External quality assurance studies for the serological and PCR diagnostics of tick-borne encephalitis virus infections

Improved diagnostics are critical for optimally detecting and managing tick-borne encephalitis (TBE) infections, and therefore quality control measures are essential for both serological and molecular diagnostics. Two external quality assurance (EQA) studies were performed to assess the quality of serological and molecular diagnostics of TBE infections. For the EQA of serological diagnostics, each participating laboratory received a proficiency panel of freeze-dried human sera containing 7 TBE-positive samples, 3 negative samples, and 2 samples positive for heterologous flaviviruses. For the EQA of molecular diagnostics, panels of prepared human plasma samples comprising 8 samples spiked with RNA from different TBE virus strains of European, Siberian, and Far Eastern subtypes, 2 specificity controls with heterologous flaviviruses, and two negative control samples were distributed. A total of 46 invited expert laboratories from 28 European and non-European countries participated at least in one of these studies. Applying proficiency criteria, the number of participating laboratories who passed the minimum requirements for successful participation was 60% for the EQA of serological (both IgM and IgG detection) and 48% for the EQA of PCR diagnostics. The EQA studies provide information on the diagnostic quality of the participating laboratories and indicate that most of them need to improve their assays.     

Quality control assessment for the serological diagnosis of tick borne encephalitis virus infections.

BACKGROUND: The diagnosis of tick borne encephalitis (TBE) is mainly based on the demonstration of specific antibodies in serum when neurological disease is manifested. Improving diagnostics is the most important step in detecting and dealing with these pathogens. Quality control measures are essential for TBE diagnosis. OBJECTIVE: To assess an external quality assurance (EQA) program for the serologic diagnosis of TBE infections. STUDY DESIGN: A panel of 12 serum samples was sent out to be tested for the presence of TBE virus-specific IgM and IgG. This panel contained seven TBE-positive samples for IgM and/or IgG; three negative samples; two samples positive either for West Nile virus (WNV) or Dengue virus (DENV). RESULTS: Fourty-two laboratories from 25 European and 2 non-European countries participated in this EQA. The correct answer by each laboratory for all samples ranked between 58 and 96% and sera with IgM antibody positive for TBE were correctly recognized by 46-88% of the laboratories. Sera with IgG antibody positive for TBE were correctly recognized by 83-95% of the laboratories. False TBE-positive results were obtained with DENV, WNV or negative sera only for IgG-based assays. CONCLUSION: Correct results for at least 90% of the samples were obtained by 33 of 40 participating laboratories for IgM and for 16 of 42 laboratories for IgG.     

External quality control assessment in PCR diagnostics of dengue virus infections

BACKGROUND: Increased travelling to countries endemic for dengue fever (DF) demands efficient laboratory diagnostics. Nucleic acid amplification techniques (NAT) are now frequently used for rapid diagnosis of imported viral diseases. Different PCR systems are available. OBJECTIVES: In order to assess the quality of molecular diagnostics of dengue virus infections, an external quality assurance (EQA) in PCR diagnostics was conducted. Study design: A panel of 10 human plasma samples was prepared and spiked with dengue virus types DEN-1 to DEN-4. In addition, a 10-fold dilution series (1:10-1:10(4) ) of DEN-3 virus was included. The panel was pre-tested by nested RT-PCR, in-house real-time PCR, and a commercial real-time PCR kit. The samples were inactivated by gamma irradiation and shipped in freeze dried state. Thirteen laboratories, within the European network for the diagnostics of imported viral diseases (ENIVD) took part using either single-round, nested, or real-time RT-PCR methods. Two laboratories used two methods in parallel, summarising up to 15 comparable results. RESULTS: 33-100% correct results were achieved. All laboratories detected DEN-2 correctly, followed by DEN-1 (14 positive results of 15), DEN-3 (12/15) and DEN-4 (11/15). Testing of the serial dilution revealed low sensitivity in many labs, with results ranging from 33 to 80% of correctly tested samples. CONCLUSION: The EQA gives a feedback of the quality of the RT-PCR system used by each respective laboratory. The different test systems and amplification conditions demonstrate the importance of external quality control measures.     

The importance of tick-borne encephalitis virus RNA detection for early differential diagnosis of tick-borne encephalitis.

