February 2024 – Lablogatory

Lessons Learned During a Cytology Staffing Shortage

No one wants to be short-staffed. Cytology programs across the country are either closing or shifting to a Master’s-only degree (to finally reflect our expanded scope of responsibilities), and during the pandemic, it seems there was a mass exodus of retiring baby-boomer cytologists. We’re in a crisis to say the least. As a prominent clinical rotation site, we have no shortage of cytology students. So much that whenever we’ve had an open position in the past, we were confident an eligible student would be able to fill our void. Over the past year, we’ve noticed that students had already secured jobs before they came to us for their clinical rotation. It wasn’t a problem until we realized that we were no longer immune to the nationwide staffing shortage. After one of our cytologists tragically passed away in November of 2022, we made do by working overtime. Before we were able to fill the empty position fifteen months later, another cytologist left to teach. Finally securing an amazing candidate with experience, we knew that we had students rotating through during the winter months, and things started looking up. We encouraged our first student to apply after being blown away by her already-fine-tuned her locator skills and hired her to start as soon as she graduates this summer. We were feeling assured that by the end of the summer (and my supervisor’s retirement), we would be fully staffed, fully trained, and ready to take on the world again. And then, another cytologist let us know she was moving to New England and her last day was five weeks from now. And just last week, another cytologist put in her notice. We’re down 4 cytologists in 15 months, the latter 3 within just 2 months. It’s the highest turnover our department has ever experienced, and our optimism was crushed. Fortunately, we do have more students rotating through this summer, but with 3 positions to fill before August, we’re treading water like our lives depend on it.

Sound familiar? I’m certain that the pervasive staffing shortage is plaguing medical laboratories all over the country. But how do we not let this impact our services? How do we continue to provide the same level of exemplary care while preventing burnout in our team? I’d like to share some lessons learned during our shortage from both a management and cytologist perspective, and I’m eager to hear if you have any you’d like to share from your own experiences.

Lesson #1 – Analyze Service Impact & Develop a Contingency Plan

Will the staffing shortage negatively impact turnaround time? With CLIA’s maximum screening limit of 100 slides in no less than an 8-hour day, a reduction in cytologists shifts the burden of the workload which can risk exceeding limits. Factoring in non-screening activities, such as performing Rapid Onsite Evaluation (ROSE) for FNA procedures, sending out tests for ancillary studies (ThyroSeq, Afirma, HPV, etc.), accessioning, scheduling, slide filing, cleaning biopsy carts, compiling statistics for QA, assisting in the cytoprep lab, maintaining continuing education, etc., it’s far too easy to exceed those limits. We pride ourselves on a one-day turnaround time. Our clinicians and patients expect it, and we refuse to sacrifice that feat. The most significant concern is the rising number of scheduled FNA procedures and not enough people to safely attend them all. We examined productivity and available time for FNAs given the number of cytologists present and daily case/slide workload. First, we looked at the number of slides that need to be screened for the day and divided it by the max mandated screening rate. Then, we counted the number of cases that need to be accessioned and the time involved. This process includes reconciling clinical history and histologic correlation, resolving the plethora of pre-analytical errors (please show us a perfect system for order entry). Considering the time spent on all other activities beyond accessioning and screening including assisting in the cytoprep laboratory, and what remains is the number of hours available for biopsies. We compare this to what has actually been scheduled for the day. Quite often, we are available for much less than what is requested and we must reallocate our resources. Postponing or reallocating out our prep assist duties, filing, and cart cleaning is an option with the cytoprep technicians also working overtime. If and when the prep techs are caught up on their work, they are able to clean carts for us. As for filing slides and paperwork, try to utilize your hospital’s resources, such as volunteers, who are incredibly valuable. Try to also share or reallocate statistics or other QA activities to reduce the burden on one employee while still maintaining operations. You could hire a temporary administrative assistant with a background in medical terminology to assist with accessioning as another option. The worst case scenario would be asking clinicians to “self-collect” FNAs in a balanced salt solution and sending it up to the lab to be processed. Our clinicians value our ROSE services, especially to confirm viability and to ensure we have sufficient material for ancillary studies such as molecular, IHC, and flow cytometry, and not being present would be an ethical dilemma for us all. To help mitigate this, we worked with the schedulers and clinicians across various departments to level out the biopsy schedule, and we postponed or reallocated non-screening activities to be able to handle the FNA workload to the best of our staffing level.

