MERS-CoV: Why We Are Not Panicking

By Tyler Wolford, Specialist, Laboratory Response NetworkPublic Health Preparedness and Response Program; and Stephanie Chester, Senior Specialist, Influenza Program, Infectious Disease Program, APHL

MERS-CoV: Why We Are Not Panicking | www.aphlblog.orgBy now you have probably heard that CDC has confirmed two cases of Middle East Respiratory Syndrome (MERS-CoV) infection in the US. Both were imported from Saudi Arabia; travelers became sick on their journey and sought care here in the US. This is the kind of stuff that typically gets us, infectious disease and preparedness folks, amped up, reaching for coffee and telling our loved ones we might be working late. We know that MERS-CoV is a serious infection – as of mid-May 2014, there have been 536 laboratory-confirmed cases and 145 deaths of MERS-CoV. However, the laboratory community is accustomed to responding to these situations—and that’s good news for public health. We have written, tested and rewritten preparedness plans, policies and procedures for dealing with novel and/or unexpected events and pathogens. We have dealt with white powders (more times than we can count), influenza A(H3N2)v, re-emerging vaccine preventable diseases and many other threats. In addition, we were given a lengthy (roughly two-year) heads-up with MERS-CoV. And while we know not to expect this luxury every time (we’re looking at you, 2009 H1N1 pandemic), the lead time meant that CDC, public health laboratories, health departments and clinicians were alerted and prepared well before the first US two cases occurred. Efforts by CDC and the public health labs ensured that, when the first cases arrived, they could be rapidly identified so proper precautions and epidemiologic investigations could begin. What are the reasons for our relative calmness despite the arrival of MERS-CoV on our shores? We were – and still are – prepared as the case count mounted on the other side of the Atlantic. Here are the specifics:

  • Planning. MERS-CoV was first reported in 2012 in Saudi Arabia. Once transmission became sustained in the Middle East, public health officials knew it was likely that a case would arrive in the US: we just didn’t know when. We had time to plan our response.
  • An approved test. CDC rapidly developed a real-time reverse transcriptase polymerase chain reaction (rRT-PCR) test which was granted emergency use authorization (EUA) by the FDA on June 5, 2013, and deployed the same month to 44 state public health laboratories and one local public health laboratory.
  • Infrastructure. The Laboratory Response Network (LRN) provided critical infrastructure for rapid distribution of the MERS-CoV test to public health laboratories across the US.
  • Training. Once laboratories received the test, they trained their staff and completed proficiency testing to demonstrate that they were trained and ready to perform testing should the need arise.
  • Experience. With health departments and physicians on alert, over 150 patients with MERS associated symptoms have been tested using the CDC assay. All were found to be negative.  This testing provided valuable opportunities for laboratories to familiarize themselves with the test.
  • Communication. CDC, APHL and other partner organizations have maintained timely communications with states, and others partners to keep everyone abreast of the current situation.
  • Dedication. Our public health labs are full of amazing scientists who are willing to spend countless hours, seven days a week to ensure rapid test results.

So if we aren’t panicking now that we have MERS-CoV cases in the US, what are we doing? We’re sprinting to keep pace with MERS-CoV and so far we have performed well, managing every step in the process with precision.

  • Indiana promptly notified CDC of a presumptive positive MERS-CoV infection and CDC rapidly confirmed this result.
  • CDC and Indiana started epidemiologic investigations and tested samples from close contacts of the infected patient.
  • APHL and CDC began communications immediately after the first case was confirmed.
  • APHL, in collaboration with CDC, held a laboratory alert call on May 6, 2014, to provide state and local public health labs with a situational update and to review laboratory testing guidance.
  • Currently CDC is distributing new proficiency testing panels so labs can refresh their competency on the CDC MERS-CoV test.

MERS-CoV is a serious threat that deserves the highest level of preparedness and attention.  Fortunately for the American public, we in the public health system are poised to handle MERS-CoV and other health threats whenever, wherever and however they enter our country. This is why we aren’t panicking, but it’s also why public health requires steady support.  Pathogens have no regard for budgets, funding cycles or economic trends. They won’t wait, and neither can we.

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USAMRIID: Biodefense from the Cold War to Present Day

Jan 08 2014 :: Published in Public Health Preparedness & Response

By Chris Chadwick, Specialist, Public Health Preparedness and Response, Tyler Wolford, Specialist, LRN, and Kara MacKeil, Associate Specialist, Public Health Preparedness and Response

Many of us in public health have become familiar with the US Army Medical Research Institute of Infectious Diseases (USAMRIID) and its role in scientific research and biodefense. However, what we don’t see in the movies is its long-term and far-reaching involvement in the overall preparedness of our nation.  APHL’s Public Health Preparedness and Response (PHPR) team recently visited USAMRIID at Fort Detrick, MD, as part of the Laboratory Response Network’s (LRN) Operational Workgroup, and we were fortunate to spend some time touring the facilities and learning more about USAMRIID’s history.

USAMRIID: Biodefense from the Cold War to Present Day | www.aphlblog.org

Officially created in 1969 when the existing US Army Medical Unit (USAMU) was renamed, USAMRIID’s stated mission is: “We conduct research on current and emerging biodefense threats, resulting in medical solutions to protect the warfighter.” The benefits of the facility’s research aren’t limited to the armed forces though.  USAMRIID’s work includes vaccine and treatment research, and their scientists offer expert consultation and training for medical personnel. During our tour we also learned that one of the first ever laboratory gloveboxes was put together in the Fort Detrick machine shops in the 1940s.