BACKGROUND: Tick-borne encephalitis virus (TBEV) is one of the most important causes of human viral infections of the central nervous system in Europe. Currently, the diagnosis of TBE is based on the demonstration of specific antibodies in patient's serum, which appear only several weeks after the infection. OBJECTIVE: To determine how successfully can viral RNA be detected by RT-PCR in the samples of body fluids of patients with TBE prior to and after the appearance of antibodies. STUDY DESIGN: Serum, whole blood and CSF samples from 34 patients with a serologically confirmed TBE were collected. Samples were tested for the presence of TBEV RNA by using RT-PCR method. RESULTS: Viral RNA was detected in all blood and serum samples collected before the development of antibodies. After the appearance of IgM antibodies, the number of positive samples dropped by at least one third. After the development of IgG antibodies, only 3% of serum and 16% of blood samples tested positive for viral RNA. Samples of cerebrospinal fluid were shown to be inappropriate for the molecular diagnosis of TBE using this assay, since only one sample (10%) that was collected in the sero-negative phase of disease was found positive by the PCR assay. CONCLUSIONS: RT-PCR is an efficient method for an early detection of TBEV in blood and serum samples collected prior to the appearance of antibodies. This method can be of valuable use for a differential diagnosis of TBEV infection in patients with febrile illness after a tick bite, particularly in regions where more than one tick-transmitted diseases are endemic.     

Quality control assessment for the serological diagnosis of dengue virus infections.

BACKGROUND: A major drawback of modern society's rapidly increasing mobility is the ease with which dangerous infections can be imported into Europe. Often these infections are not diagnosed because physicians are not familiar with the symptoms and laboratory tests are not always available in local diagnostic centres. Improving diagnostics is the most important step in detecting and dealing with these pathogens and quality control measures are, therefore, essential tools. OBJECTIVES: To assess the diagnosis of imported dengue virus infections in Europe by (1) running a pre-evaluation panel (four serum samples, sent out in 1999) and optimising sample preparation and shipping procedures and (2) initiating an External Quality Assurance (EQA) program (20 serum samples, sent out in 2002). STUDY DESIGN: All serum samples sent out were to be tested for the presence of dengue virus-specific IgM and IgG. For the pre-evaluation panel, four samples were distributed (one sample IgM+/IgG+, one sample IgM-/IgG+, two samples IgM-/IgG-) and for the EQA 20 samples (12 samples IgM+/IgG+, five samples IgM-/lgG+, one sample lgM+/IgG- two samples IgM-/IgG-). 13 laboratories took part in the pre-evaluation panel and 18 laboratories participated in the first EQA run. RESULTS: For the pre-evaluation panel, the participants reported concurrent and correct results for 88% of the IgG-positive samples and for 100% of the IgG-negative samples. The results for the IgM-positive sample were correct in 91% of the reported tests and in 97% of the IgM-negative samples. For the EQA, the participants reported concurrent and correct results for 71% of the IgG-positive samples and 89% of the IgG-negative samples. 58% concurrent and correct results were reported for the IgM-positive samples and 97% for the IgM-negative samples. CONCLUSIONS: The results presented here demonstrate the importance of quality measures for imported viral pathogens like dengue viruses and clearly indicate the need for improving the existing test systems.     

Diagnosing tick-borne encephalitis: a re-evaluation of notified cases

We set out to investigate the serological response of TBE virus (TBEV)-specific IgM and IgG antibodies in stored serum and cerebrospinal fluid (CSF) in notified TBE patients, in order to confirm or reject the diagnosis. We applied the ELISA methods used in clinical practice, Enzygnost and Immunozym, and assessed RT-PCR as a diagnostic tool. A total of 173 TBE cases were notified to the Public Health Agency. Samples from 129 patients were eligible for the study. Stored serum samples were found for 111 patients and CSF samples for 88 patients. All serum samples were analyzed with both Enzygnost and Immunozym, as well as an additional 140 control samples. CSF samples, including samples from ten controls, were analyzed with Immunozym. RT-PCR for TBEV was performed on 126 serum, two whole blood, 96 CSF, two feces and four nasopharynx samples. Only two of 111 notified patients lacked detectable TBEV IgM in serum, from whom one sample was RT-PCR positive. According to the ECDC definition, 117/129 (90.7%) of the reported TBE cases were confirmed. Positive RT-PCR results were obtained in eight patients, one from whole blood and eight from serum samples. Four out of eight of the RT-PCR positive patients were TBEV-IgM positive and none had detectable TBEV-specific IgG. All of the tested CSF, feces and nasopharynx samples were RT-PCR-negative. TBEV-specific IgG was detected in 88.4% and IgM in 31.6% of the CSF samples. RT-PCR on serum samples and CSF IgG antibodies can be used as complementary methods in TBE diagnostics, not least early in the disease course.     

