TABLE 2 (1 of 4)

SPECIMEN SELECTION1

DISEASE/

AGENT

SPECIMEN SELECTION	TIME AND TEMP	SPECIMEN PLATING

AND PROCESSING
Transport	Storage	SBA	CA	MAC	STAIN	OTHER

Anthrax

Cutaneous	Vesicular Stage: collect fluid from intact vesicles on sterile swab(s). The organism is best demonstrated in this stage.	≤2 h

RT	≤24 h RT	X	X	X	Gram

stain	India Ink for capsule
Eschar Stage: without removing eschar, insert swab beneath the edge of eschar, rotate and collect lesion material.	≤2 h

RT	≤24 h RT	X	X	X	Gram stain	India Ink for capsule

Gastro-

Intestinal	Stool: collect 5-10 g in a clean, sterile, leak-
proof container.	≤1 h

RT	≤24 h 4°C	Inoculate routine stool plating media plus CNA or PEA.	Minimal recovery
Blood: collect per institution's procedure for routine blood cultures.	≤2 h

RT	Blood culture bottles	Positive in late stages of disease.

Inhalation	Sputum: collect expectorated specimen into a sterile, leakproof container.	≤2 h

RT	≤24 h

4°C	X	X	X	Gram stain	Minimal recovery
Blood: collect per institution's procedure for routine blood culture.	≤2 h

RT	Blood culture bottles	Positive in late stages of disease

Brucellosis

Acute,

subacute or chronic	Serum: collect 10-12 cc acute phase specimen as soon as possible after disease onset. Followed by a convalescent specimen, obtained 21 days later.

2 h

RT

-20°C	Specimen should be stored and shipped frozen @ -20°C	Serologic diagnosis:

1. Single titer: ≥1:160

2. 4-fold rise

3. IgM

Blood: collect per institution's procedure for routine blood culture.

≤2 h

RT

Blood culture bottles

hold 21 days

Blood culture isolation rates vary from 15-70% depending on methods and length of incubation

Bone Marrow, Spleen or liver: collect per institution's surgical/pathology procedure

≤15 min

RT

≤24 h

RT	X	X	X

Gram stain

India Ink for capsule, and add blood cul- ture bottles or enrichment broth
hold cultures for at least 7 days

TABLE 2 (2 of 4)

SPECIMEN SELECTION

DISEASE/ AGENT	SPECIMEN SELECTION	SPECIMEN HANDLING	COMMENTS

Botulism

Specimen

Type	Clinical Syndrome

Specimen

volume

Transport temp

Specimen(s) of choice for confirming botulism:

a. Serum

b. Wound/tissue

c. Stool and incriminated food
Foodborne	Infant	Wound	Intentional Release
Enema Fluid	X	X	X	X	20 cc	4°C	Purge with a minimal amount of sterile nonbacterio- static water to minimize dilution of toxin

Food Sample

X

X

X

10-50 g

4°C

Foods that support C. botulinum growth will have a pH of 3.5-7.0, most common pH is 5.5-6.5. Submit food in original container, placing individually in leak proof sealed transport devices.
Gastric Fluid	X,A	20 cc	4°C	Collect up to 20 cc
Intestinal Fluid	A	A	20 cc	4°C	Autopsy: intestinal contents from various areas of the small and large intestines should be provided

Nasal swab

X

anaerobic

swab

RT	For aerosolized botulinum toxin exposure, obtain nasal cultures for C. botulinum and serum for mouse toxicity testing

Serum

X,A

X

X

10-12 cc

4°C	Serum should be obtained as soon as possible after the onset of symptoms and before antitioxin is given. A minimum of 10 cc of serum (20 cc of whole blood) is required for mouse toxicity testing. In infants, serum is generally, not useful, since the toxin is quickly absorbed before serum can be obtained.

