e most common rabies strain found
in rabid animals in North Carolina is the
Eastern U.S. Raccoon strain.
On November 15, 2005 the NCSLPH
rabies laboratory confi rmed the state’s
fi rst case of rabies in an opossum. Th e
opossum was located in Cumberland
County in the Fort Bragg area. Th e
animal was exhibiting symptoms of ra-bies,
including the classic indicator,
excessive salivation. Th ree people han-dled
the opossum and thus were po-tentially
at risk of exposure to rabies.
Because this was the fi rst laboratory con-
Th e North Carolina State Laboratory
of Public Health (NCSLPH) is the only
laboratory in the state that performs
routine rabies testing. NCSLPH has
three staff members dedicated to rabies
testing, with four additional staff mem-bers
cross-trained to assist with high-volume
workdays plus any required
weekend and holiday testing. Th e rabies
laboratory performs a number of routine
tests for rabies, as well as tests for quality
assurance. Th ese tests include the rapid
direct fl uorescent antigen (DFA) test, the
standard DFA test, murine neuroblastoma
(MNA) cell line inoculation for quality
assurance purposes, and monoclonal
antibody strain typing. Th e laboratory
plans to utilize molecular typing for
rabies in the future. In the past two
years, 8,247 specimens were tested and
of these, 1,052 (13%) were positive for
rabies. Th e most common animals
submitted for testing were cats (2,199),
fi rmed positive opossum in the state, the
laboratory staff repeated the test with
the original tissue and with tissue that
remained in the opossum’s skull. Th e
test results were again positive. Subse-quently,
NCSLPH notifi ed the Centers for
Disease Control and Prevention (CDC)
and sent tissue to Atlanta, Ga., for fi nal
confi rmation and strain identifi cation.
Following NCSLPH standard operating
procedures, strain identifi cation was ini-tiated
following the positive laboratory
result. Further testing revealed the ra-bies
virus strain was not the U.S. Eastern
Raccoon strain that infects the major-ity
of the specimens in North Carolina,
but rather a bat strain. CDC notifi ed
NCSLPH on November 19, 2005
and confi rmed the NCSLPH results,
demonstrating that the opossum was in-deed
positive for rabies. Th e rabies virus
strain was consistent with a variant found in
Lasiurus borealis (Eastern Red Bats).
Cont. on page 5
Th e two screening cytotechs in the study
showed increases in productivity within a
few days and continued to increase the number
of slides screened per day during the course
of the project. Cytotech A (senior CT) had
a considerable decrease in screening hours
and still had an impressive increase in
productivity.
Th e increased sensitivity was dramatic enough
to convince NCSLPH of the Imager System’s
value. Th e cytotech productivity gains made
the Th inPrep® Imaging System very attractive
to the NCSLPH Cytology Unit. Cytyc Cor-poration’s
bid for Pap packaging and Imager
processing was accepted in the fall. A second
Imager and six additional Review Scopes were
installed, and the remaining staff cytotechnologists completed Imager training
in November. A validation study for the second Imager was conducted and all
specimens were being imaged by December 2005.
Cytyc cont. from page 3
Productivity Comparison:
Manual Screening vs. Review Scope (RS) Screening
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Slides per Hour
CT A CT B
Manual Screening
RS Screening
Lab-Oratory / March 2006
5
Arboviral Summary for 2005
infected arthropod takes a blood meal.
Th e majority of human infections are
asymptomatic or may result in a
nonspecifi c fl u-like syndrome. Onset
may be insidious or sudden with fever,
headache, myalgias, malaise, etc. Infec-tion
may, however, lead to encephali-tis,
with a fatal outcome or permanent
neurologic sequelae. Fortunately, only
a small proportion of infected persons
progress to frank encephalitis. Arbo-viral
encephalitis can be prevented in
two major ways: personal protective
measures to avoid bites and public
Th e Special Serology Laboratory at the
North Carolina State Laboratory of
Public Health (NCSLPH) off ers hu-man
serological testing for the following
arboviral agents: Eastern Equine En-cephalitis
(EEE), Western Equine
Encephalitis (WEE), St. Louis Encepha-litis
(SLE), LaCrosse Encephalitis (LAC),
and West Nile Virus (WNV). Arboviruses
are viruses that are maintained in nature
through biological transmission between
susceptible vertebrate hosts by blood-feeding
arthropods such as mosquitoes.