Tick-borne encephalitis virus-specific RT-PCR--a rapid test for detection of the pathogen without viral RNA purification

Among diseases transmitted by ticks in the Czech Republic, tick-borne encephalitis (TBE) caused by Tick-borne encephalitis virus (TBEV) and Lyme disease caused by Borrelia burgdorferi spirochete are most important. We propose an effective and specific test for detection of TBEV in a single tick or a pool of ticks based on the detection of TBEV RNA using an RT-PCR technique without RNA purification. The method is very sensitive with the detection limit of about 14 fg TBEV RNA in total RNA obtained from brain suspension from suckling mice infected with TBEV per reaction. The primers were derived from the 5'-terminal non-coding region, a highly conserved part of the virus. The method was successfully applied to field-collected ticks in detecting TBEV RNA. This method can be used in studies of several aspects of TBEV: epidemiology, screening of natural foci, circulation and detection of virus genome sequences in clinical materials.     

Evaluation of influenza virus antiviral susceptibility testing in Europe: Results from the first external quality assessment exercise

BackgroundThe first antiviral susceptibility testing external quality assessment (EQA) was held for European influenza reference laboratories during winter 2010/11.ObjectivesTo assess European network influenza antiviral susceptibility testing capability and provide participants with an independent performance evaluation.Study designThe EQA panel contained ten coded specimens of inactivated human influenza A and B viruses with reduced susceptibility to neuraminidase inhibitors (NAI), or adamantanes. Twenty-four laboratories from 19 member states of the WHO European region analysed the panel using phenotypic (determination of 50% inhibitory concentration (IC₅₀) values by neuraminidase (NA) enzyme inhibition assay) and/or genotypic methods.ResultsAll 24 laboratories returned genotypic data for A(H1N1)pdm09 influenza virus, 18 (75%) for former seasonal A(H1N1), 16 (67%) for A(H3N2) and 15 (63%) for influenza B virus, correctly identifying NAI or adamantane reduced susceptibility-associated substitutions in the NA (mean 84%; range 52–100%) or M2 (mean 85%; range 73–94%), respectively. Thirteen laboratories (54%) returned phenotypic NAI susceptibility data. Despite inter-laboratory and inter-assay IC₅₀ value variation, all 13 laboratories correctly identified oseltamivir reduced susceptibility/resistance in pure preparations of A(H1N1) oseltamivir-resistant viruses. However, only 11 (85%) identified oseltamivir reduced susceptibility/resistance in a mixture of A(H1N1)pdm09 oseltamivir-sensitive/-resistant viruses. Furthermore, 3 laboratories (23%) considered oseltamivir-sensitive influenza B virus reduced susceptible/resistant.ConclusionsDetection of NA-H275Y in A(H1N1) viruses was achieved by most laboratories. IC₅₀ values and interpretation thereof varied for a sensitive/resistant virus mixture and for influenza B virus. The results of this exercise will assist harmonisation of antiviral susceptibility testing, interpretation and reporting within the European network through targeted training.     