Lesson #2- Go LEAN

Now is a great time to go LEAN, if you haven’t already. And if you think you have, do it again. Analyze your lab for forms of waste. Are there non-value-added activities that are interfering with daily operations? Is your workflow optimized? How much of your cytologist’s time is spent waiting on biopsies? Waiting to call the cytologist to the procedure after the clinician has scrubbed in and marked the targeted lesion could save the cytologist 10-45 minutes of time. By reducing excess and unproductive biopsy wait time, the cytologist can be more productive within the laboratory. You could also reduce motion waste by having one cytologist attend multiple biopsies in the same department within a short time frame. For example, if an ultrasound-guided biopsy is scheduled for 10:15 AM and a CT-scan biopsy is scheduled for 11:00 AM, the same cytologist could attend both without having to return to the lab just to be called back down to radiology. Reducing excess employee movement between departments can also reduce potential care delays by having the cytologist present, moving with the nurses and proceduralist. Similar to the previous lesson on developing a contingency plan with reallocation of resources, how much of the cytologist’s talent is wasted on miscellaneous tasks that outside of the scope of high complexity testing, such as filing, scheduling, and cart cleaning? These are tasks that could be easily assigned to an administrative assistant or prep tech. And lastly, is the lab “over-prepping?” Many hospital laboratories only produce one liquid-based preparation (such as a ThinPrep slide) for morphology and a cell block for ancillary studies. If you are also making cytospins and smears or other additional preparations that offer a higher level of quality than is actually required to make the diagnosis, it could be considered waste. To reduce supply costs and time spent both prepping and interpreting excess material, monitor the laboratory for overproduction and overprocessing waste. This is especially helpful in reducing turnaround time and freeing up existing resources for other tasks.

Lesson #3 – Promote Mental Health & Self-Care

I especially thank my supervisor for this lesson because he and our cytopathology director have always maintained the family-comes-first and quality-of-life philosophies. Recognize that you and your cytologists are humans and not automated machines. Working in a short-staffed state with an abundance of overtime for more than a year can quickly manifest in burnout. You have to protect the gems that you still have. One thing I learned from my supervisor is to continuously seek feedback. How can we prevent burnout and protect both our mental and physical well-being? The main concern was quality of life, which was flourishing when we worked 4-10’s. While the overtime is not mandatory, we had to switch back to a 5-day work week to compensate for the staffing shortage. With that said, the remaining cytologists feel a sense of duty to our patients and therefore have extended their days to 9- to 10-hour days 5 days per week just to cover basic laboratory operations. We anticipate that once our March-start cytologist is fully trained to handle biopsies which run afterhours and our June-start cytologist is fully trained on accessioning, we can return to the 4-10 workweek. But for now, we maintain morale by knowing that the future is bright and we have 3 exceptionally strong senior techs remaining who are fully prepared to train any new hires. While management responsibilities have also shifted during a staffing shortage, a good leader must sharpen their intuition and emotional intelligence, checking in with their employees who are under extreme stress. Too often the manager forgets to check in with themselves while weathering a storm. Remember the airplane oxygen mask metaphor – you must care for yourself before you attempt to help others.Make sure your employees know that too. Patients and their specimens need us, but we cannot provide exceptional services unless we take care of ourselves first.

Lesson #4 – Communicate Intentions & Goals Early & Often

Communication- It’s a two-way street. Please, for everyone involved, consider giving MORE than the minimum required notice. For our department where we clearly do much more than just screening slides and attending FNAs, you must leave enough time to train others on how to handle the processes you own, such as send-out tests or statistics. It is crucial to give the remaining cytologists sufficient time to learn these processes and be able to ask questions while you’re still onsite. Communicating your intent to resign earlier than the minimum required time also enables management to shift their duties and either actively recruit or simply consider prospective candidates to help close the gap. Please also understand that indicating your intent to leave a laboratory does not mean that management will give up on you during your remaining tenure. If anything, leadership will ensure that you are able to accomplish any residual goals within the organization and help you prepare for the next stop on your journey. This principle applies to the entire duration of your career within the laboratory. At the beginning of your tenure, be open and honest about your short-term and long-term goals both career-wise and outside of the workplace so that management can help you customize a plan to achieve those aspirations. Should your goals or intentions change, be transparent. Pivoting is not a form of weakness. While it isn’t easy to brave a storm, especially as the effects of the shortage are exponentially more evident, it’s not only okay to seek help, but strongly encouraged. If you feel overwhelmed or on the verge of burnout, lean on your team members, communicate your concerns to your manager, and take time to ground yourself. Sometimes leaving a laboratory only reduces familiar burnout, and by starting over elsewhere, the unfamiliar may turn out to be more stressful, yet sometimes that new challenge is exactly what you needed. Just keep in mind that the storm will not last forever, and the laboratory sun will shine again.

