An Outdoor Enthusiast Finds a Career in Environmental Health

Apr 23 2014 :: Published in Environmental Health

April 20-26 is Laboratory Professionals Week! This year APHL is focusing on environmental health and the laboratorians who work to detect the presence of contaminants in both people and in the environment.  This post is part of a series.

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By Henry Leibovitz, Ph.D., Chief, Environmental Sciences, RI State Health Laboratories

Growing up along the south shore of Long Island’s eastern end, my interests covered everything aquatic.  My every waking hour was spent on the water fishing, boating, clam digging, and exploring. My every dream was driven by the excitement of the sea. It was an exceptional lifestyle for an adolescent who cared more about adventure than academics. Nonetheless, my future was destined to involve higher education and research by the vision of my father who was a veterinarian, a research scientist and veterinary college professor.

An Outdoor Enthusiast Finds a Career in Environmental Health | www.aphlblog.org

While earning my BS in Biology, a close priority became serving as president of the outing club, an adventure wilderness group of students spending weekends in the Adirondack Mountains. Opportunity also came to me in campus residence life as I worked as a resident advisor and then assistant dormitory director. The training and experiences included interpersonal communication, conflict resolution, supervision and management as well as life lessons that would play a major role later in my laboratory career. Upon graduation, my passion had become feeding the world through aquaculture.

After marrying my college sweetheart I enrolled in an MS degree program of Fisheries and Allied Aquaculture at Auburn University. Waking up before dawn to measure dissolved oxygen levels in the catfish ponds and constantly worrying about the threat of O2 depletion, and losing thousands of pounds of fish was not going to be my way of life. The laboratory environment became much more interesting. My major professor introduced me to the nutritional biochemistry of fish diets and feeds. Replacing fish meal with soybean meal in catfish diets was the subject of my research and thesis. “We are what we eat!” With fish I learned that feed analysis is critical to understanding how diet affected the growth, health and production of farmed fish. I earned my MS realizing that laboratory scientists have a significant role in feeding the world just as the farmers do.

I landed a research associate position on a project at Louisiana State University funded by a NIH grant to develop laboratory grade bullfrogs (Rana catesbiana) in place of the wild caught overly-stressed specimens for neurophysiologic research. My role was to improve the diets for larval stages of tadpoles!  In the laboratory we bred and raised several bullfrog line generations. During metamorphosis however tadpoles frequently developed skeletal deformities including scoliosis. My research focused on dietary and environmental factors that were causally suspected. While the research was very interesting, I became convinced that it would be more rewarding to lead the research activities and that earning a Ph.D. was necessary to continue my career.

During my Ph.D. program at the University of Rhode Island I worked as a research associate for the Department of Food Science and Nutrition. My duties as instrumentation specialist involved me in a variety of the department’s research activities. While pursuing my doctoral dissertation developing microencapsulated diets for larval marine fish, I learned the importance of elucidating environmental components such as pesticides, PCBs and metals in natural (plankton and brine shrimp) and formulated diets (various fish meals, fish oils, grains and other ingredients) for growth and survival during fragile larval stages.

Learning to apply the tools of analytical chemistry to the analysis of environmental components in feed and living organisms, I forged my career path into environmental laboratory analysis.  After earning a Ph.D., I worked for an environmental analysis laboratory starting as supervisor and eventually as laboratory director before the company moved to South America. We provided laboratory services to national clients including the US Department of Defense, EPA and many environmental engineering contractors. We analyzed sample matrices included air, water, soil, biota and food. Professionally I was so rewarded by the teaching, research and managerial aspects of my job that I didn’t expect to find in the commercial sector. Teaching newly hired graduates, improving methodology and instrument performance, and sharing a vision of the critical paths to achieving objectives kept me interested in the work. Client centric laboratory services were important to me.

In 2004 I was hired by the RI State Health Laboratories (SHL) as Quality Assurance Officer in the Environmental Laboratory Sciences section. In 2007 I became Chief Environmental Laboratory Scientist of the section that includes the chemical and microbiological analysis of drinking water, food, air, dairy, shell fish, recreational water and ambient river samples for the health and environmental program partners we serve. I point to the dedication of staff, peers and colleagues for the successful SHL services provided to our state health and environmental program and industrial partners.

As a public servant I have come to understand that the existence of our laboratories depends on the successful outcomes of our partners in public health and environmental protection.

Outside of work I enjoy spending time with my family and I still pursue the adventure of the great outdoors all seasons of the year.

 

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My Earth Day — My Community

Apr 22 2014 :: Published in Environmental Health

April 20-26 is Laboratory Professionals Week! This year APHL is focusing on environmental health and the laboratorians who work to detect the presence of contaminants in both people and in the environment.  This post is part of a series.

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By Surili Sutaria Patel, Senior Specialist, Environmental HealthAPHL 

My Earth Day -- My Community | www.aphlblog.org
Today is Earth Day!  People all over the world plant trees, clean up their communities, contact their elected officials to take action and more. By protecting the environment, we are protecting our health from harmful pollution and hazardous contaminants found in our environments.