Vertebrate infection occurs when the
health measures to reduce the population
of infected mosquitoes.
Th is year has been interesting due to a
signifi cant LaCrosse outbreak in the
western part of the state. Our year ended
with 31 LaCrosse-positive human pa-tients,
many of whom were children,
and four humans positive for West Nile
Virus. Our laboratory worked very close-ly
with Epidemiology and Centers for
Disease Control and Prevention (CDC) to
monitor and test patients involved in the
LaCrosse outbreak. Th ese patient samples
Opossums are considered low-risk ani-mals
for contracting rabies. Laboratory
studies have shown it takes 50,000 to
70,000 times the amount of virus to infect
an opossum compared to a canid. Th ere
are two theories for the opossum’s relative
resistance to rabies virus infection. One
explanation is the presence of a peptide in
opossums called Lethal Toxin Neutraliz-ing
Factor (LTNF). Th is peptide combats
a number of animal, plant, and bacterial
toxins and is being produced synthetically
for use in medical research. Th e second
explanation for resistance to rabies is the
opossum’s body temperature. Opossums
have a lower body temperature than
other native mammals, which may inhibit
growth of the rabies virus. Since January
1, 2000, the NCSLPH rabies laboratory
has received a total of 193 opossums for
testing. Th e opossum from Cumberland
County was the fi rst to test positive,
while 131 others tested negative. Because
certain criteria for testing must be met for
low risk animals such as opossums, 34 of
the opossums were not tested since these
criteria were not met. Another 27 were
tested but with unsatisfactory results due
to the condition of the brain tissue upon
receipt by the laboratory.
How will this positive result in one
opossum aff ect the future testing of
opossums in our laboratory? Continued
NCSLPH collaborations with Dr. Lee
Hunter and Dr. Carl Williams, Public
Health Veterinarians in the Occupa-tional
and Environmental Epidemiology
Branch, led to the following updated rec-ommendations:
• Opossums will still be treated as
low-risk animals for contracting
rabies virus.
• Testing will be recommended for
opossums that bite a person or
unvaccinated pet or livestock.
Prior to this positive laboratory result,
all opossums had to have approval
before NCSLPH would test them.
• Treatment of the patient generally is
not recommended until laboratory
testing is completed, unless special
circumstances warrant treatment
and/or testing.
Th e rabies laboratory is an area full of
surprises and each day is an adventure! In
the past, NCSLPH has been called upon
to test a bear, two tigers, and a monkey.
Live bats have emerged from shipping
containers, and cans of fl ea and tick spray
are kept handy. Because rabies infec-tions
are fatal, however, it is critical that
laboratory testing on suspect animals be
done quickly and accurately, and that
laboratory results are reported imme-diately
to the proper health offi cials.
NCSLPH has an excellent staff that is
well trained and very conscientious about
following the CDC recommendations for
rabies testing. Th e partnership NCSLPH
has with Public Health Veterinarians,
local health departments and Animal
Control personnel leads to a very eff ec-tive
rabies control program in North
Carolina.
Submitted by:
Peggy C. Brantley, Supervisor,
Viral Culture/Rabies Laboratory
December 12, 2005
Opossum cont. from page 4
Cont. on page 6
Lab-Oratory / March 2006
6
A New LIMS for the Future
Th e Laboratory Information Management
System (LIMS) at the North Carolina State
Laboratory of Public Health (NCSLPH)
has passed its prime. Th e original computer
system was developed more than seven years
ago to improve laboratory reporting. Th ere
have been many information technology
changes both internal and external to the
Lab’s LIMS since that time. Currently, the
laboratory’s information technology staff
supports more than three distinct laboratory
information management systems. In this
“Information Age,” the pressures to keep
up with federal and state communication
requirements have initiated the replacement
of the NCSLPH’s LIMS.