Stool

X

X

X

X

10-50 g

4°C	Botulism has been confirmed in infants with only "pea-sized" stools. Please note: anticholinesterase given orally, as in patients with myasthenia gravis, has been shown to interfer with toxin testing
Vomitus	X	20 cc	4°C	Collect up to 20 cc

Wound/tissue

X

Anaerobic

swab or transport system

RT

Exudate, tissue or swabs must be collected and transported in an anaerobic transport system. Samples from an enema or feces should also be submitted since the wound may not be the source of botulinum-toxin
Environmental

sample	X	X	RT	Environmental swabs

TABLE 2 (3 of 4)

SPECIMEN SELECTION

DISEASE/ AGENT

SPECIMEN SELECTION	TIME AND TEMP	SPECIMEN PLATING

AND PROCESSING
Transport	Storage	SBA	CA	MAC	STAIN	OTHER

Plague

Pneumonic	Sputum/throat: collect routine throat culture using a swab or expectorated sputum collected into a sterile, leakproof container.

≤2 h

RT

≤24 h

4°C

X

X

X

Gram stain	Minimal recovery.

Prepare smears for Wayson (and DFA referral)
Bronchial/tracheal wash: collect per institution's procedure in an area dedicated to collecting respiratory specimens under isolation/containment circumstances, i.e., isolation chamber/ "bubble".

≤2 h

RT

≤24 h

4°C

X

X

X

Gram stain	Prepare smears for Wayson stain (and DFA referral)

Blood: collect per institution's procedure for routine blood cultures.

≤2 h

RT

Blood culture bottles	Patients with negative cultures

having a single titer, ≥1:10, specific to F1 antigen by agglutination would meet presumptive criteria

Tularemia

Pneumonic	Sputum/throat: collect routine throat culture using a swab or expectorated sputum colleced into a sterile, leakproof container.	≤2 h

RT	≤24 h

4°C	X	X	X	Gram stain	Minimal recovery.

Add a BCYE plate and prepare smears for DFA referral
Bronchial/tracheal wash: collect per institution's procedure in an area dedicated to collecting respiratory specimens under isolation/containment circumstances, i.e., isolation chamber/ "bubble"

≤2 h

RT

≤24 h

4°C

X

X

X

Gram stain

Add a BCYE plate and prepare smears for DFA referral.

Blood: collect per institution's procedure for routine blood cultures.

≤2 h

RT

Blood culture bottles.

Blood cultures have rarely been positive. A positive DFA from an ulcer/wound, tissues, and cultures OR a positive serology test would meet pre- sumptive criteria. Whereas, confirmation requires culture identification or a 4-fold rise

TABLE 2 (4 of 4)

SPECIMEN SELECTION

DISEASE/ AGENT

SPECIMEN SELECTION	TIME AND TEMP	SPECIMEN HANDLING

AND TRANSPORT
Transport	Storage

Smallpox

Rash

Biopsy specimens: aseptically place two to four portions of tissue into a sterile, leakproof, freezable container.	6 h

4°C	-20°C

to

-70°C	1. A suspected case of smallpox should be reported immediately to the respective state health department for review

2. And if, after review, smallpox is still suspected, CDC's Poxvirus Section @ 404-639-2184 should be contacted for approval to send

3. At this time review the packaging/shipping requirements with CDC and request assistance in co- ordinating a carrier for transport/shipment
Scabs: aseptically place scrapings/material into a sterile, leakproof, freezable container.	6 h

4°C	-20°C

to

-70°C
Vesicular fluid: collect fluid from separate lesions onto separate sterile swabs. Be sure to include cellular material from the base of each respective vesicle.

6 h

4°C	-20°C

to

-70°C
VHF	Serum: collect 10-12 cc of serum. Laboratory tests used to diagnose VHF include: antigen- capture ELISA, IgG ELISA, PCR, and virus isolation.	2 h

RT	-4°C	Specific handling conditions are currently under development..
1 Abbreviations: , delayed entry depends on instrument; A, autopsy; BCYE, buffered charcoal-yeast extract agar; C, centigrade; CA, chocolate agar; CNA, colistin-nalidixic acid agar; DFA, direct fluorescent antibody; g, grams; h, hours; MAC, MacConkey agar; PEA, phenylethyl alcohol blood agar; RT, room temperature