Yet not all environments are created equally. Some communities throughout the US are faced with environmental health issues because of where they are or their residents’ socio-economic status. Such communities are often disproportionately exposed to harmful pollutants. Achieving environmental justice – or the fair treatment and meaningful involvement of all people (regardless of race, color, national origin, or income) with respect to the development, implementation, and enforcement of environmental laws, regulations and policies – is key to truly protecting the health and environments of all.

In an effort to better link concerned communities with their public health laboratory to answer questions about environmental contaminants, APHL is proud to launch the Meeting Community Needs through Environmental Laboratories web-based tool. Created for advocacy and consumer groups to better understand the role of an environmental public health laboratory, this resource aims to address how the public health system can better utilize the rich capabilities of laboratories to meet environmental health needs. The site contains the APHL report on Meeting Community Health Needs through Environmental Health Labs, presentations from a forum held in 2012, a YouTube video, next steps and more. The site also hosts a discussion board where anyone can post questions about environmental health concerns.

Read a recent blog post by our partner, Dr. Jalonne L. White-Newsome at WE ACT for Environmental Justice, entitled, “What are Environmental Justice Communities and how can Laboratory Testing Protect the Most Vulnerable?

Join the discussion today and tell us about your community environmental health concerns!

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What are Environmental Justice Communities and how can Laboratory Testing Protect the Most Vulnerable?

Apr 22 2014 :: Published in Environmental Health

April 20-26 is Laboratory Professionals Week! This year APHL is focusing on environmental health and the laboratorians who work to detect the presence of contaminants in both people and in the environment.  This post is part of a series.

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By Dr. Jalonne L. White-Newsome, Federal Policy Analyst, WE ACT for Environmental Justice

Choices. One of the most difficult choices my 4-year old had to make before starting school was which bookbag she wanted. It was a close call between the shiny Dora bookbag with the pink and purple zippers or one of her favorite Disney princesses. As a mom, however, there are slightly more difficult choices I have to make.

What are Environmental Justice Communities and how can Laboratory Testing Protect the Most Vulnerable? | www.aphlblog.org

My choices are based on keeping my children safe, happy and healthy. So when I found out that many of the products I typically purchased for my daughter – like the Dora bookbag – were made from chemicals like phthalates and bisphenol-A (BPA), I grew concerned. The chemicals found in these products commonly sold in variety stores, or price-point retailers that sell inexpensive items with a single price for all or most of the items in the store, are linked to adverse reproductive and neurodevelopment health outcomes, as well as higher predisposition to diabetes and asthma. While avoiding EVERY hazardous product is unrealistic, having the choice – as well as the resources and knowledge to make informed choices – is key. But not everyone has that choice or access to this knowledge.

Environmental justice (EJ) communities are usually described as communities of color and/or low income communities that are disproportionately burdened with environmental pollution. Members of EJ communities are often the same people exposed to potentially unhealthy products. Residents’ choices are limited to products sold at these retail establishments, such as local variety store or bodegas, due to financial and transportation barriers. At the same time, members of EJ communities are often unaware of the health consequences of their product choices.

As a Federal Policy Analyst for WE ACT for Environmental Justice, I have the opportunity to work on multiple environmental issues that disproportionately impact communities of color and/or low income communities. While the specific issue of toxic exposures from consumer goods has typically been omitted from the traditional definition of EJ, it is now more important than ever that we make these connections, especially in a world where cumulative impacts and risks are becoming an integral part of analyzing risk.

So the question becomes: are communities of color, and/or low income communities more exposed to hazardous consumer goods than communities with a different socio-demographic profile? To begin answering this question, WE ACT’s environmental health team engaged in a community-academic partnership to quantify the proliferation of toxic chemicals in northern Manhattan, NY. WE ACT created a database of businesses that sell products that typically contain hazardous ingredients – such as skin-lightening cream and hair relaxers – that target EJ communities.

This is not a concern limited to the northern Manhattan communities, but communities across the US. Many national coalitions are forming across the country to raise awareness about consumer products that contain potentially-toxic chemicals. Additional concerns surround chemicals used in certain industries – like hair and nail salons – where minorities are exposed to toxic fumes daily without proper ventilation. Although we can speculate that some communities are disproportionately exposed to harmful chemicals, the ability to quantify the exposures to research on the potential health impacts remains critical.

While efforts by the U.S. Environmental Protection Agency (EPA) and other non-governmental organizations aim to protect EJ communities from environmental hazards, limited research compares the health impacts of consumer goods and the exposure profile of communities that face EJ issues to other communities.  It is very important that researchers answer some of these concerns with hard data. By testing common products for potentially-toxic chemicals, especially products sold in variety stores, we can inform community members and advocate for better choices.