-Taryn Waraksa-Deutsch, MS, SCT(ASCP)^CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.

Shish Kebabs, Pears and Grapes: All “Clue(s)” to Diagnosing Microbial Infections on Pap Smears

What is the test?

In the 1920s, the Greek physician Georgios Papanikolaou developed a method of cervical cancer screening, now reliably used and colloquially known as a “Pap smear”. During a Pap smear, a healthcare provider swabs cells from the cervix for further analysis by the lab¹, including cytopathologic examination. Regular utility of Pap smears in women aged 21 to 65 has decreased the incidence and mortality of cervical cancer by at least 80% in the United States alone². 95% of cervical cancer cases worldwide are caused by persistent human papilloma virus (HPV) infection of the cervix³. However, other sexually transmitted infections (STIs) and common non-STIs with associated morphological changes can also be identified on Pap smears.

Bacteria

Bacterial vaginosis (BV) is the most common cause of abnormal discharge in young women, characteristically with a “fishy” ammonia-like odor. Although not strictly considered an STI, this infection is associated with severe rare complications including pelvic inflammatory disease (PID), infertility and premature labor. The vagina typically have an abundance of Lactobacillus spp., which is a gram positive bacilli (Figure 1). However, if the normal vaginal flora is disrupted with high abundance of gram negative bacteria such as Gardnerella vaginalis or Mobiluncus, then BV may occur. On pap smears, ‘clue cells’ which are squamous epithelial cells with coccobacilli, appear as dark purple staining and cloudy appearance suggest BV. In cervicovaginal samples typically found in women using intrauterine device usage, clumps of filamentous bacteria suggestive of Actinomyces species may also be visible. For cases pertaining to bacterial etiologies, staining of the rods or filaments usually warrant suspicion of infection. Other the other hand although Chlamydia trachomatis is the most common bacterial STI in the United States, with up to 4 million new cases every year, diagnosis on pap smears is not the definitive diagnosis since the cytopathology is non-specific. The interpretations include visualization of inflammatory exudates and inflammatory cells. Oftentimes, further testing is needed.

Figure 1. *Lactobacilli* spp. bacilli seen as part of normal flora (red arrow, top left and top middle). Example of a clue cell (red arrow): intermediate squamous cell coated with grape-like short coccobacilli (*Gardnerella vaginalis*) with a shift in normal flora (top right). What appears to be a clue cell (red arrow) at first glance is actually an intermediate squamous cell covered with normal flora upon closer inspection (bottom left). Follicular cervicitis due to *Chlamydia* infection (bottom right). Note lymphohistiocytic aggregates with polymorphous lymphocytes and histiocytes (red arrow). Tangible body macrophages may also be identified (ThinPrep, 40X).

Parasite

Trichomonas vaginalis is the most prevalent non-viral STI in the United States, strongly associated with an increased risk of HIV infection among women⁴. Majority of the patients may exhibit symptoms such as burning, itching and vaginal discharge. T. vaginalis is a parasitic flagellated protozoan although in some cases, a flagella may be found. Typically, it is of a pear-shape and staining of a nucleus may be visualized (Figure 2).

Figure 2. Pear-shaped round-oval *Trichomonas* spp. (red arrows) ranging in size from 15-30 µm present singly and in groups, known as “Trich parties”. Note pale vesicular eccentrically located nucleus and eosinophilic cytoplasmic granules. Reactive cytological changes (black arrow) such as nuclear enlargement and perinuclear halos are also identified. (ThinPrep, 40X. Case courtesy of Dr. Edina Paal, VA Medical Center, Washington DC).

Fungus

Yeast infections (vulvovaginal candidiasis) due to Candida infection occur in 75% of women at some point in their lives. Classic clinical presentation includes itching, erythema, and thick white “cottage-cheese” discharge. There is also an increased association with HIV infection, diabetes, and any cause of immunosuppression (e.g. transplant, chemotherapy, steroids). Morphologically, budding yeast forms (conidia, small and oval measuring 3-6 µm) and pseudohyphae (long filamentous spores) are found. The combination of pseudohyphae and yeast forms are referred to as “sticks and stones” and frequently, squamous cells lined up along the pseudohyphae are found referred to as having “shish kebab” appearance (Figure 3)⁵. Note that no true septation is found.