In cooperation with the Centers for
Disease Control and Prevention (CDC),
the federal government, and the Division of
Public Health, the NCSLPH Information
Technology and Laboratory staff will in-stall
a new LIMS. Th e project will kick off
in February 2006 and will take more than
a year to develop. Th e goal is to unify all
of the NCSLPH laboratories onto a single
information technology platform. Th is will
allow the lab to continue to meet regulatory/certifi cation requirements,
improve service to our customers in the state of North Carolina, and
communicate more eff ectively with state and federal agencies.
An agreement has been reached and a contract signed with STARLIMS of
Hollywood, Fla., for the new system. STARLIMS is specifi cally designed to
fully integrate the daily functions of a multidisciplinary public health
laboratory and manage analytical data covering a variety of diverse
healthcare programs. It off ers comprehensive public health reporting,
surveillance and network capability compatible with national and international
standards. Currently there are more than ten state public health laboratories
that utilize STARLIMS.
Please be patient and support the NCSLPH in this major project.
Everything associated with the NCSLPH will be impacted to some
extent by the new LIMS. Both internal and external customers will
have new challenges and will need to work together to work out
solutions for the fi nal product. Future issues of Lab-Oratory will detail the
progress of the LIMS. Th e new LIMS will be hard work, but the
potential for contributing to the public health of North Carolina is both
exciting and promising.
Article submitted by:
Anthony L. Ivosic, BS,MT(ASCP),CHSP
Clinical Laboratory QA Coordinator
Arboviral cont. from page 5
were also sent to CDC for confi rmatory
testing.
Th e NCSLPH also performs arbovi-ral
testing for other species within the
state. In conjunction with Public Health
Pest Management (PHPM), the NC-SLPH
conducts surveillance for arboviral
activity through sentinel chickens and
mosquito trapping. Th e sentinel chick-ens
are placed in various areas in the state
and are tested periodically for Highlands
J (HJ), EEE, WNV and California-like
viruses. In 2005, our lab tested 980
sentinel chicken samples. Mosquitoes are
trapped and speciated into pools that are
tested by molecular real-time RT-PCR
for EEE and WNV. A total of 1,158
mosquito pools were tested at the
NCSLPH. Equine and other veterinary
surveillance for arboviruses is performed
at Rollins Animal Laboratory, Depart-ment
of Agriculture.
For any NCSLPH arboviral-related ques-tions,
please call
919-733-7544.
Article submitted by Holly Lee, Medical Lab-oratory
Technologist II, BS, Zoology), Special
Serology Department, NCSLPH
Lab-Oratory / March 2006
7
Microscope Tips
• A built-in illuminator is preferred to an
external light source. Halogen lighting
provides a white, bright, concentrated
light. To decrease the heat emitted from
the light, the scope should be fi tted with a
transformer or rheostat (i.e., a dimmer).
Always use the bulb recommended by the
microscope manufacturer. Never inter-change
microscope bulbs and keep extra
bulbs on hand!
• Better microscopes are equipped with
a fi eld iris diaphragm in the base of the
microscope. Th e diaphragm controls the
amount of light that passes from the bulb.
Th e iris diaphragm is preferred over a disk
diaphragm, as it allows an almost infi nite
number of settings.
• Dual, low mounted, coaxial coarse and
fi ne adjustment controls with
a metal gear system are more
durable than those constructed of
plastic or nylon.
• A sub-stage, movable condenser with
an aperture iris diaphragm allows better
control of lighting with the higher
magnifi cations. Th e condenser should
have a numerical aperture of 1.25 if the
microscope is equipped with a 100x oil
objective. Th e most common type of
condenser and least expensive is the Abbe
condenser, which is well-suited for the
clinical laboratory. Look for a dovetail
mount with rack and pinion movement.