The Toxic Substances Control Act (TSCA), enacted in 1976, is one of the laws that serve as the primary source of protection for human health related to consumer products. Revisions to TSCA are currently underway in Congress, with many members of the EJ community and national coalitions fighting to ensure that the revisions reflect their concerns and codify the solutions needed to address the particular sensitivity of EJ communities such as cumulative risk. Comprehensive chemical policies at the federal level combined with consumer products testing can change the landscape of the market. APHL aims to promote good laboratory practice and data quality for consumer product testing. To join APHL in a discussion on environmental justice and consumer product testing, please visit the Meeting Community Environmental Health Needs webpage. This site aims to help you navigate the system, while ultimately improving the governmental environmental health system, while ultimately improving that very same system for other concerned communities.

To learn more about Achieving Environmental Justice through public health laboratory practice, visit the Fall 2012 issue of APHL’s Lab Matters magazine.

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Scientist? Actress? Or President?

April 20-26 is Laboratory Professionals Week! This year APHL is focusing on environmental health and the laboratorians who work to detect the presence of contaminants in both people and in the environment.  This post is part of a series.

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By Laurie Peterson-Wright, Chemistry Program Manager, Colorado Department of Public Health and Environment

Who would have known that the 1973 fifth grade class of Beadle Elementary in Yankton, South Dakota could predict the future?  As a classroom exercise, we all had to vote on what we would each be when we grew up.  I received 10 votes to become an actress, 10 votes to become a scientist and even one vote to be the first woman president!

Scientist? Actress? Or President? | www.aphlblog.org

My parents were adamant that I finish every project, class, book, craft or book I started.  This instilled within me a commitment to never quit and a sense of wonderment at where the next bit of knowledge and hard work would take me. My passion for any type of science began at a young age.  I would stay glued to my microscope or my telescope at night.  I wanted to learn everything about how humans and the universe operated.  I had so many educational ambitions – teaching, mathematician, certified public accountant, physicist, medical doctor, astronaut (and let us not forget Hollywood Star) – but after many years in school, I reeled my focus in to chemistry, mathematics and business administration.

My first position was in cancer research, but I was shortly introduced to environmental chemistry and project management.   I was intrigued by how chemical and radiological pollutants interacted with the environment and what we could do to mitigate exposure, especially for sensitive populations.  I spent 15 years in the environmental remediation/waste management field and then accepted a position with the State of Colorado Chemistry Program in 2001.  Immediately I embraced public health and how these same contaminants in the environment could be so easily transported.  I was fascinated by how they interacted with the human body including sensitive human and animal endocrine systems.

This world is an amazing place! By continuing to focus on my passion in public health, I will only increase my knowledge of how all sensitive systems are interconnected.  Live gently, and also boldly, my fellow scientists.

Oh, and by the way….I still act…and PS don’t tell my parents I never finished Moby Dick.

 

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Where are they Now? APHL/CDC Emerging Infectious Disease Fellow Looks Back

Apr 10 2014 :: Published in Workforce & Professional Development

By Laura Siegel, Specialist, NCPHLL

It’s fellowship season at APHL! Last month we received over 315 applications for the 2014-2015 class of EID fellows. As the review committee evaluates this year’s applicants, let’s take a look back and see what members of last year’s class are up to.
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“It boggled my mind that there are invisible little creatures that can infect you. The fact that you can’t even see them with the naked eye – and they’re crawling all over you, is fascinating,” said Kayleigh Jennings, PulseNet Specialist and Biological Scientist III, at the Florida Department of Health- Bureau of Public Health Laboratories in Tampa, Florida.

By the time Kayleigh hit middle school, she knew she was interested with science, and ever since that first microbiology lesson, her interest never faltered.

Where are they Now? Looking Back at Class of the 18 EID Fellowship: Kayleigh Jennings | www.aphlblog.org

Kayleigh attended the Ohio State University where she majored in Microbiology and minored in Public Health. In her third year at school, she worked at a research facility alongside Michelle Landes, a student who had just received her acceptance into Class 17 of the Emerging Infectious Diseases Fellowship Program. Michelle discussed the program with Kayleigh and encouraged her to apply for Class 18. Kayleigh was so excited about the opportunity she completed the application nearly a year before it was due.

Ten months later, she packed up her life into her small sedan and made the trek from Ohio to sunny Florida to start her dream job as an EID fellow.  Florida was high on Kayleigh’s list not just for its sunny weather, but because her host laboratory, the Florida Department of Health, allowed her to rotate through all the various departments within the lab. This flexibility led her to discover what she enjoyed doing most – working with Salmonella outbreak surveillance using pulsed-field gel electrophoresis (PFGE) and PulseNet – the Centers for Disease Control and Prevention’s national network connecting cases of foodborne illness to detect outbreaks.

“Analyzing Salmonella – I felt like I was doing something important,” said Kayleigh. “It’s gratifying — I’ve seen a series of DNA patterns that are exactly the same, which means they could be a cluster contributing to an outbreak.  I’ve had times where I’ve had to make a phone call to the epidemiologist, and say ‘You should take a look at this…”

One day Kayleigh was glad she didn’t have to make that call; the day she came across one of the most virulent Salmonella strains she had ever seen.

