Regional Workshop on
strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO
South-East Asia Region
Bangalore, India 22-26 April 2019
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
© World Health Organization 2019
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2. Objectives ……… 2
3. Key Discussions and recommendations ……….…… 3
Recommendations ……….….…. 3
4. Acknowledgement ……… 6
Annexes 1. InBios JE Kit algorithm ……….………..………… 7
2. Agenda ………..……….. 8
3. List of participants ………..……… 11
1. Brief Overview
Japanese encephalitis is a vector-borne zoonotic viral disease mostly prevalent in tropical and sub-tropical areas of Asia. Currently, 10 out of 11 countries in the SEA Region are endemic for JE except for the Maldives.
Vaccination is the most cost-effective strategy to prevent and control JE and immunization has been demonstrated to reduce the economic burden of Japanese encephalitis disease. WHO recommends that Japanese encephalitis vaccination should be integrated into national immunization schedules in all areas where JE is recognized as a public health priority.
The majority of JE cases occur in children <15 years old. Although most persons infected with JE virus are asymptomatic, the case fatality rate among those who develop encephalitis is up to 30%, and approximately 30%-50% of survivors have long-term neurologic sequelae. A 2011 systematic review of JE disease burden estimated that approximately 68,000 cases occur globally each year, and only about 10% of these cases were reported to WHO.
Approximately 13 600 to 20 400 deaths occurred, and an overall incidence rate is 1.8/100 000 population in the 24 countries with JE risk.
Laboratory-based diagnosis for Acute Encephalitis Syndrome (AES) is very important, as multiple organisms can cause AES. Cross-reactivity with the dengue antigen occurs in 20–40% of samples tested for JE (using ELISA). There is a need to follow the algorithm for all specimens tested for JE to overcome the issue of cross-reactivity.
JE is considered endemic in all SEAR countries except Maldives. The South-East Asia Regional Vaccine Action Plan (2016-2020) has identified acceleration of Japanese encephalitis control as one of the eight goals.
Currently Myanmar, Nepal, Sri Lanka and Thailand have introduced JE vaccination in the entire country. India has introduced JE vaccination in 232 endemic districts and Indonesia has introduced the vaccine in one province.
Bangladesh, Bhutan, DPR Korea and Timor-Leste have been considering the disease burden and cost effectiveness to decide JE vaccine introduction. One of the strategic objectives of the JE goal of RVAP is “Develop and sustain AES surveillance through integrated national surveillance system or sentinel surveillance with accredited national laboratories in endemic countries”. SEAR ITAG 2018 recommended that
1. “National programmes in all countries should ensure high-quality laboratory supported JE surveillance in line with the recently-released Regional JE Surveillance Guide”.
2. NITAGs of potentially—JE-endemic countries, such as Bangladesh, Bhutan, DPR Korea, Indonesia, and Timor-Leste, should engage with national programmes to review disease burden and the potential benefit of JE vaccine introduction in RI, and report back to the ITAG at the next meeting
Due to variability of type of surveillance in different countries, there is a variation in the confirmed cases reported in each country. In 2017 no JE cases were reported from DPR Korea and Maldives. India reported 2043 cases in 2017. Other countries have reported 4996 cases and 592 were serologically confirmed. With the introduction of the JE vaccine, either nationwide or in selected high-risk areas as SIAs followed by routinely for infants, JE is under control in Nepal, Sri Lanka and Thailand. In India, despite SIAs in 232 high-risk districts and the inclusion of JE vaccine in the national immunization programme for infants for a decade, certain states still experience seasonal outbreaks, perhaps due to low immunization coverage.
In order to ensure that the JE laboratory network in the South-East Asia Region (SEAR) is able to adequately support surveillance and identify the disease burden for the introduction of JE vaccine and monitor the impact of vaccine introduction, WHO SEARO organized the Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia. This was to provide hands-on practice on WHO recommended procedures for laboratory diagnosis of JE, including quality assurance, standardized protocols, the use of new kit and updated standardized algorithm for testing for the new assays, interpretation, troubleshooting and reporting.
2. Objectives
The overall objective of the meeting was to strengthen laboratory capacity for supporting JE surveillance in the South-East Asia Region.
