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SCOTTISH CLINICAL VIROLOGY CONSULTANTS GROUP

APPROVED MINUTES OF MEETING

Wednesday 12 June 2013 (10am-1pm) – Board Room, Perth Royal Infirmary

1. / Welcome and Apologies / Actions
Welcome (Present)
Ingó Johannessen (Chair; IJ), Celia Aitken (CA), John AG Bremner (JAGB), Roger Evans (RE), Paul McIntyre (PMcI), Pamela J Molyneaux (PJM), Sandeep Ramalingam (SR – by teleconf), Kate Templeton (KET), Emma Watson (EW), Eleri Wilson-Davies (EWD – by teleconf), Dave Yirrell (DY)
Apologies
Kate Cuschieri (KC), Kirstine Eastick (KE), Craig Ferguson (CF), Rory Gunson (RG)
2. / Draft Minutes of Last Meeting
Draft minutes of last meting (6 March 2013) accepted as accurate record; IJ will forward to SMVN for uploading on website. / IJ
3. / Matters Arising
3.i Blood-Borne Viruses (BBV)
3.i.i HBV (and HAV) testing/vaccinations in the sexual health setting
PMcI had circulated an overview of options for an approach to HAV IgG and HBcAb IgG testing in the GUM setting alongside estimated costs. Considerations included the likelihood of HBsAg-pos/HBcAb(IgG)-neg results in the GUM setting (deemed to be very rare) as well as approaches adopted already by the Scottish laboratories. Following discussion, it was agreed to adopt option 1 (see document). This approach entails testing all GUM patients for HBcAb only but adding HBsAg testing to any HBcAb-pos samples. All patients would be offered the first dose of a combined HAV/HBV vaccine at time of blood sampling followed by further 2 doses or, in HBcAb-pos individuals, a further dose of HAV vaccine only. The estimated cost of this approach is 71K, which represents the cheapest option as well as being in line with NaSH requirements. PMcI/KET will inform Scottish BASHH and SHIVAG of the adopted approach. Furthermore, it was agreed that the Scottish laboratories would supply PMcI with data to ascertain the nationwide situation as regards HBsAg/HBcAb status of GUM attendees. / PMcI/KET
All
3.i.ii Universal HIV testing
PJM informed the meeting that Grampian GPs were now expected to offer BBV screening to all new patients registering with their surgeries irrespective of context (eg, background). At least one Grampian surgery has embarked on such an approach, which clearly will have major implications for the ARI laboratory in terms of logistics, resources and cost. CA explained that such an approach is being adopted at GGH with regard to immigrants. PMcI informed that Tayside focuses its BBV test efforts on areas with high deprivation scores. IJ stated that universal HIV testing was being considered for Edinburgh acute receiving units as a result of Lothian (uniquely in Scotland) being assessed to have reached the 2/1,000 HIV infections threshold (as shown schematically in the ‘HIV in the United Kingdom: 2012 Report’ published by HPA; IJ to circulate) underpinning current guidance on when to trigger universal HIV testing. Discussion took place about the robustness of the 2/1,000 figure as well as the likelihood of different geographical areas within Lothian having reached this threshold. Interestingly, KET informed that universal HIV test approach data from Liverpool presented recently at CROY had failed to identify a significant number of new HIV infections.
The meeting agreed for CA/KET to recommend to HPS increased granularity of current HPS data on HIV prevalence in Scotland (see the 2012 Report above) with a view to consider focusing HIV/BBV testing on postcodes shown to have the biggest challenges (in liaison with HPS).
The meeting discussed the matters above at considerable length with emphasis on resources and cost implications as well as expressing concern over the decision-making process behind such approaches being adopted – at times without any consultation with the Scottish Virology Consultants body. As a result, the meeting agreed that IJ seek input and assessment from the HPS Medical Director’s Office of how best to ensure SCVCG representation in such processes.
CA will forward GGH’s document on BBV testing in immigrant populations in GGC.
PJM will discuss the Grampian approach outlined above with Prof Goldberg as well as Dr Martin Donaghy of HPS to seek insight into the business case behind such measures.
