executive summary meeting report...report of the rotavirus laboratory technical working group...

Report of the Rotavirus laboratory technical working group meeting, 17-18 November 2014

EXECUTIVE SUMMARY MEETING REPORT

WHO-Coordinated Rotavirus Surveillance Network

Laboratory Technical Working Group Meeting

17-18 November 2014 Rio De Janeiro, Brazil

Hotel Marina Palace


Meeting Report of the laboratory Technical Working Group of the

WHO Rotavirus Surveillance Network Rio de Janeiro, 17-18 November 2014

EXECUTIVE SUMMARY Background Following recommendations made at the Global Invasive Bacterial Vaccine Preventable diseases (IB-VPD) and Rotavirus (RV) Sentinel Surveillance Meeting, Geneva 2011, WHO established a laboratory technical working group (TWG) to assist with technical guidance needed to strengthen laboratory capacities within the Global Rotavirus Surveillance Network, improve the quality of diagnostic and genotyping data, standardize lab methods/training modules and improve the Quality Assurance (QA)/Quality Control (QC) systems. Members of the TWG include WHO Global and Regional Laboratory coordinators and selected technical experts in the field of rotavirus surveillance from the WHO Global Rotavirus Surveillance Network. The previous in-person meeting was held in Bangkok in November 2013, which reviewed progress, discussed issues with data quality, the results of the five year strategic review and the possibility of leveraging parts of the network for informing other issues of importance in diarrhoeal diseases. In 2014, the group met via conference call in April, July and September to review the progress made following the 2013 strategic reviews conducted for both rotavirus and the invasive bacterial diseases networks in all WHO regions, and to refine the performance indicators and define the timelines for reporting. Several issues were identified, and while progress was made, some items that required more detailed discussion were deferred to the in-person meeting. This meeting was held November 17-18, 2014 in Rio de Janeiro. Meeting objectives

Review global and regional updates

Identify areas of improvement and assess quality of rotavirus 2013 laboratory data

Assess progress of the implementation of quality assurance/quality control programmes

Review preliminary results of the Bill and Melinda Gates Foundation grant to leverage the Rotavirus network and allow additional enteric pathogen detection

Review additional and optimal use of laboratory procedures at different levels of the network.


Background documents in participant file

October 2014 Update on Status of Action Points of the 2014 WHO Management Framework for the Global Invasive Bacterial Vaccine Preventable Diseases (IB-VPD) and Rotavirus (RV) Sentinel Hospital Surveillance Networks

List of core variables for genotype data reporting from regional and national laboratories

Expectations for level of performance by the sites and laboratories, including the Regional Reference lab (RRL) performance indicators

User manual for the web-based Rotavirus Surveillance Reporting System from WPRO.

Meeting structure 1. Global and Regional Updates The rotavirus (RV) and IB-VPB sentinel hospital surveillance networks transitioned to WHO in 2008 and completed 5 years of activities in 2013. During the Strategic Review conducted by WHO and partners in 2013, although the objectives of the rotavirus surveillance networks were met in terms of documenting disease and describing disease epidemiology for the pre-vaccine period in most regions, and for assessment of impact with special studies in early introducing regions, it was recognized that there was a need for improvement in order to ensure cohesiveness in the separate regional networks, to use data for real time monitoring, and prepare to conduct studies on vaccine impact, where possible. Recommendations were laid down for i) reporting case level data in standard format, linking laboratory results with the clinical and epidemiologic data on the same patient, ii) frequency of reporting, iii) defining characteristics and testing and reporting requirements of a clinical site and iv) standardization of sample selection for genotyping to examine country-level genotype distribution, in addition to distribution at regional and global levels. Although the strategic review recommendations were not applicable to 2013 data given that they were recommended in Q4 2013, it was encouraging to see that in supported networks in Gavi eligible countries, there was a high proportion of sites meeting performance indicators. These data were also presented to WHO’s informal technical advisory group for new vaccines surveillance at their in-person meeting in October 2014. Recommendations for actions to be undertaken for discussion by the laboratory technical working group were highlighted. These included:

Resolve issues related to sample transfer and MTAs

Linkage of laboratory and clinical data

Determination of core elements for non-Gavi sites and laboratories

Standardize system for performance monitoring and accountability at each level of the network where support is provided