The specific objectives of the meetings were:
➢ To review progress and provide update on the important role of JE laboratory network in supporting accelerated JE control in the countries;
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
➢ To provide hands on practice on updated technology and standardized algorithm including new test kit and quality assurance programme for JE diagnosis; and
➢ To review the laboratory performance in supporting the JE control programme and identify areas of improvement.
3. Key Discussions and recommendations
The important role of JE laboratories to support JE case confirmation was discussed. At present, there are three type of test kits used in the region, (1) InBios JE test kit (used in Bangladesh, Bhutan, Indonesia, Myanmar, Nepal, Sri Lanka and Timor-Leste), (2) NIV JE test kit (used in India) and (3) Thai NIH In-house IgM capture JE test kit (used in Thailand).
Key quality indicators to meet WHO criteria for IgM detection are:
1) Test results reported by the laboratory within 7 days of receipt of samples (target ≥ 80%)
2) The accuracy of JEV IgM detection (target≥ 90%)
3) The score on the most recent WHO JEV IgM proficiency test (target
≥ 90%)
4) Number of samples tested per year (target > 50)
5) The score from the annual on-site review of laboratory operating procedures and practices (target ≥ 80%)
Recommendations
1. An onsite training should be provided by participants to colleagues in their laboratories to share knowledge from the workshop. Also, an annual laboratory safety refresher onsite training should be provided by supervisors. Documentation of the training activities should be prepared and shared with the WHO SEARO laboratory coordinator.
2. Laboratories that use the InBios JE IgM assay should follow the WHO revised April 2019 version of the InBios algorithm (Annexure 1) and retest all equivocal samples in duplicate, with the average ISR outcome reported (as described in the InBios kit insert).
3. Samples for confirmatory testing should be sent to the Regional Reference Laboratory (RRL) annually. Upon request of the WHO SEARO laboratory coordinator (RLC) or RRL, laboratories may need to send samples more frequently. The laboratories have to communicate with RLC and HoD RRL and confirm timing of referral and number of samples to be referred.
The guidance as below for confirmatory testing sample submission should be followed:
a. Laboratories should use the standard referral reporting form (example provided in the workshop USB drive),
b. If the annual number of JE IgM positive results for all samples received is 50 or more, submit a maximum of 86 samples for confirmatory testing. Samples should include 50 JE IgM positives, where numbers for each sample type (CSF/Serum) should be in proportion to the number of each sample type that tested positive during the past year. In addition, submit a selection of 18 samples that gave equivocal results for JE IgM, DEN IgM (if InBios kit used) or both. If less than 18 equivocal samples exist, submit all equivocal samples. Finally, submit 18 negative samples, where the number of each sample type submitted is in proportion to the numbers of each sample type that gave negative results,
c. If the annual number of samples resulting JE positive is less than 50, all positives are to be referred. In addition, 10% of all samples testing equivocal should be referred, plus 10% of all samples with negative results should be submitted, where the number of each sample type is in proportion to the numbers of each sample type that tested negative for a total of less than 86,
d. Samples should be representative in time and geography and with a minimum volume of 200ul for serum and 150ul for CSF,
e. Samples giving discordant results during confirmation should be retested by both the NL and RRL labs and action taken to resolve the discordancy,
f. The results of the confirmatory testing should be communicated to the NL and RLC by the RRL within 30 days of receipt of samples.
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
4) The WHO data reporting form has been revised and has been included in the USB drive associated with the workshop. The revised form should be used for all future data reporting to WHO on a monthly basis.
5) The JE test Kit insert should be reviewed regularly, any changes noted, and SOPs modified. The assay limitations outlined in the insert should be considered carefully.
6) The laboratory director should plan ahead and arrange logistic support for shipment of samples and communicate with the program officers within the country and WHO for identifying funds for covering courier costs.
7) The laboratories are encouraged to meet with the surveillance program officers of the country at least monthly. Communication with the program officers is important for linking the laboratory and surveillance data and arriving at the true picture of JE prevalence in the country. Laboratories should hold regular meetings with surveillance colleagues to resolve any case classification issues.
8) For the InBios kit, based on data from the Global Specialised Lab, all CSF samples should be used at a dilution of 1:10 rather than the dilution recommended in the kit insert.