“An 18 year old boy originally from Nigeria came to a local ER soon after he presented with symptoms, and passed away a few hours later. The medical examiner routinely sends cultures to the Clinical Microbiology Department at the Department of Health for analysis, and it was determined to be an atypical septicemic Salmonella infection.  Since the Salmonella was isolated, the sample was then sent to our PFGE laboratory, and thus landed in my hands.” said Kayleigh.

After running PFGE, uploading the pattern to the appropriate databases, and sending the sample to the CDC for further verification, it was quickly determined that it was a rare strain, not typically endemic to the U.S. Thankfully, this particular strain posed little risk to the rest of the population.

While death from Salmonella is rare, foodborne illnesses are quite common and can make individuals very ill without proper treatment. With more than 48 million people in the US acquiring foodborne illnesses each year, food surveillance systems and the laboratory professionals that support them are critical.

“Foodborne illnesses are not going away anytime soon. If someone is sick, you want to know if that strain is contributing to an outbreak. If there was no PFGE or food safety… an outbreak could be spreading rampant and no one would know.”

Other highlights from Kayleigh’s fellowship include working in a BSL-3 laboratory for the first time, touring the CDC headquarters in Atlanta, GA, and training at the local county health department.

“I never would have had any of these life-changing experiences if not for this fellowship,” she said.

When asked about her future plans, she said, “Will I stay in public health? Definitely — I don’t even know what else I would do,” she joked.  “I enjoy helping, and I like the feeling that what I do matters.

Stay tuned for more posts on past EID fellows!

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Measuring Household Dust for Potentially Dangerous Chemicals

Apr 08 2014 :: Published in Environmental Health

This blog post is part of a biomonitoring series.

Can analyzing our household or workplace dust help scientists predict the levels of potentially dangerous chemicals inside our bodies?

In a world where furniture, carpets, curtains and electronics are treated with potent flame-retardant chemicals, we are exposed continuously to novel chemical substances upon which little research has been conducted. The use of flame retardants has become necessary due to changing types of materials used in our household goods.

Measuring Household Dust for Potentially Dangerous Chemicals | www.aphlblog.org

“Think of your living room and all the synthetic materials used in the furnishings and curtains,” said Myrto Petreas, PhD, MPH, from the California Department of Toxic Substances Control. “Now compare that to what was in your grandmother’s living room. Her furniture was probably made with horsehair and wool, and was inherently not prone to fire. With synthetic fabric, there is more fire danger.”

The concern about flame retardants, she said, is that very little is known about these chemicals or what levels, if any, are safe for humans.

Around the time polychlorinated biphenyls, more commonly known as PCBs, were banned in 1979 due to human carcinogenic effects, chemists began creating new flame-retardant chemicals. Fifteen years ago, Petreas and her staff encountered one of the newer ones for the first time. “We were measuring chemicals in a study of breast cancer and looking at the body fat, levels of PCBs, etc. I went to a meeting in Sweden in 1998, where a researcher presented on these new chemicals, PBDEs (polybrominated diphenyl ethers), found in high levels in human breast milk. Back at the lab, I wondered, ‘Can we see it here?’ The levels were so high, I thought it was a mistake.”

Pausing, Petreas added, “The levels are 30 times higher in California now than they were in Sweden then.”

While researchers do not know for sure that the brominated flame retardants, especially the PBDEs, are carcinogens, they are structurally similar to the banned PCBs. They also assimilate into our fat. PCBs, although banned 35 years ago, are still found commonly in people, said Petreas, “because they are in the food web now.” Banning a chemical cannot eradicate it from the population, she explained, but “PBDEs are placed on purpose in our products. We are exposed through dust more than diet. After they are banned, 20 years from now, those PBDEs will be in the food web too, in birds and cows. They stay a long time in the body.”

PBDEs are endocrine disruptors that compete with the thyroid’s hormones, potentially affecting development and cognitive abilities. “In animals,” said Petreas, “they are carcinogens; in humans, we can now look and see but do not have the answers yet.”

The question about whether chemical levels found in dust can help predict the levels in our bodies is an interesting one to biomonitoring scientists who study chemical levels in the human body. “What you see in the dust takes many steps to reach your body,” said Petreas. Just because the chemical is in the air or dust does not mean that your body will absorb it. Also, it is possible that chemicals may be dangerous in combinations rather than alone. Genetics also likely influence susceptibility. Biomonitoring is a sufficiently new science that many questions remain unanswered.

However, it is feasible that scientists could get a good idea of exposure merely by studying the contents of a household’s vacuum cleaner.

Petreas’ lab has worked on two dust studies. One, the California Childhood Leukemia Study, with UC Berkeley, is looking for correlations between childhood leukemia and chemical exposures found in the home. The study is not complete but after looking at the dust samples, Petreas said, “we have seen differences among homes and geography. There is a socio-economic factor: there are higher levels of PBDEs in house dust among lower income households and people of color.”

They also found a high correlation in results from dust tests repeated 3-8 years apart on the same home, showing that the chemical levels were not declining much over time.

The second study, the Firehouse Dust Study that compared levels of pollutants in the blood of firefighters and in the dust of the firehouses, was a side-study of the Firefighters’ Occupational Exposures (FOX) study, conducted by Biomonitoring California with UC Irvine.

