Biochemistry Sample Management in Hospital Universiti Sains Malaysia during COVID-19 pandemic
Julia Omar1,3, Aniza Mat Jelani1,3, Noor Azlin Azraini Che Soh1,3, Wan Norlina Wan Azman1,3, Tuan Salwani Tuan Ismail1,3, Hanim Afzan Ibrahim2,3, Nur Karyatee Kassim2,3 Noorazliyana Shafii1,3, Zulkarnain Mustapha1,3
- Pengarang Koresponden:
Dr Wan Norlina Wan Azman
Department of Chemical Pathology, School of Medical Sciences,
Health Campus, Universiti Sains Malaysia, 16150 Kubang
Our Ministry of Health (MOH) together with other ministries have become the leading agency to tackle this fatal infection. As part of MOH mitigation strategies, various selected health clinics and hospitals become screening and admission facilities for the COVID-19. Unlike the MOH General Hospitals, Hospital Universiti Sains Malaysia (USM), a tertiary teaching hospital under the Ministry of Higher Education (MOHE) is not gazetted as COVID-19 hospital. While not designated as a COVID-19 hospital, the preparation for the Hospital USM for covid-19 screening and management was similar to that of a COVID-19 hospital. We also receive various cases, including severe acute respiratory illnesses (SARI) and influenza-like illnesses (ILI) patients, even a runny nose, which should be approached as potential COVID-19 cases until proven otherwise4. Thus, our biochemistry laboratory is also not spared from the COVID 19-related sample.
Beyond COVID-19 etiological diagnoses, clinical laboratories play an essential role in this pandemic. For etiological diagnosis, the real-time polymerase chain reaction (RT-PCR) is the most widely used method to identify SARS-CoV-2. This test is considered the most accurate method to measure SARS-CoV-2. The sensitivity of the test has improved for the diagnosis of COVID-19. The sputum (97.2% [90.3%-99.7%]) presented higher sensitivity for detecting the virus, while other areas such as rectal stools/swab, urine, and plasma demonstrated less sensitivity 5,6. The biochemical analysis of COVID-19 was necessary to detect disease extent, review the therapeutic and progression through in-vitro diagnostic testing. In unfavourable COVID-19 advance cases, many in-vitro diagnostic test criteria are included, which can provide valuable predictive details7 (Figure 1).
Figure 1. The essential role of laboratory diagnostics in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
All laboratories were ordered to be prepared to receive suspected COVID-19 samples. At Hospital USM, samples for biochemistry testing made up the majority (70%) of all samples sent on routine monitoring from inpatient and outpatient clinics. Balancing the demands of these potentially high-risk specimens while maintaining the service for most routine samples presented a challenge to the laboratory management and staff. The most crucial part is the clinical laboratories that are expected to comply with proper biosafety guidelines when handling samples from suspected COVID-19 patients. Thus, it pushes us to adopt some aspects of clinical laboratory services to the best practices.
Guidelines on sample collection & handling of severe acute respiratory infection/ patient under investigation /COVID-19 positive were based on: World Health Organization (WHO), Laboratory testing strategy recommendations for COVID-19, Ministry of Health Malaysia (MOH) and Biochemical Monitoring of COVID-19 Patients; The International Federation of Clinical Chemistry (IFCC) (Figure 2).
Figure 2. Example of guideline for biochemistry sample collection in suspected COVID-19 patient.
The samples are then packed in triple layers as recommended by MOH and send to our laboratory through an innovated carrier for transportation (Figure 3).
Figure 3. Innovated airtight container, easy to carry and safe for transportation of the suspected COVID biochemistry sample.
All samples must be registered through Laboratory Information system (LIS) and the laboratory technologist must be notified prior sending. The laboratory technologist will prepare themselves with personal hygiene and personal protective equipment (PPE) (Figure 4)
Figure 4. Laboratory technologist in PPE
Upon arrival to the laboratory, decontamination of samples suspected of COVID-19 were done (Figure 5).
Figure 5. Decontamination of samples
The centrifugation of samples were done according to the set time using the aerosol-tight centrifuge with safety covers for the buckets (Figure 6).
Figure 6. Centrifuge with safety covers for the buckets.
Samples were analyzed using automated biochemistry analyzer and in the absence of a closed sampling system in the laboratory, the only protective measure possible was to ensure that all instrument covers were in place and closed during analyser operation.
Samples were sealed immediately after testing. High-risk specimens were put in a closed dedicated bin until promptly disinfected or autoclaved. Decontaminate working surfaces were done with standard disinfectants (70% alcohol) (Figure 7).
Figure 7. Decontamination of working surfaces and dedicated bin.
To overcome the shortage of PPE and hand sanitizer during the initial COVID-19 outbreak, our staff volunteered to sew the PPE materials and prepare the hand sanitizers (Figure 8 and 9).
Figure 8. Preparation of PPE gown.
Figure 9. Preparation of hand sanitizer.
To conclude, the management of samples during the COVID-19 outbreak was a tough challenge for the laboratory and has continuously changed local work procedures, as the majority of the samples are analyzed for biochemical testing. Thus, these new norms explained the importance of safety in laboratory work and the need to plan for the unexpected.
- [Breaking] 3 coronavirus cases confirmed in Johor Baru New Straits Times. [Internet]. New Straits Times. 2020 Jan 25; Available from: https://www.nst.com.my/news/nation/2020/01/559563/breaking-3-coronavirus-cases-confirmed-johor-baru.
- First coronavirus cases in Malaysia: 3 Chinese nationals confirmed infected, quarantined in Sungai Buloh Hospital [Internet] 2020 Jan 25; Available from: https://www.theborneopost.com/2020/01/25/first-coronavirus-cases-in-malaysia-3-chinese-nationals-confirmed-infected-quarantined-in-sungai-buloh-hospital/
- First case of Malaysian positive for coronavirus [Internet] 2020 Feb 4; Available from: https://www.bernama.com/en/general/news_covid-19.php?id=1811373.
- Health DG: All cough, flu-like symptoms must be viewed as possible Covid-19 cases [Internet] The Star. 2020 Apr 22; Available from: https://www.thestar.com.my/news/nation/2020/04/22/health-dg-all-cough-flu-like-symptoms-must-be-viewed-as-possible-covid-19-cases
- Ali AM, Yousif AA, Abuelhassan AO. fawzi EM, Elbasheer SA, Ahmed NS (2020) Is a Real Time-Polymerase chain Reaction a Reliable Confirmatory Test for COVID-19. J Blood DisordTransfus.;11:442.
- Böger B, Fachi MM, Vilhena RO, de Fátima Cobre A, Tonin FS, Pontarolo R. Systematic review with meta-analysis of the accuracy of diagnostic tests for COVID-19. American journal of infection control. 2020 Jul 10.
- IFCC Information Guide on COVID-19 - Monday 28 September updates [Internet] The International Federation of Clinical Chemistry (IFCC). 2020 Aug 23; Available from: https://www.ifcc.org/ifcc-news/2020-03-26-ifcc-information-guide-on-covid-19/
We want to thank the Chemical Pathology Department staff, Hospital Universiti Sains Malaysia, for their co-operation and contribution to this article. Some of the pictures had been presented in Pandemic Online Congress, World Islamic Health Union (23-25 December 2020).