• Adding a phase contrast condenser to
the microscope will enhance the ability
to study unstained, transparent objects
in urine sediment and wet mount slides.
Th e improved contrast will yield elements
and organisms visible that are not readily
observed with a brightfi eld condenser.
• Equipping the microscope with a me-chanical
stage and spring-loaded stage
clips will allow for easier and more precise
Purchasing a microscope can be a confusing task, but merits careful
consideration as it is usually a long-term investment. Before making a
decision, plan and discuss current and future microscope
needs with the users.
Consider the following tips when buying a quality
microscope:
• Th e basic construction should be a sturdy,
well-built frame constructed of metal,
which will minimize vibration. Never
consider a scope made of plastic!
• Quality glass optics, or lenses, are
among the most important com-ponents
in a microscope. For the
clinical laboratory, the achromat
lens on each objective is a
standard choice. Achromat
lenses are color-corrected, thus
preventing many optical distortions
that are caused by inferior lenses. However, at
higher magnifi cation, the fi eld of view with the achromat
lens appears to be out of focus at the edges and does not appear to
be fl at. Th erefore, planachromat lenses for the objectives may be a more
appropriate choice. A plan (fl at fi eld) lens corrects for the curvature
of fi eld so that the entire fi eld of view is in focus.
• A broad range of objectives will enhance viewing ability. 10x and 40x
dry objectives and a 100x oil immersion objective are recommended.
A safety feature for objectives with very short working distances, such as
the 40x and 100x, is the spring-loaded retractable front lens assembly.
Th is feature will reduce the danger of inadvertently crashing the front
of the objective into the cover glass or specimen. Th e objectives should
attach to a revolving, ball bearing nosepiece that has a fi rm, audible click
when an objective is engaged into the working position.
• Wide-fi eld eyepieces widen the fi eld of view, thus reducing the need to
move the slide as often while viewing. Th e magnifi cation of the eyepieces
should be 10.0x or 12.5x. High-focal-point eyepieces allow the user to
wear glasses when viewing a slide, and compensating eyepieces correct for
color errors in the optics. A combination of these three features for the
eyepieces will enhance the ability to visualize microscopic images.
• Th e eyepieces should attach to an interchangeable, binocular head that
is inclined to + 30o 45o. Working comfort can be improved with a
tiltable head that enables the operator to select the most suitable viewing
position. An interpupillary distance control compensates for diff erent
spacing between people’s eyes. Cont. on page 8
Lab-Oratory / March 2006
8
adjustments of the slide. Dovetail mount
construction and ball-bearing slideways
are recommended.
• A dust cover should be included in the
purchase.
• It is important to purchase the instrument
from a reliable source. Th e manufacturer
should provide detailed specifi cations for
its microscopes.
Before making the fi nal decision, “test drive”
one or more of the microscopes that you are
considering. Use a familiar slide to determine
if the image is clear and crisp at all magni-fi
cations. Assure that the placement of the
controls is convenient and comfortable.
Obtain a printed warranty card with your new microscope and return it
promptly so that your instrument can be registered by serial number and date
of purchase. With proper care and regular maintenance and service, your
purchase should be usable for many years.
Lind, J. How to Buy the Right Microsocpe. Available at: http://www.greatscopes.com.
Accessed January 3, 2006.
Davidson, M., Abramowitz, M. and Florida State University. Molecular Expressions, Optical
Microscope Primer. Available at: http://www.microscopy.fsu.edu/primer. Accessed January 3, 2006.
Article submitted by Colleen Miller, BS MT (ASCP),
Laboratory Improvement Consultant, NCSLPH
Microscope cont. from page 7
A Case Study
A 10-week-old female was examined by
a pediatrician after developing a fever
and amber-colored urine. Th e infant’s
temperature was 103.7 F (39.8 C).
Laboratory tests included a white blood
cell count of 4,600ų/L (normal range:
9,000 – 30,000 ų/L) and hemoglobin
of 8.7 g/dL (normal range: 10.0 – 14.0
g/dL).1 She was admitted to a local
hospital for treatment and further evalu-ation.