“In this pilot study, we tested the blood and urine of 99 men and 2 women,” said Petreas. “We had questionnaires about their work: do they work with forest fires or structural fires? What kind of protective gear do they have and is it used? Later, we wanted to combine the environmental measure with this earlier biological measure. We took samples of dust from the station’s vacuum cleaners. This gives an overall integrated measurement to what the firefighters have been exposed to over time in the firehouse.”

They discovered, perhaps unsurprisingly, that firefighters did have much higher levels of flame retardants in their blood than an average person. Researchers are still trying to identify the main sources of exposure.

Actually, PBDE levels in Californians are higher than in most Americans, largely because of the state’s unique flammability requirements. Petreas pointed out that because the California market is so large, many corporations are designing products to meet the state’s stringent flammability standards and then selling them across North America. As a result, PBDE levels in North Americans are much higher than in Europeans or Asians.

“[Researchers] are always a few levels behind the marketplace,” said Petreas. “We measure the PBDEs now, but already there are different chemicals being used and we don’t know what they are. We can see these chemicals in our samples, but we haven’t studied them yet.”

An important factor in launching these studies has been the creation of Biomonitoring California, a legislatively mandated program that aims to determine baseline levels of environmental contaminants in Californians, study chemical trends over time, and advise regulatory programs. Biomonitoring California is a collaborative effort between the California Department of Public Health, the Office of Environmental Health Hazard Assessment, and the Department of Toxic Substances Control.

“What else is out there that we don’t know about and haven’t looked for?” Petreas asked, echoing a concern that led to the creation of Biomonitoring California.

To reduce exposure to potentially dangerous chemicals, whether from dust or other sources, Petreas said, “Wash your hands before you eat. Just like your mother told you. Never eat at your computer. Leave your shoes outside. These things help with most public health concerns, whether avian flu or chemicals.”

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Without biomonitoring, public health practitioners face challenges in understanding whether environmental contaminants are actually being absorbed into people’s bodies. Given improvements in technology, the capabilities and expertise that exist in public health laboratories, and the increasing demand from the public for more information about chemical exposures, biomonitoring is poised to become an integral component of public health practice.

To learn more about biomonitoring, check out some of APHL’s Biomonitoring Resources:

Stay tuned for our soon-to-be-unveiled Meeting Community Needs page and of course, let us know if you have any feedback or suggestions.  

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APHL Global Health: My Touchstone

Apr 01 2014 :: Published in Global Health

by David Mills, PhD, Director, Scientific Laboratory Division, NM Department of Health

It all began with a late afternoon phone call from my boss, asking if I had any interest in volunteering my time on an APHL project to help public health laboratories in Central America recover from the devastation of Hurricane Mitch. “Sure,” I casually replied, not realizing that my answer was launching me on a journey that, over the next 14 years, would take me to 17 countries on four continents and provide me with some of the most meaningful and rewarding experiences of my professional life.

Looking back, I have to say that I have thoroughly enjoyed the ride. Much of the satisfaction and enjoyment my experiences with the APHL Global Health Program have provided are what I might have anticipated when I first got involved. Philosophically, I had always been a proponent of international assistance and a fan of engineer and inventor, R. Buckminster Fuller, who described the planet as a boat and pointed out the fallacy of the notion that people living in the starboard side of the boat could allow the port-side to sink “without getting their own feet wet, let alone being drowned.” So, international work appealed to me on that level.

APHL Global Health: My Touchstone | www.aphlblog.org

In addition, I have always enjoyed travelling and experiencing different cultures, and my work with the APHL Global Health Program has certainly provided that. And then there was the opportunity for adventures; finding time, after the official work of APHL was finished, to squeeze a day or two for personal activities before returning home, e.g. a safari in Tanzania or a visit to the Forbidden City in China. Other “excitements” were smaller, serendipitous and, perhaps because of that, even more memorable. I will always remember stepping off a small plane near Mt. Kilimanjaro at sunset, catching my first intoxicating whiff of dry grass and faint smoke and being told, “You will never forget that; it is the smell of Africa,” or eating breakfast at sunrise on the edge of a Namibian water hole and spying a troupe of baboons, with babies on their backs, moving through the brush on the far side. Nor will I forget an initially staid and formal evening dinner in a Ukrainian garden that (d)evolved into a boisterous evening of singing, toasting (vodka…) and laughing with new friends after the electricity failed and the gathering continued long into the night by candlelight.

Teaching has also always brought me a great deal of satisfaction—I was a university professor before switching to a public health career—so developing courses and providing training to laboratory professionals for APHL has been extremely enjoyable. I have had the good fortune to be able to share the lessons of my professional experiences (successes and failures) with colleagues in other countries and also to learn from theirs.