Review of the progress indicated that 21% of genotyping information could be linked to case-based data and this will provide a baseline against which future activity can be measured. There has been a large increase in the number of laboratories participating in the global laboratory’s EQA program, from 9 in 2011 and 2012 to 82 participant labs in 2013, and the majority of laboratories are performing well (96% passed EQA in 2013). Overall, the data presented by the WHO HQ demonstrated that improvement was seen in all regions following the strategic review. Impressively, of 50 suggested actions for 2014, work was completed or ongoing for 46. This responsiveness on behalf of the network had resulted in

Improved monitoring of performance at all levels

Improved data quality and timeliness of reporting

Improved selection criteria for the RV positive samples to be genotyped

Improved QC at regional level

The regional networks presented data on site and laboratory participation, the numbers of children recruited, samples tested and genotyping and on performance in the proficiency testing panel for ELISA and genotyping. Overall, most Gavi-supported laboratories and regional networks are working well and the reporting of case based data is underway. There are a few remaining challenges in some regions with regard to some site- and country-specific issues in terms of sample shipment and reporting of data. The use of performance indicators for evaluation of site and laboratory performance has begun, but the need to more consistently use the indicators and to standardize updates and presentation formats across all regions in the future was highlighted. In keeping with the need for quality data, for future analyses estimating RV positivity data only from sites that report for all months of the year will be used. The final recommendations were:

• Emphasize importance of data linkage (genotype and surveillance data) and use of unique ID number

• Emphasize importance of country ownership and transition if Gavi funds comes to an end

• Consider inter-regional meetings and experiences sharing • Early planning so when funds are available implementation can start • RRL Performance indicators will be reported in July for the previous year

2. Improve quality of RV laboratory data The analysis of data from 2013, showed that case-based data was received from 7/9 Regional Reference Laboratories (RRLs) and 4 National Laboratories (NLs), with 3 RRLs reporting data in standard agreed form. Aggregated genotype (GT) data was received from 2 regions, AMR and SEAR. Overall, RV GT data is relatively easy to consolidate and upload into regional/global lab database because of the number of variables are limited and the drop-down options are optimal. QC data was received from


some labs/regions, which is not required for reporting to HQ, but is needed at the regional level. Data analysis included genotype distribution by country, region and globally for all genotypes with more than 1% prevalence. Common errors and missed fields were identified and the necessity for completion of all fields in the standard reporting form were discussed. The recommendations following discussion were the following:

• Use of the standard form for reporting the GT • Completion of all data fields • RRL to only test the samples that have Unique ID number to improve linkages • Consolidation of data at RRL and RO • RRL to have access to individual country databases for a better understanding of

data generated at their level and tackling any discrepant results in timely manner • QC data to be updated at the regional level and should include confirmation of

negatives and GT; QC data not to be included in the reporting form • WHO to draft data analysis and interpretation guidelines to include laboratory

component (RV positivity to be analysed with caution and reflect inclusion criteria).

3. Quality Assurance/Quality Control The 2014 Quality Assurance survey using lyophilized non-infectious proficiency testing (PT) panels of 10 samples each conducted by the CDC Global Reference Laboratory (GRL) was in progress and the results so far indicated a high level of proficiency in the lab network. So far, samples had been shipped or handed-off to 115 laboratories (10 RRLs, 86 NLs, 17 Provincial Laboratories in China, and 2 Referee Laboratories at the University of Liverpool and NICD, South Africa). All laboratories who had reported data until October 2014 had greater than 80% score for EIA and GT. In discussion, the work by the GRL for overcoming of the challenges of specimen shipment was appreciated, as well as the scale of the exercise to validate the use of the lyophilized, non-infectious PT panels. There was discussion of whether NLs should be expected to correctly identify challenging samples in the PT panels. There was further discussion on the use of QA data to determine the validity of submitted surveillance data and the timing of corrected reporting and corrective actions relative to the cycle time of the PT, because long cycle times do not permit labs to implement corrective actions within the same year. Data from the ongoing confirmatory testing of samples sent to the GRL from RRLs was also presented and showed a high level of concordance (>95% of all labs) and was considered a useful exercise which should be continued. The recommendations following discussion were:

• Rather than the GRL taking responsibilities for all shipments, the GRL should arrange regional distribution in coordination with RO and RRL

• Panels should be shipped in May to ALL regions • No changes in panels development and strategy • More emphasis for the role of the referee labs to adjust the scoring


• If lab fails the EQA (both EIA or GT), then 50 samples need to be sent to RRL for QC before data is accepted from that site; These samples will include at least 10 EIA negatives and 25 EIA positives. WPR and EMR have already a QC system in place where NLs send 40 EIA positives and 10 EIA negatives to RRL.