Additional laboratory studies
included cultures of blood, urine, and
cerebrospinal fl uid (CSF), a complete
blood count (CBC) and urinalysis. Th e
urine tested positive for bilirubin. A
decline in hemoglobin (6.6 g/dL) was
demonstrated on the CBC. Th e infant
was started immediately on intravenous
antibiotic therapy.
Two days later, a peripheral blood smear
was reviewed and reported to contain
malaria parasites. After obtaining and
staining additional blood fi lms, the lab
identifi ed the infecting organism as
Plasmodium malariae. Treatment with
the anti-malarial drug chloroquine was
initiated and the infant was transfused
with two units of packed red blood
cells. All bacterial cultures obtained on
admission were reported to be negative.
Th e infant’s clinical condition improved
and she was discharged from the hospital
after completing chloroquine treatment.
Th is is a case of congenitally acquired
malaria, which is rarely reported in
the United States. Th e infant had not
traveled or received blood products be-fore
hospitalization. Her parents had
immigrated from the Democratic Repub-lic
of Congo (formerly known as Zaire)
about seven years earlier. Th e infant’s
mother had been treated for malaria
before leaving the Congo.
P. malariae can persist in humans as an
asymptomatic erythrocytic disease for
many years following an untreated or
incompletely treated primary infection.
Pregnancy can make women more sus-ceptible
to infection with malaria and
might allow a suffi cient increase in the
density of parasitemia for passage of
parasites though the placenta to the
fetus1.
Th is unusual case should alert health-care
providers to consider a diagnosis of malar-ia
in sick infants with unexplainable fever.
Obtaining travel and residency history on
the child’s parents and close relatives may
aid in the diagnosis, although the absence
of recent foreign travel may not rule out
malaria. Blood fi lms must be examined
on the patient before a defi nitive diag-nosis
for malaria is possible. After the
infant’s diagnosis, the mother was retested
and retreated for the disease.
1 CDC Morbidity and Mortality Weekly Report
(MMWR). Congenital Malaria as a Result
of Plasmodium malariae – North Carolina, 2000.
pp. 164-165. Atlanta, Georgia. March 1, 2002.
Article submitted by Colleen P. Miller,
BS MT(ASCP), Laboratory Improvement
Consultant, NCSLPH
Following the beat of a dif-ferent
drummer? When it
comes to phlebotomy, march-ing
to an old tune… or your
own tune… could lead to disas-ter
for you, your employer, and
the patients you serve. Why not let the
industry’s standards call your cadence? Th e
beat is set for you by established standards,
literature and regulations. All you have to
do is keep in step and encourage your blood
collection personnel to do likewise. If we
march together, North Carolina Public Health
might just fi nd the rest of the nation falling in
line behind us!
Who’s Calling Your Cadence?
Each of us likes to think of ourselves as unique. Whether it is in regard to
our knowledge, skills, talents or appearance, some of us take great pride in the
fact we hear and follow the beat of a diff erent drummer. But when it comes
to collecting blood specimens, it is imperative that the standards we follow are
documented, current, consistent and based on sound information. One needs
to look no further than the industry’s standard of care for phlebotomy to fi nd
its cadence.
Th e standard of care for phlebotomy is loosely defi ned as what a well-trained,
competent and reasonable phlebotomist would do in the
performance of his/her blood collection duties. Th e recognized standards for
phlebotomy are collectively based on current literature, regulations, and expert
opinion. One such source is the Clinical and Laboratory Standards
Institute (CLSI), an international, non-profi t organization that promotes the
development and use of voluntary consensus standards and guidelines within
the health care community. CLSI documents serve as the gold standards
for blood collection procedures worldwide. Two of the institute’s most
recently revised blood collection standards include H3-A5, Procedures
for the Collection of Diagnostic Blood Specimens by Venipuncture, and
H4-A5, Procedures and Devices for the Collection of Diagnostic
Capillary Blood Specimens. Since both documents have been recently revised,
the “drummer” is the same but the beat has changed. It is the responsibility
of laboratory managers and employers everywhere to ensure their blood
collection staff keeps in step.