9) The laboratory supervisors should perform regular internal audits by using WHO accreditation checklist and submit the checklist report to Regional laboratory coordinator annually (by the end of every January).
10) The laboratory supervisors are encouraged to address any shortcomings detected in the operating procedures and further strengthen the laboratory performance by:
• Communicating the results within 7 days of the receipt of the sample,
• Update SOPs and write SOP for data management and reporting,
• The IQC should be used for all assays and particularly when starting a new kit and when a new technician is performing the test. The RLC should be informed of any unexpected variation,
• The Levey-Jennings chart should be prepared and reviewed and analysed after every test. Westgard rules should be used in determining follow-up action,
• An inventory of equipment should be maintained with details of instructions of correct use and a breakdown and maintenance log,
• A regularly updated inventory of kits can help in avoiding stock-out situations.
11) Countries with multiple JE laboratories should develop strong network collaboration with the other laboratories and hold inter-lab comparisons of samples at least annually. A minimum of 10 is recommended.
4. Acknowledgement
The Immunization and Vaccine Development (IVD) team of the WHO Regional Office for South-East Asia expresses its sincere thanks to all participants of the Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region for their active participation. It also expresses its profound gratitude to the JE Regional Reference Laboratory at National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India for their support, coordination and overall facilitation of the Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region held in Bangalore, India in April 2019.
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
__________ Annex 1 InBios JE Kit algorithm
____________ Annex 2 Agenda
Day1: Monday, 22 April 2019
08.00 – 08.30 Registration 08.30 – 09.00 Pre-test
09.00 – 09.20 Welcome address by Director of NIMHANS Welcome remark by WHO-SEARO
09.20 – 10.00 Group Photograph and Coffee break 10.00 – 10.10 Objectives of the meeting
10.10 – 10.20 Administrative announcements 10.20 – 10.30 Self- Introductions of participants
Session 1: Update information and technology
10.30 – 11.00 Global and Regional update on JE SEAR─ progress and the challenges 11.00 – 11.30 Experience on AES surveillance in India
11.30 – 12.00 JE Laboratory Network: Global Perspective
13.00 – 13.20 JE SEAR Laboratory Network: Progress and Challenges 13.20 – 13.40 Regional reference laboratory (RRL): Update and Challenges 13.40 – 13.50 Global specialized laboratory (GSL): Update and Challenges 13.50 – 14.20 The recent technologies for JE diagnosis, algorithm of testing
and results interpretation
14.20 – 14.40 JE-NIV test kit using in JE laboratory network of India: Application, validation result and trouble shooting
15.10 – 15.30 Investigation of deaths in children during a JE vaccination campaign in Myanmar, 2017
15.30 – 16.30 Data reporting system of JE laboratory network in SEAR
16.30 – 17.30 Introduction NIMHANS training facilities, Institute biosafety, group divisions, preparation for benchwork practices and etc.
Adjourn
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
Day 2: Tuesday, 23 April 2019
Session 2: Safety & Quality assurance programme 08.30 – 09.00 RECAP : Day1
09.00 – 09.30 Safety & Quality assurance implementation
09.30 – 10.00 Accreditation review: checklist, WHO requirements and challenges 09.30 – 10.30 Proficiency testing results 2017 and introduction of new PT 11.00 – 11.20 Lecture: Introduction of InBios JE Detect MAC-ELISA