On pap smears, sometimes there could be superficial mucosal infections that may appear associated with enlarged hyperchromatic nuclei with halos, which can be confused with low grade squamous intraepithelial lesions.

Figure 3. Shish kebab: entangled streaming intermediate and superficial squamous cells along *Candida* spp. pseudohyphae (red arrow, top). Partially treated *Candida* infection. Note poorly formed granular pseudohyphae (red arrow) with significant treatment effect (red arrow, bottom) (ThinPrep, 40X).

Viruses

HPV with its associated risk of cervical cancer remains the most crucial microorganism to detect on Pap smears. Given HPV’s association to cancer development, it is crucial to examine the samples for cervical lesions and their associated pathologies. HPVs in the low-risk category typically is associated with low-grade squamous intraepithelial lesions and HPVs in the high-risk category is associated with high-grade squamous intraepithelial lesions and invasive squamous cell carcinoma. Other viral etiologies seen in PAP smears include Herpes simplex virus (HSV) and cytomegalovirus (CMV). Infections with HSV can be asymptomatic but the most common symptom is the development of vesiculopustular or small ulcerative lesions on the genitalia. The classic cytopathological findings of HSV infection are the 3 “Ms”: multinucleation, nuclear molding, and margination of chromatin. CMV infections are rare, usually asymptomatic and can be transient. On the pap smears, the infected cells may appear with intranuclear inclusions surrounded by a halo.

Conclusions

While Pap smears are routinely performed on women and can provide a presumptive diagnosis, current developments in molecular technologies (e.g. Nucleic acid amplification tests (NAATs)) is transforming the field. There are several FDA-approved molecular platforms available for clinical diagnostic labs to test for HPV and can even genotype the strain to determine risk levels. Crucially, the remaining sample from liquid-based Pap tests⁶ can also be submitted for both NAAT testing and HPV-DNA testing, facilitating a quicker turnaround time and obviating the need for additional patient sampling. Most recently, a PCR-based test is now on the market (Cepheid, Sunnyvale, CA) that can diagnose all three etiologies, BV, Candidiasis, and Trichomoniasis, within 60 minutes from a single specimen. In summary, accurate examination of the Pap smear often incidentally provides the first step in the diagnosis and further work-up of all these infectious diseases.

References

1. Pap Smear: MedlinePlus Medical Test [Internet]. [cited 2024 Feb 4]. Available from: https://medlineplus.gov/lab-tests/pap-smear/ 

2. PDQ® Screening and Prevention Editorial Board. Cervical Cancer Screening (PDQ®): Health Professional Version. National Cancer Institute [Internet]. 2022 [cited 2024 Feb 4];1–26. Available from: https://www.cancer.gov/types/cervical/hp/cervical-screening-pdq 

3. Lei J, Ploner A, Elfström KM, Wang J, Roth A, Fang F, et al. HPV Vaccination and the Risk of Invasive Cervical Cancer. New England Journal of Medicine. 2020 Oct 1;383(14):1340–8.

4. Davis A, Dasgupta A, Goddard-Eckrich D, El-Bassel N. Trichomonas vaginalis and Human Immunodeficiency Virus Coinfection Among Women Under Community Supervision: A Call for Expanded T. vaginalis Screening. Sex Transm Dis [Internet]. 2016 Sep 15 [cited 2024 Feb 5];43(10):617–22. Available from: https://pubmed.ncbi.nlm.nih.gov/27631355/ 

5. Kamal Meherbano M. The Pap smear in inflammation and repair. Cytojournal [Internet]. 2022 Apr 30; 19:29. Available from: doi: 10.25259/CMAS_03_08_2021

6. Hawthorne CM, Farber PJ, Bibbo M. Chlamydia/gonorrhea combo and HR HPV DNA testing in liquid-based pap. Diagn Cytopathol [Internet]. 2005 Sep [cited 2024 Feb 5];33(3):177–80. Available from: https://pubmed.ncbi.nlm.nih.gov/16078250/ 

-Zoon Tariq is a pathology resident at George Washington University. Her interests include surgical pathology and cytopathology.