• RO and RRL to prioritise site visits and corrective actions for labs who fail EQA and QC

• RRL scoring for the EIA and GT parts of the EQA to be increased to 90% and 80% target will continue for sentinel sites and NL.

Regarding the confirmatory testing process, the recommendations were

• Continue the exercise once a year and involve other labs in the process: in 2015, 4 labs will receive samples from the 9 RRLs. These labs are:

• SEAR, WPR (Australia), AFR (NICD) and CDC GRL. It was agreed that EUR, EMR and AMR RRLs will send QC samples to CDC GRL, AFR RRLs will send samples to NICD

• Inter-regional QC is very important • Structure the report for feedbacks to reflect level of testing and re-testing

(methods used, baseline, concordance at each level assessed) • QC monitoring between NLs and RRLs to continue at regional level • Sequencing of 10% or 5 of each GT at each RRL

To improve the quality control systems between the RRL and labs in countries, it was further recommended that:

• EIA data (OD values) should be monitored during site visits • RRLs should provide internal quality control (cultured RV) for EIA to all sentinel

sites and National labs (NL) such that in each run an internal QC is included. 4. BMGF grant implementation to leverage RV network The University of Virginia investigators presented experience to date from the use of the Taqman Array Cards (TAC) with several of the GEMS and other sites (MAL-ED Study). The training and plans of testing were described. Preliminary data of year 1 from the testing done in SEAR and WPR was presented. The data emphasized the need for samples of good quality from the network, but showed that as expected by testing using higher sensitivity molecular methods, multiple potential pathogens can be identified in both RV positives and negative samples from children with gastroenteritis. Although more RV positive samples were identified by TAC than by EIA, sensitivity for GT by the TAC is low versus the “standard” nested PCR. More data will be generated by the 4 labs in 2015 and further analysis will be carried out. Recommendations included:

• Selection of samples from good quality sites • Use (as far as possible) of the same aliquot for conventional and TAC

approaches • Correlation of results with clinical data.


5. New laboratory procedures

The GRL presented data on new procedures being used at the CDC GRL including the move to develop next generation sequencing as tool for characterization of RV strains. Data on the one step conventional and one step qRT-PCR developed at CDC indicated that the assays may be useful for the surveillance network, if adapted for regional needs by the use of other primers as needed. However, existing primer sets which are performing well in several regions will continue to be available. The need for guidance on long-term storage of samples was discussed and it was recommended that:

• If resources are a constraint, the lab should keep all RV positives (by reducing volume if necessary)

• keep negatives for 18 months. Additional discussion on unusual strains and sharing across regions resulted in a recommendation that:

• Unusual strains should be adapted to culture when possible. The WPRO RRL volunteered to adapt strains for culture but cautioned that multiple aliquots of multiple strains of the unusual genotype should be sent to them because only a proportion of strains and samples could be adapted to cell culture.


Annex 1. Meeting agenda

Monday 17 November 2014 Chair: Carl Kirkwood

Rapporteur: Miren Iturriza & Gagandeep Kang Session I. Global and Regional Updates

9:00-10:30

Welcome and Introductions

Update on Global RV Surveillance Network and status of strategic review recommendations

Meeting objectives and expected outcomes

Regional updates: o WPR

F. Serhan M. Agocs

V. Grabovac

C. Kirkwood

10:30-11:00 COFFEE BREAK

11:00-13:00 Regional updates (continued) o EUR o EMR o AMR

D. Videbaek E. Samoilovich H. El Mohammady G. Rey J.P Leite

13:00-14:00 LUNCH

14:00-15:00

Continued Regional Updates o AFR o SEAR

J. Mwenda G. Armah M. Seheri G. Kang

Session II. Improve Quality of RV laboratory data

15:00-15:30

2013 data review

GT data: Data reporting issues, linking GT data with clinical data, standardization of GT data and status of implementing the guidelines for strain characterization in regions

RL Performance Indicators

F. Serhan Group discussions


16:00-17:30

Continued data session

Discussions and way forward to improve data reporting and analysis

17:30 END DAY 1


Tuesday 18 November 2014 Chair: Gagandeep Kang

Rapporteur: Miren Iturriza Session III. Quality Assurance/Quality Control

9:00-10:30

Quality Assurance / Quality Control 1. EQA (30 min)

2014 results

Feedbacks from group

Development of regional QA plans

Discussion and recommendations

M. Bowen Group discussions


11:00-12:00 2. Quality Control for confirmatory testing:

Preliminary results of confirmatory testing at GRL

Discussion and strategy on way forward

M. Bowen C. Kirkwood Group discussions

Session IV. Optimization of laboratory procedures

12:00-12:30 BMGF grant implementation to leverage RV network

Background and update on status of the BMGF grant implementation

E. Houpt D. Operario

12:30-13:30 LUNCH

13:30-14:30 Review of two RRLs preliminary data

Discussions and recommendations on way forward

C. Kirkwood G. Kang

14:30-15:30 New Laboratory procedures:

Group discussions to include: o Optimal use of new lab procedures in the network o Primers use and availability in regions o EIA cut-off o Stool samples long term storage o Specimens with unusual strains and inter-regional sharing

M. Bowen Group Discussions


16:00-17:00 Summary of recommendations and meeting conclusions

17:00 Meeting Closing


Annex 2. List of participants

REGIONAL REFERENCE LABORATORIES AND OTHER LABORATORIES

George ARMAH Department of Electron Microscopy and Histopathology Noguchi Memorial Institute for Medical Research College of Health Sciences University of Ghana P.O. Box LG 581 Legon, Accra Ghana

E-mail: [email protected]

Hanan EL-MOHAMMADY Head, Laboratory for BPDRP Bacterial and Parasitic Diseases Research Program U.S. Naval Medical Research Unit-3 (NAMRU-3) Bldg 67 Room 315 Cairo Egypt


Miren ITURRIZA-GOMARA Institute of Infection and Global Health Department of Clinical Infection, Microbiology and Immunology University of Liverpool The Ronald Ross Building 8 West Derby Street Liverpool L69 7BE United Kingdom


Gagandeep KANG Head Department of Gastrointestinal Sciences Christian Medical College Ida Scudder Road 632004 Tamil Nadu, Vellore India


Carl KIRKWOOD NHMRC CDA Fellow & Group Leader, Enteric Virus Research Group Murdoch Children Research Institute The Royal Children's Hospital Flemington road Parkville Victoria, 3052 Australia


José Paulo Gagliardi LEITE Laboratorio de Virologia Comparada e Ambiental Instituto Oswaldo Cruz Oswaldo Cruz Foundation - Ministry of Health Avenida Brasil, 4365 - Pav. Hélio & Peggy Pereira 21040-360 Manguinhos - Rio de Janeiro Brasil


mailto:[email protected]





Nicola PAGE

National Institute for Communicable Diseases Private Bag X4, Sandringham 2131 Johannesburg Afrique du Sud


Elena SAMOILOVICH Laboratory of Vaccine-preventable Diseases Republican Research and Practical Center for Epidemiology and Microbiology 23, Filimonova Minsk Belarus


Mapaseka SEHERI University of Limpopo, Medunsa Campus Department of Virology MRC Diarrhoeal Pathogens Research Unit/ Rotavirus Regional Reference Laboratory Medunsa 0204, Pretoria South Africa


GLOBAL REFERENCE LABORATORIES AND PARTNERS

Mike BOWEN Center for Disease Control and Prevention 1600 Clifton Road Altanta, GA 30333 United States of America


Jon GENTSCH Center for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 United States of America


Darwin J. OPERARIO Research Scientist University of Virginia Health System Division of Infectious Diseases and International Health P.O. Box 801340 Charlottesville, VA 22908 United States of America


Eric R HOUPT Division of Infectious Diseases and International Health University of Virginia Health System Division of Infectious Diseases and International Health P.O. Box 801340 Charlottesville, VA 22908 United States of America


WHO REGIONAL COUNTERPARTS & HEADQUARTERS









Varja GRABOVAC Regional Office for the Western Pacific (WPRO) P.O. Box 2932 1099 Manila Philippines


Jason MATHIU MWENDA Regional co-ordinator, New Vaccines Surveillance WHO Regional Office for Africa (AFRO) Box 06 Djoue Brazzaville Congo Republic


Gloria REY Regional Advisor Immunization, VPD Laboratory Network Pan American Health Organization (PAHO) / WHO Regional Office for the Americas 525 Twenty-third Street Washington DC 20037 USA

E-mail: [email protected] ; [email protected]

Dovile VIDEBAEK WHO Regional Office for Europe (EURO) UN City, Marmorvej 51 Copenhagen 2100 Denmark


Fatima SERHAN Expanded Programme on Immunization World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland


Mary AGOCS Expanded Programme on Immunization World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland


Claudia STEULET Expanded Programme on Immunization World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland










executive summary meeting report...report of the rotavirus laboratory technical working group...

Documents