Test based on subtype-specific μ-capture IgM immunoassay can distinguish between infections of European and Siberian subtypes of tick-borne encephalitis virus

BackgroundIn many European countries (including Finland, Estonia, Latvia and Russia) two subtypes of tick-borne encephalitis virus (TBEV) occur with overlapping geographic distribution yet with apparently different severity and persistence of symptoms. However, it has not usually been possible to distinguish these infections in the laboratory, as TBEV RNA or sequences have rarely been retrieved from patients seeking medical care in the second phase of infection when the neurological symptoms occur, and serological tests have so far not been able to discriminate between the subtype-specific responses.ObjectivesThe aim of this study was to assess the applicability of a μ-capture enzyme immunoassay (EIA) based on TBEV prME subviral particles produced in mammalian cells from Semliki-Forest virus replicons (SFV-prME EIA) to distinguish reactivity to European and Siberian strains of TBEV.Study designAltogether 54 TBEV IgM positive acute human serum samples and 6 positive cerebrospinal fluid (CSF) samples from different regions of Finland were tested in EIA with subtype-specific antigens and TBEV-IgM subtype-specific index ratios were determined.ResultsAll 30 samples from patients whose transmission had occurred in foci where only Siberian subtype of TBEV is occurring had an index ratio of more than 1.8, whereas all 30 acute TBE samples from an area where only European subtype circulates had an index ratio below 1.5.ConclusionsWe conclude that the assay is a useful tool to distinguish between acute infections of European and Siberian strains of TBEV, and should help in further studies of the clinical outcome of these two subtypes.     

The first external quality assessment of isolation and identification of influenza viruses in cell culture in the Asia Pacific region, 2016

BackgroundThe isolation and propagation of influenza viruses from clinical specimens are essential tools for comprehensive virologic surveillance. Influenza viruses must be amplified in cell culture for detailed antigenic analysis and for phenotypic assays assessing susceptibility to antiviral drugs or for other assays.ObjectivesTo conduct an external quality assessment (EQA) of proficiency for isolation and identification of influenza viruses using cell culture techniques among National Influenza Centres (NICs) in the World Health Organisation (WHO) South East Asia and Western Pacific Regions.Study designTwenty-one NICs performed routine influenza virus isolation and identification techniques on a proficiency testing panel comprising 16 samples, containing influenza A or B viruses and negative control samples. One sample was used exclusively to determine their capacity to measure hemagglutination titer and the other 15 samples were used for virus isolation and identification.ResultsAll NICs performed influenza virus isolation using Madin Darby canine kidney (MDCK) or MDCK-SIAT-1 cells. If virus growth was detected, the type, subtype and/or lineage of virus present in isolates was determined using immunofluorescence, RT-PCR and/or hemagglutination inhibition (HI) assays. Most participating laboratories could detect influenza virus growth and could identify virus amplified from EQA samples. However, some laboratories failed to isolate and identify viruses from EQA samples that contained lower titres of virus, highlighting issues regarding the sensitivity of influenza virus isolation methods between laboratories.ConclusionThis first round of EQA was successfully conducted by NICs in the Asia Pacific Region, revealing good proficiency in influenza virus isolation and identification.     

Tick-borne encephalitis (TBE) virus prevalence and virus genome characterization in field-collected ticks (Ixodes ricinus) from risk,non-risk and former risk areas of TBE,and in ticks removed from humans in Germany

Tick-borne encephalitis (TBE) is recognized as the most important viral tick-borne zoonosis in 27 countries in Europe. In this study, ticks were collected in Germany from two non-risk areas in the states of Saxony-Anhalt and Mecklenburg-Western Pomerania, where several single human TBE cases have occurred in recent years. Ticks were also collected from a region in Thuringia, known to be a former risk area for TBE virus (TBEV), where numerous human cases were reported between 1960 and 1975. Detection of TBEV RNA was conducted by real-time RT-PCR. No TBEV was detected in any field-collected ticks. However, ticks were also collected from volunteers living in Bavaria. Three of 239 ticks from this collection were positive for TBEV genome and two genetically distinct TBEV strains were detected and characterized.     

Tick-borne encephalitis virus in a highly endemic area in Kemerovo (Western Siberia,Russia)