-Rebecca Yee, PhD, D(ABMM), M(ASCP)^CM is the Chief of Microbiology, Director of Clinical Microbiology and Molecular Microbiology Laboratory at the George Washington University Hospital. Her interests include bacteriology, antimicrobial resistance, and development of infectious disease diagnostics.

Homicide by Unspecified Means

Let’s imagine you are a forensic pathologist, called by investigators to the basement of an abandoned house where a building inspector found human remains. Upon your arrival, you identify a human skeleton, still partially encased in trash bags. The plastic trash bags have melted over the exposed surfaces, and there are charred cans of lighter fluid lying on top of the body. After a full examination of the body at your morgue, however, you cannot find any remaining signs of injury. One need not be an expert to recognize that the circumstances in which this body was found are extremely concerning, regardless of the absence of injuries at autopsy. This is when the diagnosis of “homicide by unspecified means” (“HUM”) enters consideration.

As we have previously discussed (see Undetermined, Undetermined – Lablogatory), in situations of extensive soft tissue loss or incomplete remains, we may not be able to identify the cause of death. It is unfortunately not uncommon for bodies of homicide victims to be concealed, delaying their discovery and allowing decomposition to progress. Out of a desire to hide the victim’s identity or to conceal the crime itself, attempts may be made at dismembering or destroying the body, which can further hinder efforts to identify injuries. Still, there are situations which are easily recognized as suspicious – yet we need to be careful to not rush to conclusions. There are less malignant explanations for some strange circumstances – for example, a person who accidentally overdoses may be moved to a different location, to divert law enforcement attention from a specific house or person. A hiker in an isolated location may suffer a natural cardiac event but not be found before decomposition and animal predation have occurred.

There are five criteria required to meet the diagnosis of “homicide by unspecified means,” a term which was originally coined by the late Dr. Joe Davis in Miami, Florida. These criteria were designed to ensure that all possible alternatives are thoroughly considered before arriving at the diagnosis. The criteria, as delineated in the original 2010 article, are:

Objectively suspicious circumstances of death. This would include evidence that the body was deliberately concealed (in trash bags, luggage, or a shallow grave, for example), attempts were made to destroy the body (e.g. with fire, or bleach), or that the victim was restrained. There may be evidence at the scene (or in the victim’s home) of significant blood loss, or there may still be non-lethal injuries (for example, a shallow laceration, or numerous bruises) identifiable on the body.
No anatomic cause of death. Meeting this criterion requires the completion of a full autopsy, despite the potential lack of tissue or complete remains. Sometimes evidence of lethal trauma is still identifiable – for example, gunshot wounds or knife marks on bone – and in this situation, the better “cause of death” is the specific type of injury. In other situations, there may be significant cardiovascular disease found at autopsy; the presence of a competing, natural cause of death must be carefully weighed with the other evidence.
No toxicological cause of death. This essentially means we have excluded an overdose as a possible cause of death. At times, this is a difficult standard to meet – in the example of skeletal remains, no material may be present to test. Other remains may be so decomposed that obtaining quantitative results (rather than qualitative) is impossible. Even if results are ‘positive’ for drugs of abuse, there is strong evidence that intoxicated individuals are at increased risk for interpersonal violence, and it would be a public disservice to automatically ascribe these deaths to overdose. This criteria, much like criteria #2, needs to be considered carefully in the context of all other findings.
No environmental, circumstantial, or historical causes of death. One always needs to consider the scene investigation and surrounding environment. Take the example above of a hiker in an isolated location – a death from hypothermia can have no or minimal findings at autopsy, let alone in the context of decomposition. Deaths due to drowning, epileptic seizures, or transient exposure to a toxic agent (like carbon monoxide) are similarly difficult to identify in these circumstances. If any of these possibilities cannot be confidently excluded, the diagnosis of “HUM” should not be made.
A more specific cause of death cannot be suggested by the data set. Essentially a reminder to review the totality of the evidence. Ruling a death as a ‘homicide’ sets off a chain of events which could result in a person being permanently incarcerated or executed. It is not a ruling to be made lightly.

Not every jurisdiction uses “HUM” as a term. Some will rule the cause of death as purely ‘undetermined’ and the manner of death ‘homicide’. In either case, the point is the same – there are clear indicators of homicidal violence, yet we cannot determine the specific type – and these criteria are still helpful to make sure alternative manners of death are thoroughly considered.