11.20 – 17.00 Practice1: group divisions (14 groups X 2 persons and 1 group X 1 person from WCO, DPRK)
17.00 – 17.30 Result interpretation and discussion Adjourn Day 3: Wednesday, 24 April 2019 Lab Practice2 : InBios Dengue Detect MAC-ELISA 08.30 – 09.00 RECAP : Day2
09.00 – 09.10 Lecture: Introduction of InBios Dengue Detect MAC-ELISA 09.10 – 15.30 Practice2: group divisions (15 groups)
15.30 – 16.30 Result interpretation and discussion
16.30 – 17.00 Testing algorithm of using InBios JE/Dengue for JE diagnosis Adjourn
Day 4: Thursday, 25 April 2019
Lab Practice3: performing their own kits by using the same sera panel (Indian participants and Non-Indian participants)
08.30 – 09.00 RECAP : Day3
09.00 – 09.30 Lecture: Introduction of NIV JE kits 09.30 – 15.30 Practice3: group divisions (15 groups):
15.30 – 16.30 Result interpretation and discussion 16.30 – 17.00 Post-test
Adjourn
Day 5: Friday, 26 April 2019 Session3: Laboratory presentation 08.30 – 09.00 RECAP : Day4
09.00 – 13.30 15 laboratories X 15 minutes 13.30 – 14.30 Group work:
15.00 – 16.00 Group work presentation: Questions & Answers 16.00 – 17.00 PT panel and certificates distribution and closing
Adjourn
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
_____________
Annex 3
List of participantsBangladesh
1. Dr Sharmin Sultana Department of Virology
Institute of Epidemiology Disease Control and Research (IEDCR) Mohakhali, Dhaka, Bangladesh email: dr.sharmin1579@yahoo.com 2. Ms Shahnaz Pervin
Medical Technologist (Lab) Institute of Epidemiology Disease Control and Research (IEDCR) Mohakhali, Dhaka, Bangladesh shahnazparvin815@gmail.com Bhutan
3. Mr Rinzin Wangchuk Senior Lab Technician
Royal Centre for Disease Control Department of Public Health Thimphu, Bhutan
email: rchukura@yahoo.com 4. Mr Tenzin Dorji
Senior Lab Technician
Royal Centre for Disease Control Department of Public Health Thimphu, Bhuta
email: tenzind@health.gov.bt
India
5. Dr Devjyoti Majumdar Microbiologist
Lt Baliram Kashyap GMC Jagdalpur, Chhattisgarh, India email: dmsmims@gmail.com 6. Ms Rani Soni
Microbiologist & Research Scientist Lt Baliram Kashyap GMC
Jagdalpur, Chhattisgarh, India ranisoni01011990@gmail.com 7. Ms Anjali Singh
Microbiologist, IDSP
Ranchi SHQ, Jharkhand, India email: anjali.sngh1@gmail.com 8. Ms Priyadarshini Das
Microbiologist
Malkangiri District, Odisha, India priyadarsinid2013@gmail.com 9. Dr (Ms) I. Ryntathlang
Junior Specialist
SSH Shillong, Civil Hospital Shillong, Meghalaya, India email: dribahunlang@gmail.com 10. Dr Arun Kumar Chaudhary
Pathologist cum Microbiologist SSH Lab, District Hospital, Basti Uttar Pradesh, India
email: chaudhary.arun.dr@gmail.com
11. Mr Syed Akhter Moghni Senior Lab Technician
Regional Lab, Swasthya Bhawan Lucknow, Uttar Pradesh, India email: aesjestate@gmail.com 12. Mr Santosh Kumar
Lab Technician
Primary Health Center Masaurhi Patna, Bihar, India
email:santoshkumar72217@gmail.com 13. Mr Mervin Andrew Allya
Lab Technician Civil Hospital
Shillong, Meghalaya, India
email: mervinandrew71@gmail.com 14. Mr Md Shamun Alam
Lab Technician, DPHL Chaibasa West Singhbhum, Jharkhand
email: mdshamunalam@gmail.com Indonesia
15. Dr Mursinah, SpMK Virologist of JE Laboratory Centre for Research and Development of Biomedical &
Basic Health Technology Jakarta, Indonesia
email: mursinah_my@yahoo.com 16. Ms Juwita Kurniawati, Amd
Technician of JE Laboratory Centre for Research and Development of Biomedical &
Basic Health Technology Jakarta, Indonesia
email: juwitakurniawati17@gmail.com
17. Dr Zahrotunnisa Epidemiologist
Center for Environmental Health and Diseases Control,
Surabaya, Indonesia