In 2006, the North Carolina State Laboratory of Public Health will
begin addressing this need facing local health departments and other
public health agencies through a new program, Th e North Carolina
Public Health Phlebotomy Initiative. Based on the rhythm set by
CLSI, reputable texts and experts in the fi eld, this program will assist local
agencies in establishing their own competency assessment programs for blood
collection personnel. Qualifi ed evaluators regularly assessing staff with blood
collection duties is simply good risk management in the prevention of
phlebotomy-related injuries and subsequent legal liability. Ensuring that
proper blood collection protocols and procedures are being consistently
followed also promotes improved specimen quality, which translates into
lower specimen-rejection rates and more accurate patient results.
Needle Points
By Lisa O. Ballance, BSMT (ASCP)
EDITORIAL
Lab-Oratory / March 2006
9
The Safety Corner
OSHA’s Bloodborne Pathogen Regula-tion
is an essential part of laboratory
safety. Th is regulation applies to all
persons who may anticipate contact with
blood or other potentially infectious
materials. Th is consists of contact with
skin, eyes or mucous membranes, or
contact from piercing the skin. A key
element of this regulation is the creation
of a written Exposure Control Plan, which
describes, in detail, how the employer
will protect the employee from potential
exposure. In upcoming Lab-Oratory
publications, we will discuss the diff e-rent
elements that provide the framework
for an Exposure Control Plan. Th ese
include:
• Exposure determination
• Employee education and training
• Control measures, including
engineering controls and work
practice controls
• Vaccinations
• Post-exposure evaluation and
follow-up
• Waste disposal
• Tags, labels and bags
• Housekeeping and laundry practices
• Record keeping
Stay tuned for future articles on all you
ever wanted to know about OSHA’s
Bloodborne Pathogen Regulation and the
Exposure Control Plan!
Article submitted by
Kristy O’Briant, BS,
Laboratory Improvement Consultant,
NCSLPH
Newborn Screening
Form Training
After many months of development, a new
educational resource is now available on the
web. Th e Laboratory Improvement Branch,
in conjunction with the Newborn Screen-ing
Program, has deve-loped a PowerPoint
educational program about the collection of
Newborn Screening fi lter form specimens.
Go to the State Laboratory of Public Health
web site (http://slph.state.nc.us/) and locate
“Form Training” under Newborn Screening.
Th e program takes participants through fi lling
out the fi lter form properly, collection of the
blood spot specimen, and mailing procedures. It is an excellent tool for new
staff as well as a refresher for experienced nursery and laboratory personnel.
Colleen Miller, BS MT(ASCP)
Laboratory Improvement Consultant
NCSLPH
Lab-Oratory / March 2006
10
Lab Week 2006
April 23-29, 2006
Th e 11 sponsoring organizations for this
year’s NMLPW event are:
American Society for Clinical
Laboratory Science
American Society for Clinical
Pathology
American Association for Clinical
Chemistry
American Association of Blood Banks
“ National Laboratory week has grown
increasingly important over the years
as laboratory personnel celebrate their
professionalism and are recognized for
their eff orts on behalf of their patients
and clients. Often, laboratorians use
this time to inform and educate medical
colleagues and the public about the
medical laboratory. Since laboratory
professionals often work ‘behind the
scenes,’ few people know much about the
critically important testing that labora-torians
perform every day. Lab Week is
also an excellent opportunity to promote
laboratory professions, recruit students
to the fi eld, thank technologists and
technicians, build morale, and gain
visibility for the laboratory throughout
the institution and the community.”
—American Society of Clinical
Pathologists
American Medical Technologists
American Society of Cytopathology
American Society for Microbiology
Association of Public Health
Laboratories
Clinical Laboratory Management
Association
College of American Pathologists
National Society for Histotechnology
For more information and lab week
celebration ideas, go to:
www.ascp.org/general/labweek/
www.ascls.org/conferences/2006NMLW/
index.asp
www.amt1.com/site/epage/
9363_315.htm
Lab-Oratory / March 2006
11
UPCOMING EVENTS . . .