Western Siberia is the region with the highest known incidence of tick-borne encephalitis (TBE) in the world, with 40 to >80 cases/100,000 population. Few data are available on the circulation of TBE virus (TBEV) strains in the region. In the present study, a total of 468 pooled ticks (Ixodes persulcatus) collected in 7 areas around Kemerovo, Western Siberia, were tested for the presence of TBEV RNA by real-time RT-PCR. Positive tick pools were further investigated by conventional PCR and the nucleotide sequences of the partial TBEV E protein genes were compared to known nucleotide sequences of (Siberian) TBEV strains. In 4 of the 7 areas tested, TBEV RNA-positive ticks were found. Seven out of 28 tick pools were positive in real-time RT-PCR. Assuming only one tick of each pool to be positive, the overall minimal infection rate (MIR) was 1.5% (7/468), ranging from 0% up to 4% for positive regions. Molecular characterization of the E protein of 6 of the 7 positive pools exhibited a sequence variability of 1.4–2.6% in comparison to the nucleotide (nt) sequence of the Aina strain of the Siberian subtype of TBEV. The phylogenetic analysis of the nt sequences clearly indicates that two clusters of the Siberian subtype of TBEV seem to circulate simultaneously in the Kemerovo region. The pathogenicity of the respective virus variants, however, warrants further examination.     

Reliability of methods for hepatitis B virus DNA detection.

A quality assurance program has been established by the European Group for Rapid Viral Diagnosis and the European Expert Group on Viral Hepatitis for monitoring nucleic acid detection methods for hepatitis B virus (HBV) DNA in serum samples. Thirty-nine laboratories participated in this quality program and generated 43 data sets. Of the participating laboratories, all but one used the PCR technique to detect HBV DNA. A coded panel was tested that was composed of seven undiluted HBV DNA-positive serum samples and five HBV DNA-negative donor serum samples. Furthermore, two dilution series, one from a positive patient and one from a full-length recombinant DNA, were included. Twenty-six data sets (60.5%) had faultless results with both dilution series. Twelve data sets (27.9%) recognized the undiluted serum samples, and 19 data sets (44.2%) had false-negative and/or false-positive results. Ten data sets (23.3%) performed well with the entire panel of samples. From these results, it can be concluded that in a large group of laboratories HBV detection by PCR shows specificity and sensitivity problems; therefore, PCR test interpretation should be done with great care.     

Molecular epidemiology of tick-borne encephalitis virus in Ixodes ricinus ticks in Lithuania

In Lithuania, 171-645 serologically confirmed cases of tick-borne encephalitis occurred annually [Mickiene et al. (2001): Eur J Clin Microbiol Infect Dis 20:886-888] in 1993-1999, and the tick-borne encephalitis virus (TBEV) seroprevalence in the general population was found previously to be 3.0% [Juceviciene et al. (2002): J Clin Virol 25:23-27]. To assess the risk for TBEV virus infection in Lithuania and to characterize the agent a panel of 3,234 ticks combined into 436 pools [Juceviciene et al., 2005] were tested for presence of TBEV RNA by a nested RT-PCR targeting at the NS5 gene. Six pools were confirmed positive and the prevalence of the infected ticks was 0.2% (if one tick per pool [Juceviciene et al., 2005] was considered positive) and the proportion of positive tick pools was 1.4%. The prevalence of the infected ticks in the Panevezys, Siauliai, and Radviliskis regions (in central Lithuania) was 0.1%, 0.4%, and 1.7% corresponding with a higher TBE disease burden in these regions. The 252-nucleotide NS5-region amplicons, and a longer sequence (737 nucleotides) obtained from one sample from the PrM-E gene region, were sequenced. Phylogenetic analysis of the latter showed that all western type TBEV PrM-E sequences, including the Lithuanian strains, were monophyletic, showed no clustering and had very little variation. The NS5 sequences, although identical within one locality, did not show any mutations common to strains from the two Lithuanian regions, nor could any geographical clustering be found among western type TBEV strains from other areas.     

Evaluation of the efficiency of external assessment of the quality of determining antibodies to hepatitis C virus in the network of screening laboratories

A regional external quality assessment (EQA) system for determining anti-hepatitis C virus (HCV) was developed and introduced. For this, a control panel comprising 14 samples with anti-HCV and 6 samples without anti-HCV was tested in the reference laboratory of Moscow Infectious Hospital One. A total of 6 sessions were conducted with the participation of 8 laboratories. The regional EQA system covering a limited number of laboratories was shown to significantly improve the quality of detection of hepatitis C virus antibodies. The optimal multiplicity of sessions for the developed EQA system was ascertained to be once fortnight. It is possible to define the current rating of screening laboratories in the sensitivity criterion and to elaborate address organizational-and-methodic measures according to the results of control tests.