email: zahrotunisa@yahoo.com 18. Ms Alis Sisca Nurmalela
Virology and Parasites Lab staff Center for Environmental Health and Diseases Control, Jakarta, Indonesia email: alis.sisca@gmail.com Nepal
19. Dr Harischandra Upreti Director
National Public Health Laboratory Ministry of Health and Population Kathmandu, Nepal
email: upreti77harish@gmail.com 20. Dr Basudha Khanal
Head of Department
Department of Microbiology B P Koirala Institute of Health Science, Dharam, Sunsari, Nepal email: basudhak@gmail.com 21. Mr Shravan Kumar Mishra
Senior Medical Technologist National Public Health Laboratory Ministry of Health and Population Kathmandu, Nepal
email: shravan.nepal@gmail.com
Regional Workshop on strengthening the capacity of Japanese Encephalitis (JE) Laboratory Network in the WHO South-East Asia Region
Sri Lanka
22. Dr Janaki Abeynayake Consultant Virologist Medical Research Institute Ministry of Health, Nutrition &
Indigenous Medicine Colombo, Sri Lanka
janakiiabeynayake@yahoo.com 23. Ms Lakmini Gunathilaka
Medical Laboratory Technician Medical Research Institute Ministry of Health, Nutrition &
Indigenous Medicine Colombo, Sri Lanka
tharakagunathilaka92@gmail.com Thailand
24. Ms Sarinee Chumnanraksa Medical Scientist
Arboviris Unit, Medical Virology Group, National Institute of Health Ministry of Public Health
Bangkok, Thailand
email: Sarinee.c@dmsc.mail.go.th 25. Ms Arisara Pasanacharoen
Medical Technologist
Arboviris Unit, Medical Virology National Institute of Health Ministry of Public Health Bangkok, Thailand
email: arisara.p@dmsc.mail.go.th
Timor-Leste
26. Ms Julia Maria Angelina Laboratory Expert
National Health Laboratory Dili, Timor-Leste
email: juliaangelina14@gmail.com 27. Mr Jose Goncalves Monis
Laboratory Expert
National Health Laboratory Dili, Timor-Leste
email: jgoncalvesmoniz@gmail.com Special Invitees/Temporary Advisers 28. Dr Ravi Vasanthapuram
Professor and Head
Department of Neurovirology, Registrar and Dean (Basic Science) National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore 560029, India email: virusravi@gmail.com 29. Dr Nalini Ramamurty
Consultant WHO Chennai, India
email: ramamurtyn@gmail.com 30. Mr David A. Featherstone
Consultant WHO New Zealand
email: featherstoned@gmail.com 31. Dr Alison Jane Basile
Diagnostic and Reference Activity Arbovirus Diseases Branch US CDC, Fort Collins, USA email: ajj1@cdc.gov
32. Dr Vijay Bondre
Scientist-E, National Institute of Virology (ICMR), Pune, India email: bondre.vp@niv.co.in 33. Dr Anita Desai
Professor
Department of Neurovirology NIMHANS, Bangalore, India email: anitasdesai@gmail.com (Senior Technical Adviser to this workshop)
NIMHANS Facilitators 34. Dr Ayushman Ghosh
Project Coordinator
email: ayushdon28@gmail.com 35. Ms S J Kamala
Medical Laboratory Technologist email: sjkamala@gmail.com 36. Ms Sampada Sudarshan
Junior Research Fellow
sudarshan.sampada@gmail.com 37. Ms Risha Rasheed
Technical Officer
email: risha.rasheed88@gmail.com 38. Mr Suman Das
Medical Laboratory Technologist email: sahebdas1989@gmail.com 39. Mr Raghavendra Setty TK
Laboratory Technician
email: raghutk143@gmail.com
WHO:
WCO – DPR KOREA
40. Dr Anupurba Roy Chowdhury Technical Officer – Lab Specialist WHO Country office for DPR Korea Pyongyang, DPR Korea
email: roya@who.int WHO – SEARO
41. Dr Jayantha Liyanage
Regional Adviser – Immunization Systems Strengthening
IVD/FGL, WHO-SEARO, New Delhi email: liyanagej@who.int
42. Ms Sirima Pattamadilok Scientist, IVD/FGL WHO-SEARO, New Delhi email: pattamadiloks@who.int 43. Mr Md Sharifuzzaman
Data Management Officer IVD/FGL, WHO-SEARO, New Delhi email: sharifuzzamanm@who.int 44. Mr Rajiv Maken
Executive Assistant
IVD/FGL, WHO-SEARO, New Delhi email: makenr@who.int