CA will forward a draft of indicator conditions that the Scottish laboratories may wish to adopt as a reference to when to add an automated reporting comment suggesting additional HIV testing. / IJ
CA/KET
IJ
CA
PJM
CA
3.i.iii BBV VL reporting
The meeting discussed BBV VL reporting and agreed that HBV and HCV VL assessment by PCR should incorporate international standards and be reported in IU/mL. Both Grampian and Tayside report HBV and HCV VL in both numerical values (rounded up to 2 significant digits) as well as log10. The meeting agreed to aim for such an approach across Scotland with a view to provide more clinically meaningful results to users. As for the IT aspects of such log10 reporting, PJM will assess whether ARI’s lab system (Apex) is able to convert assay values automatically into log10 values since this would have implications for other laboratories using the same system.
Whilst it was deemed helpful clinically at this time to maintain HIV VL reporting in c/mL, Tayside offered to trial reporting HIV VL in both c/mL as well as IU/mL for a period of 3 months and report their experience back to SCVCG (PMcI/DY).
The meeting expressed concern over detectable BBV below assay cut off values but agreed that such results should not be repeated as a matter of routine. Rather, they should be reported as such findings - ie, detectable but below cut off. / PJM
PMcI/DY
3.ii Gastroenteritis Viruses
3.ii.i Hepatitis A virus typing
CA informed the meeting of an HAV outbreak involving 4 cases in the West of Scotland. All had genotyped as HAV 1b. The index case (an adult) suffered abnormal LFTs and tested HAV IgM-pos but (interestingly) was not jaundiced. There was no travel history of note, and the original source of virus is not known at this time although possible food sources are being considered.
The meeting discussed the outbreak above and noted that most laboratories did carry out HAV IgM testing in the context of raised LFTs once HBV and HCV had been excluded - although there was not always an appreciation of the risk to older generations as a result of increased hygiene standards and falling numbers of older individuals that are immune to HAV.
It was also noted that low-level HAV IgM results may present difficulties of interpretation (and confirmation; HAV PCR plays a role) to the laboratories – although significance should be tied in with LFT assessments as well as clinical picture (in particular, jaundice – although the index case above did not present in such a manner). GGH is pursuing HAV genotyping of all acute HAV cases in Scotland this year and the Scottish laboratories should forward any such samples to RG for assessment. / All
3.ii.ii Hepatitis E virus typing and business case
IJ explained that he had submitted the SCVCG HEV Business Case to Camilla Wuiff at HPS for assessment of best route to travel and received rejection for specific funding as the matter was not deemed to warrant establishment of a reference service. Clearly, this was not the intention of the SCVCG so some misunderstanding had occurred. As a way forward, SR will amend the wording of the document with a view to ensure it reflects that funding is being sought to enhance each laboratory’s HEV serological diagnostic service and then forward to Alison Smith-Palmer for assessment. SR will report back to SCVCG in due course. / SR
3.ii.iii Norovirus study and Report
KET informed the meeting that the Norovirus Report had been amended and submitted to Lorna Willocks at SGHD (now back at Lothian HPT). Whilst the document is somewhat aspirational, it sets out the agreed road to travel for enhanced norovirus diagnostic service across Scotland although the meeting recognised the lack of evidence for an impact of norovirus diagnostics on clinical service. However, the meeting agreed that rapid norovirus diagnostic service supports infection prevention and control (IPC) measures and hospital management. As such, the approach supported clinical governance.
Major resource questions remain and testing should only proceed when results can be acted upon. As a result, the meeting agreed that the Norovirus Report should go to the SMVN Steering Group for assessment with a view also to seek input from the HPS HAI Task Force (IJ/KET). The meeting recognised the need to gather further data to inform a future approach with particular reference to views of users of such an enhanced norovirus diagnostic service, the resources required by individual laboratories (incl cost) to provide a PCR-based rapid testing service and the resource implications for clinical service to ensure appropriate handling of results (eg, impact on IPCN services). / IJ/KET
3.ii.iv Rotavirus strain diversity
HPS has made funding available for assessments of rotavirus strain diversity. PJM informed that an UoA colleague has in place an appropriate assay to address the issue. As a result, PJM will co-ordinate such assessments of Scottish stool samples collected between Sept 2012 and May 2013. To this end, the Scottish laboratories should forward such samples to PJM. / All
3.iii Rash Viruses
3.iii.i Measles IgG testing in the OHS setting revisited
IJ informed that a letter had gone out from Dr Martin Donaghy of HPS to Grampian OHS following input from SCVCG and PHE in an effort to address concerns over the use of measles IgG in determining measles immunity in an exposed individual/HCW without documented evidence of having received 2 doses of MMR (at least 1 month apart). The letter is in line with previous SCVCG discussions and UK immunisation guidance (the ‘Green Book’).