References:

Matshes EW, Lew EO. Homicide by unspecified means. Am J Forensic Med Pathol. 2010 Jun;31(2):174-7. doi: 10.1097/PAF.0b013e3181df62da. PMID: 20436340.

Krywanczyk A, Gilson T. Homicide by Unspecified Means: Cleveland 2008 to 2019. Am J Forensic Med Pathol. 2021 Sep 1;42(3):211-215. doi: 10.1097/PAF.0000000000000657. PMID: 33491950.

-Alison Krywanczyk, MD, FASCP, is currently a Deputy Medical Examiner at the Cuyahoga County Medical Examiner’s Office.

Microbiology Case Study: Traveler’s Diarrhea in a 59 Year Old Patient

Case History

A 59-year-old man presented to the Emergency Room with bright red blood per rectum, associated with nausea, vomiting, abdominal cramping, and persistent watery diarrhea. Several days earlier, he had returned from a three-week trip to the Dominican Republic. On physical examination, he was afebrile. His abdomen was soft and not tender or distended.

A stool sample was sent to the Microbiology Lab for PCR testing, and both Vibrio and Vibrio cholera targets were detected. The stool was then plated for culture confirmation. Hemolytic colonies grew on the blood agar plate (Figure 1), and yellow (original medium color green) colonies grew on thiosulfate citrate bile sucrose selective agar due to sucrose fermentation (Figure 2). Gram stain from these colonies showed gram negative, curved, comma-shaped rods (Figure 3) and MALDI-ToF identification revealed Vibrio albensis. The specimen was sent to the Department of Public Health for confirmation, which reported Vibrio cholerae O1 serovar Ogawa with O1 antigen typing.

Figure 3. Gram negative, curved, comma-shaped rods

Discussion

Vibrio albensis is a gram negative, halophilic bacterium belonging to the Vibrionaceae family. V. albensis is a recently identified species within the Vibrio genus and is believed to be a member of the Vibrio cholera complex. Although primarily considered non-pathogenic, V. albensis has been associated with rare cases of human infections, particularly in individuals with compromised immune systems.¹ While previously reported studies indicated V. albensis as a non-O1, non-O130 serogroup of V. cholerae,²the Department of Public Health confirmed our patient’s isolate as O1 serovar Ogawa by O1 antigen typing. V. albensis is an emerging pathogen with limited information regarding its clinical significance and optimal management. The infections are predominantly associated with contaminated seawater or seafood exposure. The primary transmission mode is through open wounds or ingesting raw or undercooked seafood.³

Clinical presentation of this organism can be similar to V. cholerae, as diffuse watery diarrhea, the hallmark of cholera, or asymptomatic. Other case reports presented bacteremia, septicemia, and urinary tract infections.^4,5

Laboratory diagnosis of Vibrio cholerae albensis infection involves isolating and identifying the bacterium from stool samples. This can be achieved using selective culture media, such as thiosulfate-citrate-bile salts-sucrose (TCBS) agar, which allows for the growth of V. cholerae and its variants.⁶

Antimicrobial resistance is a growing concern in the management of cholera. Studies have reported varying resistance levels to commonly used antibiotics in V. cholerae, including V. cholerae albensis. It is essential to monitor antimicrobial susceptibility patterns to guide appropriate treatment strategies.⁷ Further research is needed to better understand the epidemiology, clinical manifestations, and optimal treatment strategies for V. albensis infections as members of V. cholerae complex are being identified/recognized with more advanced diagnostic tools.

References

Baker-Austin C, et al. (2016). Vibrio albensis sp isolated from a mesophilic bacterial culture, abalone (Haliotis spp.), and seawater. International Journal of Systematic and Evolutionary Microbiology, 66(1), 187-192.
Ahmed AOE, Ali GA, Hassen SS, Goravey W. Vibrio albensis bacteremia: A case report and systematic review. IDCases. 2022 Jun 30;29:e01551. doi: 10.1016/j.idcr.2022.e01551. PMID: 35845827; PMCID: PMC9283503.

3. Sharma P, et al. (2018). Vibrio albensis: An Emerging Pathogen Causing Necrotizing Fasciitis. Journal of Clinical Microbiology, 56(3), e01454-17.

4. Araj GF, Taleb R, El Beayni NK, Goksu E. Vibrio albensis: An unusual urinary tract infection in a healthy male. J Infect Public Health. 2019 Sep-Oct;12(5):712-713. doi: 10.1016/j.jiph.2019.03.018. Epub 2019 Apr 10. PMID: 30981654.