March 30, 2006 PHTIN: CLIA Updates presented by Karen Sanderson of DHHS Facility Services
(more information to follow)
April 5, 2006 Advanced Microscopy: Viewing and Reviewing*
April 6, 2006 Wet Mount*
April 18, 2006 Clinical Packaging and Shipping*
May 11, 2006 Food-Borne Pathogens*
May 23, 2006 Policy and Procedure Writing*
June 7-8, 2006 Lab Methods in the Diagnosis of Gonorrhea*
June 20-23, 2006 Bacteriologic Methods in the Analysis of Drinking Water*
July 18, 2006 PHTIN: Group B Strep, presented by Melissa Miller, PhD, of UNC Hospitals,
and Sheila Cromer of Women’s and Children’s Health (more information to follow)
*Additional information for laboratory improvement workshops and applications can be found
on the SLPH web site at http://slph.state.nc.us/LabImprovement/default.asp.
Lab-Oratory / March 2006
12
Who’s New in Public Health?
We have many newcomers to North Carolina’s Public Health arena since our last publication. Here
are a few to whom we would like to personally extend a warm welcome. To all others not mentioned,
welcome to you as well. We hope you will continue to stay with us and will fi nd your job both enjoyable
and fulfi lling as you serve the citizens of North Carolina.
Macon County Health Department welcomes
Debbie Reeves, BSMT; Helen Cunningham, MT;
Melissa Leatherman, BSM; and Leigh Tabor, CPBLT, EMT.
---------------------------------------------------------------------------
Rowan County Health Department welcomes
Cassi Barringer. An MLT from Rowan Regional Hospital
in Salisbury, Cassi joined the Rowan County team
on October 31, 2005.
---------------------------------------------------------------------------
Guilford County Public Health has hired several new
employees, including Melissa Kindley and Bert Arico.
---------------------------------------------------------------------------
Mecklenburg County Health Department’s new employees
include lab supervisor Rebecca Drechsel, MT (ASCP);
Beth Goad, MT (ASCP); Christina Velez, MT (ASCP);
and Lea Ann Nhoybouakong, MLT (ASCP).
---------------------------------------------------------------------------
Person County Health Department has a brand-new
medical lab technologist, Laura Whitfi eld. Laura is a
UNC-CH graduate and joined the Person County team
on January 23, 2006.
---------------------------------------------------------------------------
Albermarle Regional Health Services (consisting of seven
counties—Pasquotank, Perquimans, Chowan, Bertie,
Currituck, Camden, and Gates Counties) has undergone
quite a few changes over the last couple of years.
Welcome to their new lab manager Barbara Danchise;
Bobbie Jo White, MLT II; and Pam Luton, MLT I.
Th e North Carolina State Lab of Public Health would also
like to welcome a few of their own.
Welcome to Mr. Zhong Zhang, in the Radiochemistry group.
Zhong’s responsibilities as Chemist I include Radiochemistry
QA Offi cer and assistant Radiation Safety Offi cer. He joins
us from the Inner Mongolia region of China and graduated
from N.C. State University with a master’s degree in
environmental engineering and chemical engineering.
Julie Long is a Micro Lab Tech and joined the Environmental
Microbiology lab on October 3, 2005.
Th e Serology Unit welcomes Benita Artis.
Finally, the Newborn Screening/Clinical Chemistry
department welcomes several newcomers, including
Mary Ann Klyne (GAL), Tinika Watters (FIA), Lynn Beverly
(HemaChem), Rosanne Rimbey (Clerical), Angelia Heybroek
(Clerical), and Marcia McGinnis (Clerical).
Lab-Oratory / March 2006
13
Kudos!
We would like to
extend hearty congratulations to Lisa Ballance, Re-gional
Laboratory Consultant out of Fayetteville for being
chosen as North Carolina Public Health Association’s Laboratorian of the Year, 2005.