But what I never could have anticipated so many years ago and what, more than anything, has kept me coming back again and again to volunteer are the inspiration and humility that that I experience on every single project for Global Health. My day job is terrific—as director of a state public health laboratory, I go to work every day in a new multi-million dollar facility equipped with millions of dollars of analytical instrumentation (and a staff engineer to maintain it) and sophisticated engineering safety systems. Our laboratory is supported by a central team that responds immediately to IT issues, and a courier system that delivers specimens overnight. We have access to federal laboratories for specialty testing and technical support and a national organization, APHL, which provides training and professional support. And yet, with all of these resources, I find that much of my time is spent focusing what is perceived as lacking—budget, staff, competitive salaries, flexible work schedules, new instrumentation, software and so on. These challenges, difficult and ubiquitous, are the reality of management in public health. Over time, however, immersion in these details day after day can make the excitement over the greater purpose of the mission and the people we serve fade and seem very far away, and it is this that keeps me coming back to volunteer.

To periodically leave my day job and travel to a place where smart and talented professionals pursue the mission of the public health laboratory, performing testing similar to that in our own laboratories, but under very difficult conditions, is inspiring. What do I mean by difficult? Difficult is a laboratory performing serology testing when it has electricity irregularly for only 2-4 hours per day. Difficult is washing and reusing latex gloves because of their scarcity. Difficult is performing microscopy in a room with high water stains on the walls a meter off the floor and all of the refrigerators on blocks to keep them above the periodic floodwaters. Difficult is not having a single repair technician in the country to service analytical instruments. Despite these incredible challenges, the people I have worked with in country are enthused, dedicated and optimistic about the work they perform and its importance. Seeing how much they accomplish under these circumstances, I often have thought to myself, “If these people had even half of the resources and support that I have in my laboratory, they would leave me in their dust!”

Quite simply, the international projects are my touchstone. They remind me how fortunate we are, and they re-energize me and rekindle my enthusiasm for my career as a scientist in public service… and after each experience, I return to my laboratory able to do my job better than before I left. Without a doubt, I gave my boss the right answer.

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HIV Testing Where Ice Melts Fast: EID Fellow Reports from Botswana

Mar 26 2014 :: Published in Workforce & Professional Development

By R. Suzanne Beard, PhD, Emerging Infectious Disease Research Fellow

Dried blood spots (DBS), drops of blood collected to screen newborns for congenital disorders, are the wave of the future for HIV testing of all sorts; at least that is what I am trying to prove during my Emerging Infectious Disease Research Fellowship. How am I doing this, you ask? Great question! I am helping design studies to evaluate filter papers from different manufacturers for viral load testing and drug resistance genotyping in resource-limited settings.

As antiretroviral treatment expands in resource-limited areas, so does the need to complete testing quickly. The problem is that plasma – to date the gold standard in HIV testing — requires separation from whole blood, and then it needs to be frozen and kept that way until testing. This leads to the need for cold chain transport in places that may not have stable electricity or the infrastructure to maintain freezers. And all this in a place that makes summer in the south look refreshing. Trust me, if you order an ice water in Botswana in November, the ice doesn’t last very long, and the same thing goes for ice in a cooler with specimens.

HIV Testing Where Ice Melts Fast: EID Fellow Reports from Botswana | www.aphlblog.org

In the year since I started working with HIV, I have discovered that much of the research with DBS does not consider conditions in resource-limited settings, as a result, when protocols are implemented in these areas, the impact on patient care may not be as profound as it could or should be. My team is working to produce quality research that takes this into account and actually conducts the work in areas where cold chain transport isn’t an easy, inexpensive option.

I spent a month in Botswana initiating a protocol to investigate the usefulness of three DBS filter paper cards to evaluate viral loads, and in those failing treatment, the prevalence of HIV drug resistance in pediatric patients on anti-retroviral therapies (ART). As with every protocol, what you dream up sitting in your cubicle, doesn’t always account for the issues you find on the ground during implementation. It took almost two weeks before specimen collection could begin. In the meantime, we amended the protocol to speed up specimen collection and added a collaborator (Baylor Pediatric Clinic). The key to a successful trip to a new country is to be flexible and focus on the unique assets in front of you!

I also assisted in troubleshooting several assays in use at the Ministry of Health and CDC-Botswana labs. The opportunity to do technology transfer and troubleshooting is one of the things I like best about traveling to labs in other countries. Each new lab represents a completely different set of obstacles and challenges, even if those labs are right across the street from each other. On this trip, I was working to transfer a new, more cost-effective in-house HIV drug resistance genotyping test.  I had a great time working together with all of the technicians. We modified the protocols to fit what they had available to them and worked on sequencing analysis. After a couple of days, they felt more confident in their own abilities.

My final job was to visit clinics around Gaborone (the capital) and Francistown (the second largest city) to collect information on ART enrollment for an upcoming protocol with the Ministry of Health. After database issues delayed efforts to collect numbers needed to determine how many clinics should be established in the region, we decided to tackle the problem in a low tech fashion.  With the approval of the Ministry of Health, we spent several days visiting clinics. This gave me a chance to get to know the country a bit better and to interact with nurses, doctors and other community health support staff who work on the front lines of the HIV pandemic.