5. Sack RB, et al. (2004). Cholera. The Lancet, 363(9404), 223–233.

6. Centers for Disease Control and Prevention (CDC). (2021). Laboratory Methods for the Diagnosis of Vibrio cholerae. Retrieved from https://www.cdc.gov/cholera/laboratory.html

7. Ceccarelli, M., et al. “Editorial–Differences and similarities between Severe Acute Respiratory Syndrome (SARS)-CoronaVirus (CoV) and SARS-CoV-2. Would a rose by another name smell as sweet.” European review for medical and pharmacological sciences 24.5 (2020): 2781-2783.

-Eros Qama, MD, is a 2nd year AP/CP pathology resident in the Department of Pathology at Montefiore Medical Center in Bronx, NY

-Phyu Thwe, Ph.D, D(ABMM), MLS(ASCP)^CMis Associate Director of Infectious Disease Testing Laboratory at Montefiore Medical Center, Bronx, NY. She completed her medical and public health microbiology fellowship in University of Texas Medical Branch (UTMB), Galveston, TX. Her interests includes appropriate test utilization, diagnostic stewardship, development of molecular infectious disease testing, and extrapulmonary tuberculosis.

The 3 Hazards of Hazardous Waste Management

Managing chemical (hazardous) waste in the laboratory is easily one of the most complicated areas of safety to understand. The regulations are set forth by the Environmental Protection Agency (EPA) and enforced by them or representatives of their state branches. For laboratories that are housed in hospitals or other large facilities, hazardous waste is often removed and handled through other departments like environmental services or maintenance. In the eyes of the EPA, the waste generated by the lab is the responsibility of the lab until it gets to its final disposal location. If other departments manage lab waste, the lab should routinely make sure it is being handled appropriately.

One of the most common areas where hazards occur in waste management regards storage. There are two types of chemical waste storage areas that can be designated in a facility, a Satellite Accumulation Area (SAA) and a Central Accumulation Area (CAA). Chemical waste is initially stored in a SAA which must be within the line of vision from where the waste is generated. Labs may store up to 55 gallons of waste in a SAA, and the EPA does not permit moving waste from one SAA to another. If the waste stored at the SAA is flammable, it should be kept inside of a flammable storage cabinet, but that cabinet would also need to be visible from the point of waste generation.

A second common issue surrounding hazardous waste is container labeling. In most US states, it is required that all containers of chemical waste display the words “hazardous waste.” The label must also show a description of the waste (i.e. stain waste, xylene waste, etc.). Finally, there must be some sort of hazard warning on the label. That warning may be in the form of a pictogram, a NFPA or HMIS warning label. If waste is poured into an empty reagent container, no elements from the original product label may be used, even if the waste is the same as the original reagent. Cross out the original label and place a new complete hazardous waste label on the container.

Containers placed in a SAA should not have an accumulation start date on the container. Facilities are allowed to store waste on site for specific periods of time based on the generator status selected as part of the EPA registration process. However, that storage time limit does not start until the waste is moved to the Central Accumulation Area. All waste in the CAA must be labeled with an accumulation start date.

The third hazard that crops up often in laboratories surrounds recordkeeping. Chemical waste vendors will come to the facility and they may remove waste containers from the CAA or any SAA. When they remove waste, they present a waste manifest which must be signed by a facility representative. Whoever signs that initial manifest must have a specific hazardous waste training that is required by the Department of Transportation (DOT). It is easy for a lab to monitor their own staff training, but if a different department signs waste manifests for lab waste, you need to check that those signing have the required training documentation.

Keep initial waste manifests in a file. The facility should receive final waste manifests within 45 days, and those final copies should be matched up with the initial paperwork so the lab can be sure all waste has been delivered to its final destination point. If the manifest records are kept in other areas of the facility, a lab representative should make routine checks to ensure records are kept up to date.

As you can see, it is fairly easy to make an error when managing hazardous waste for your facility. The regulations are complicated, and we only scratched the surface of them in this blog. Perform waste audits regularly, and include all storage areas and departments in the facility that may handle your waste. Reach out to the EPA or a state branch representative and feel free to ask questions. Managing hazardous chemical waste can be tricky, but it can be done so that the lab follows all regulations and laboratory staff can remain safe.

–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.