3.iii.ii Enterovirus/Parechovirus testing
KET stated that RIE submits enterovirus/parechovirus data to PHE’s WHO reference laboratory every 6 months. Samples include CSF, stool, etc (in line with UK SMI P1i4: ‘Surveillance of Polio in the UK’ – IJ to circulate). The approach – which entails sequencing of VP1 followed by VP4 (at RIE and in Prof Peter Simmond’s laboratory) - is not funded and KET may approach HPS to seek such support to cover consumables at least. This service is open to the other Scottish laboratories that should submit appropriate samples (see above) to RIE. Recent analysis has demonstrated parechovirus type 3 as well as a variety of enterovirus types in CSF – but, thankfully, no polio.
EW reminded SCVCG that the tick season had started in Scotland and that borrelia could be the cause of any case of lymphocytic meningitis (a prodrome of up to 12 days before frank symptoms/signs has been observed). Currently, there is much tick around in all of Scotland. For diagnosis, the Raigmore laboratory requires serum sample (serology) and CSF (PCR). The tick season is expected to last well into autumn. / IJ
3.iv Respiratory Viruses
3.iv.i Novel Coronavirus
Middle East Respiratory Syndrome – MERS (and MERS-CoV): There have not been any recent major developments but vigilance is warranted.
3.iv.ii Influenza A H7N9
Similarly, there have not been any recent major developments but vigilance is warranted.
Under this heading, EW explained that CPA had raised concern (non-conformity) over the Raigmore laboratory not receiving respiratory swabs in lysis buffer. This is not the general approach in Scotland with laboratories having carried out individual risk assessments (in liaison with HSE) to support handling of respiratory swabs received in VTM in class 1 hoods in Cat 2 laboratories. Similar approaches are employed for sputa although GGH handles sputum samples in a Cat 3 laboratory, which is not workable for most laboratories. Lysis buffer is primarily reserved for sampling patients at high risk of being infected with highly pathogenic respiratory agents (eg, H5N1, H7N9, MERS-CoV) and such reagents should be available in units that might receive such patients (eg, A&E, Infectious Diseases, etc). EW will draft a response to CPA and circulate to SCVCG for comments in order to align the Raigmore approach to that of other Scottish laboratories. / EW
3.iv.iii Influenza B and Resistance
KET informed that HH is carrying out a typing study in liaison with HPS.
3.v Viral Haemorrhagic Fever (VHF)
SR outlined a recent ?VHF case in Lothian and the lessons learned – both those specific for RIE as well as more general ones.
For RIE, lessons include obtaining further clarification of the role of individual staff grades in handling and shipping samples as well as ensuring appropriate packaging is kept in designated locations (HH/SR).
In more general terms, SR raised the matter of ID colleagues packaging and shipping samples directly to the Rare and Imported Pathogens Laboratory (RIPL), HPA Salisbury (Porton Down) with a view to retrospective assignment of laboratory numbers – although the necessity for urgent malaria testing locally might challenge that approach in some centres unless it was agreed that malaria be assessed by RIPL.
As for couriers, it seems that most send samples by road although Marken (Edinburgh-based) makes use of airplanes as well.
SR also raised the role of continuous learning – perhaps through LearnPro – to ensure all staff are aware of procedures aimed at dealing with ?VHF cases. The meeting agreed that this was a good idea, and HH/SR will draft such a module in liaison with SCVCG and NHS Scotland.
The role of the Imported Fever Service (IFS) was discussed and the meeting agreed that this needs to be clarified with reference to if/when their advice does not align with local risk assessments as it seems that IFS routinely recommends shipping and testing of samples. Such a routine approach is very costly and perhaps not always the most appropriate direction of travel. Currently, the service is seeking feedback through its website, which SCVCG members can use to make any comments. Also, SR pointed out that during the recent Lothian ?VHF case, communications between IFS and RIPL staff had been by email only that the RIPL BMS staff had not picked up until ‘phoned directly by SR, which had caused an unnecessary delay.