If we are to have a chance at achieving an AIDS free generation, we must collaborate to build capacity in labs and clinics through training and access to inexpensive specimen collection and testing. This capacity isn’t just useful in far-off, exotic places; everything we do is applicable here at home. During emergencies when power is down for long periods of time — think Katrina or Super Storm Sandy — DBS technology can keep key public health initiatives on track.

I look forward to returning to Botswana to continue working with my colleagues to transfer technology and expand use of DBS.

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TB Vanquished by Lab System in the “Malibu of the Midwest”

Mar 24 2014 :: Published in Infectious Diseases

By William Murtaugh, specialist, HIV/TB programs, Infectious Disease, APHL

“Defeat TB: Now and in the Future.”  This was the first theme of World Tuberculosis Day declared by the International Union Against Tuberculosis and Lung Disease (IUATLD) 32 years ago today in 1982, and 100 years after Dr. Robert Koch announced his discovery of the bacteria that cause tuberculosis disease (TB).

Well, the future is March 24, 2014, and TB has not yet been defeated.  But year after year,  and theme after inspiring theme,  the global public health community still proclaims a call to arms, aiming to inspire the world to take up the cause of TB elimination.

TB Vanquished by Lab System in the “Malibu of the Midwest” | www.aphlblog.org

In the United States, the burden of TB is very low relative to many parts of the world. Why then should we be concerned with Mycobacterium tuberculosis, the obligate bacillus demanding our attention today?

It is common to cite TB statistics to emphasize the disease’s impact and the progress toward its elimination. Indeed any TB expert can pull some staggering historical numbers out of his or her pocket.  But reconciling unembellished phrases like “billions infected,” “millions of new cases,” “over a million deaths,” with the experience of those of us average Americans who’s TB “exposure” is limited to news bulletins on World TB Day, is challenging. For us, World TB Day serves as a gentle nudge that the disease is still a threat, and the fight for its elimination continues. Yet while I would be remiss if I did not mention that the United States has seen 21 years of consecutive decline in annual TB cases, I must contend that TB awareness is particularly important here in the United States because of the country’s low TB burden.

Lest we take our progress for granted, repeating the mistakes of the 1980’s and 90’s, it’s important to remember the consequences when the health system falters.  But for the one day, hour or minute that we consider World TB Day, let’s recognize that our progress to date has been achieved through the quiet efforts of a public health system that functions not one day, but all year long.

A TB outbreak in April 2013 exemplifies this point. Along the shores of Lake Michigan sits Sheboygan, WI, a city whose description could be mistaken for a Garrison Keillor monologue “where all the children are above average” and so too are its TB case rates. This Midwestern community learned the hard way that the damaging effects of TB can still be very real.

Prior to 2013, Sheboygan County typically saw fewer than three TB cases per year.  Known as the “Malibu of the Midwest” for its lake surfing competition (the largest in the world in fact), Sheboygan was a place more familiar with the phrase “Hang Ten” than “MDR-TB.”  Then in mid-April, the Sheboygan County Health Department was notified of a suspected TB case that would lead to an outbreak that would engage its resources and generate national media coverage for the remainder of the year.

Before it was over, the outbreak would cross the county and spread through multiple generations of a single family, school children and healthcare workers. It would lead to a case of MDR-TB, 11 additional cases of active pulmonary TB disease and 38 latent (non-symptomatic, non-contagious) TB infections. Over $6 million in state and federal funds ($4.7 million state, $1.4 million federal) would be expended to cover costs associated with outbreak investigation, testing, treatment and prevention measures.

Because TB is uncommon in the US, doctors may not consider it as a potential diagnosis. The first (i.e., index) case in the Sheboygan outbreak sought medical care for symptoms at least eight months before receiving a diagnosis of TB. What should have been a straightforward case – in which a suspected TB patient is diagnosed, treated and transmission prevented – led to eight months of transmissions.

Once TB was finally proposed as a diagnosis, the Wisconsin State Laboratory of Hygiene (WSLH) responded quickly, performing initial screening in two days and confirming diagnosis in less than two weeks. This diagnosis kick-started the TB control system into high gear. The patient was isolated and treated, and contact investigations were initiated to find related cases.

Next the WSLH assessed the standard drug regimen to determine if it would prove effective with this patient. With assistance from the Centers for Disease Control and Prevention (CDC), the lab identified  multi-drug resistant TB (MDR-TB) a category of infection that involves resistance to multiple drug therapies, is more difficult and expensive to treat, and holds a higher risk of death — as the cause of the patient’s illness. Now the concern was, “Had other patients been exposed to MDR-TB in the past eight months?”

More specimens began arriving at the local laboratory near Sheybogan, which quickly exceeded its capacity. With the threat of an MDR-TB outbreak, a solution was needed quickly. Enter the integrated public health laboratory system!  State and local laboratories coordinated with the community hospital in Sheboygan and decided jointly that all specimens from TB suspects would go to the WSLH.

As diagnosis after diagnosis of active pulmonary TB was confirmed, the state TB Control Program wanted to know if all these cases were part of the same outbreak.  While this may seem an obvious “YES!”, not all TB is created equal. Numerous strains of TB are continually in circulation. Without identification of the specific strain, public health officials could not understand the chain of transmission, and without this information, they could not control the outbreak.