Lisa is a dedicated individual whose visions have become a reality for the betterment
of those she serves.
In the spring of 2005, the NCSLPH began naming a State Lab Employee of the
Month. Employees are encouraged to nominate co-workers who demonstrate great
work ethics and always lend a helping hand. Th e 2005 winners included Lee Outlaw,
Microbiology; Lou Harwood, Virology/Serology; Larry Th omas, Administration; Leslie
Wolf, Administration; Alisa Alston, Virology/Serology; Karson Turner, Microbiology
and Paul Burt, Administration. Susan Weavil in our Newborn Screening section was
recognized as our 2006 January Employee of the Month and most recently, Alex
Huff man in our IT department won for February. Congratulations to all of our
winners and thank you for your contributions to the NCSLPH!
Cora Gibson and Colleen Miller in NCSLPH Lab Improvement deserve a big round of
applause! Cora and Colleen attended an extensive two-week course and graduated as
N.C. Certifi ed Training Specialists in December 2005. Congratulations to both!
Please contact Kristy O’Briant at (919) 733-7186 or kristy.obriant@ncmail.net if you
would like to recognize a co-worker at your facility.
Lab-Oratory / March 2006
14
Learning On-Line
Due to rapid advances in medical technol-ogy,
continuing education is vital to laborato-rians.
It is important to review information
previously learned to maintain current skills,
and continuously learn new information in
order to provide the best possible care for
patients. Often, employers require a certain
number of hours of continuing education
each year as well. With budgetary and staffi ng
constraints, this is sometimes diffi cult to
achieve. Fortunately, there are many sources
of laboratory continuing education, many
of them FREE or very inexpensive, on the
Internet. We will be sharing some of our
favorites each quarter in the Lab-Oratory.
Two such sites are
www2a.cdc.gov/stdtraining/self-study/
default.asp
www.publichealthgrandrounds.unc.edu/
We have provided the links to these sites because they have information that
may be of interest to our users. Th e State of North Carolina and the N.C. State
Laboratory of Public Health do not necessarily endorse the views expressed
or the facts presented on these sites. Further, the State of North Carolina and
the N.C. State Laboratory of Public Health do not endorse any commercial
products or information that may be presented on or could be advertised on
these sites.
Holly Lee, Virology/ Serology; Patty Atwood, NBS/ CC; Susie Lavender, Cytology; Brenda Webber, Cytology
Jennifer Anderson, Lab Improvement; Kristy O’Briant, Lab Improvement; Colleen Miller, Lab Improvement
Crystal Poppler, Lab Improvement; Tony Ivosic, QA; Debra Springer, Microbiology
E D I T O R I A L
b o a r d
Lab-Oratory / March 2006
15
Microbiology Word Search
P B N H C E J O T M A C S C L
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C C P I N I R C K I T F P B N
A R D T D A R B X E I B S O P
E O Y A I O R O O T B A I R M
I G S S S D T F K N I C S E C
Y E A C T O O E A S O I F A N
P J O H X A V G F S T L A N E
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E P R O T E I N S Y C I C S I
V I O L E T S R Y N C O P U T
N I A T S Y A D N A C A J R N
M U L L E G A L F C E Y N I A
A W R X A B E D I X O I D V G
F L L L Y O N K V X N L R V S
AGAR
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Created by Puzzlemaker at DiscoverySchool.com
Lab-Oratory can also be found on the web at http://slph.state.nc.us/ under “Lab Improvement”.
Laboratory Improvement
P.O. Box 28047
Raleigh, NC 27611
State of North Carolina • Michael F. Easley, Governor
Department of Health and Human Services • Carmen Hooker Odom, Secretary
Division of Public Health • www.dhhs.state.nc.us
N.C. DHHS is an equal opportunity employer and provider.
03/06
“Dear Lab-bey…”
If you have a technical laboratory question
that you would like to have answered
please submit it to:
Jennifer.A.Anderson@ncmail.net.
The answer to your question may be
featured in the next edition of Lab-Oratory.