Through a CDC initiative designed to strengthen national response to TB outbreaks, state public health laboratory in Michigan performed complex testing to uniquely identify each strain of M. tuberculosis (called genotyping). They determined that the MDR-TB patient was infected with two different strains of TB, one of which was not MDR-TB.  The state laboratories confirmed that other TB strains also belonged to the outbreak. None of these strains, however, were MDR-TB and therefore were more easily treated.

Not bad for a low burden TB setting.

Sheboygan’s story reminds us that TB outbreaks can happen anywhere. Yet if an outbreak does occur in our community we can look with confidence to the response capability of the nation’s public health laboratory system. The impressive response to the outbreak in Sheboygan testifies to the expertise and commitment of  these laboratory professionals. It also epitomizes CDC’s World TB Day theme:  “Find TB. Treat TB. Working together to eliminate TB.”

To learn more about public health laboratories and TB, check out APHL’s TB page. Additional information and resources for World TB Day and related events can be found at CDC’s dedicated website.

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Days End; Unending Night?

Mar 18 2014 :: Published in Public Policy

By Peter Kyriacopoulos, senior director of public policy

The federal fiscal year 2014 appropriations process concluded on January 17, 2014, with enactment of the Consolidated Appropriations Act. That bill funded federal government operations for the eight month remainder of fiscal year 2014, which began October 1, 2013 with the shutdown of the federal government and runs through September 30, 2014.

Overall, the 2014 appropriations levels provide some relief for many programs on which the nation’s public health laboratory system depends. Instead of the full $36 billion cut in nondefense discretionary spending – the budget account that funds the Department of Health and Human Services and its agencies like the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA) and the Food and Drug Administration (FDA) – required by current law, only $14 billion will be cut in 2014.

Days End; Unending Night? | www.aphlblog.org

This $22 billion in “additional” funding has led to $30 million in funding for the CDC Advanced Molecular Detection initiative, an additional $31 million for state and local preparedness, and $9 million more for CDC food safety activities. Most other areas of CDC, HRSA and FDA of interest to the public health laboratory community get level funding, the exception being CDC’s Public Health Workforce which is cut over $11 million – a cut that imperils the APHL fellowship program in the coming year. Funding for the Environmental Protection Agency (EPA) Clean Water and Drinking Water revolving funds are also increased $73 million and $46 million respectively.

While the 2014 funding levels offer some respite, it is transitory as the agreement for spending levels in fiscal year 2015 includes a much smaller reduction is spending cuts of only $9 billion. This also means the amount cut will be $27 billion – or $1 billion more than the amount cut in 2013. Complicating the picture further, $7 billion of the $9 billion in relief is directed to other specific funding needs so that the actual relief from cuts for the rest of nondefense discretionary is closer to only $2 billion. Federal funding in 2015 will be substantially below what was provided in 2013 with the possibility that it will have the effect of a $34 billion cut, and each of the fiscal years 2016 through 2023 will have no relief from the $36 billion that will be cut annually.

One hopes that the impact of these current and projected cuts provide ample evidence on why sequestration and automatic cuts in spending were never intended to become actual policy and are so punitive that they lead to a more inspired and thoughtful resolution of financing federal government operations. If not, the dark forecast will indeed appear as unending night.

  •  SEQUESTRATION!
  • American Taxpayer Relief Act (ATRA)
  • Sequester 2013 Operating Plans
  • CDC funding cut $340 million; PHEP hit hardest at -$34 million
  • HRSA: -$365 million
  • FDA: -$209 million
  • Global Health: -$411 million
  • EPA: -$385 million
  • After Sequester?
  • Fiscal Year 2014
  • House-passed budget – 3/2013 (Congressman Paul Ryan)
    • Continues reduced sequestration funding for nondefense discretionary (NDD);
    • Cancels the reductions in defense and transfers those cuts onto NDD; and
    • Imposes  additional cuts of $700 billion on NDD over the next ten years.
    • Senate-passed budget – 3/2013 (Senator Patty Murray)
      • Eliminates sequestration,
      • Imposes cuts of $145 billion on NDD over next ten years.
      • President’s budget request – 4/2013
        • Eliminates sequestration
        • Imposes cuts of $98 billion on NDD over next ten years, staring 2017
        • CDC takes largest cut of any HHS agency, -$270 million
        • SHUTDOWN!

(Partial)

  • We Have a Deal?!
  • What is That Number?
  • Murray/Ryan Agreement
  • 2014 Appropriations

 

  • WHAT’S NEXT?!
  • What’s Next?
  • Total spending for 2015 is set –
    • $1.013  trillion
    • NDD sequestration for 2015 is set –
      • $27 billion (+$1 billion over 2013; ~+$6 billion)
      • President’s budget for 2015 March 4
        • So what?
        • How Does This End?
        • 2015 funding cuts worse than 2013 – no delays
        • 2016 full $36 billion NDD sequestration
        • Impact of mid-term election results?

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