There are more interesting things than gloveboxes in Fort Detrick and USAMRIID’s history though.  One of the most thought-provoking things we observed on our tour was USAMRIID’s famous Eight Ball, a piece of US history that’s protected under the National Register of Historic Places. This one million liter metal sphere is currently tucked away behind a service building, but at one point it was the epicenter of Operation Whitecoat, the US Cold War biodefense program.  From the 1950s through the ‘70s, researchers developing treatments for biological agents released small amounts of these selected agents into the eight ball, allowed them to disperse, and then exposed volunteers to this contaminated air via specially rigged gas masks.  By treating the volunteers (who signed consent forms) with their newly developed vaccines and therapies, scientists were able to develop effective methods to respond to biological warfare. Whitecoat volunteers were exposed to agents that cause diseases such as rabbit fever (tularemia), Q fever, yellow fever, and plague.

Operation Whitecoat and the eight ball experiments may seem shocking to modern readers, but the volunteers were scrupulously screened and educated on the risks and gory details before agreeing to participate.  They received the best medical attention possible at the time, and they were free to end their participation at any point.  Although work in the eight ball was discontinued in the mid 70s, many still return to USAMRIID for annual get-togethers commemorating their work.

Of course, the work didn’t end with Operation Whitecoat.  National laboratories like USAMRIID are the pinnacle of the Laboratory Response Network (LRN), and are responsible for specialized strain characterizations, bioforensics, and handling highly infectious biological agents. These activities require significant planning and state of the art facilities to ensure the safety and security of scientists and that the right results are obtained.

Although most LRN testing at USAMRIID is done in Biosafety Level 3 (BSL-3) equipped laboratories, it is one of a few laboratories in the United States that has BSL-4 facilities. Biosafety level is the level of biocontainment required to work with specific biological agents based on the risk posed by the agent and the activities required for testing. Each level requires a unique set of safety equipment, facility designs, and practices that reduce the risk of laboratory-acquired infections. BSL-4 laboratories are equipped to handle the most dangerous organisms, such as Marburg, Ebola and Smallpox viruses that are highly infectious and potentially lack countermeasures (prevention and treatment).

The most noticeable difference in BSL-4 laboratories is the use of full-body pressurized suits, often referred to as “space suits.” For reference, imagine the movie scene from E.T. the Extraterrestrial where the space garbed scientists ominously invade a home searching for the alien. These suits are the highest form of personal protective equipment and are required for work in BSL-4 labs. BSL-4 also requires scientists to take chemical showers, enter vacuum rooms, and be exposed to UV light in order to destroy any trace amounts of the organisms after testing.

USAMRIID is a vital resource for definitive testing of emerging high-risk biological threats. For an interesting read, check out The Hot Zone written by Richard Preston, which highlights USAMRIID’s involvement in the 1989 discovery of Reston virus, a mutated strain of Ebola virus that surfaced near the nation’s capital.

USAMRIID is also heavily involved in the training of first responders across the world, including hazardous materials teams and National Guard Civil Support Teams (CSTs), tactical response teams, emergency communications, and others. These trainings have gained significant respect in the public health and public safety communities. In addition to their high quality, the trainings are standardized, so a team from Washington will receive the same training and competencies as a team in Maryland. These courses have also benefitted from partnership with other LRN members over the years, allowing USAMRIID to truly integrate all players involved in a typical threat response. For example, we learned of several instances where public safety (law enforcement and fire) was integrated with one of APHL’s own member laboratories to provide on-scene screening and then confirmatory analysis via the LRN.

USAMRIID’s Field Operations and Training Branch (FO&T) provides two courses to first responders: the Biological Agent Identification and Counterterrorism Training (BAIT) and the Field Identification of Biological Warfare Agents (FIBWA) Course. BAIT provides first responders with one- or two-day realistic bioterrorism scenarios that require an integrated response, emergency communications, rapid decision making, analysis of biological threat agents, and an after action review once the exercise is complete. During APHL’s visit to USAMRIID, we had the opportunity to tour the onsite facilities that FO&T utilizes for these training scenarios. The facilities are actual trailers that have been rigged to serve as mock clandestine laboratories. As part of the scenarios, supposed terrorists have a DIY setup for weaponizing agents (e.g., making anthrax-like powders to stuff into envelopes and packages). To test the first responders, there are clues throughout the trailer (think quirky living arrangements, basic chemistry textbooks, and large plastic containers…the kind of stuff you probably saw in Breaking Bad) that suggest the presence of a clandestine lab. Another scenario involves searching a packed storage unit (a replica from an episode of Hoarders, probably) for suspicious powders; participants especially dislike this one because they’re required to remove and test every piece of equipment even though the powder is rather easy to find. The BAIT program is nationally recognized as a premier course for all first responders, and therefore, FO&T is constantly training a variety of groups from all over.

FO&T’s other course, FIBWA, provides first responders with an intensive four-week syllabus on conducting laboratory operations under field conditions. Participants become very familiar with agent detection assays over the four weeks as they work to extract nucleic acid, perform polymerase chain reaction (PCR), and practice electrochemiluminescence (ECL) to detect threat agents and toxins. FO&T has several mobile laboratories at their disposal, so the trainees must adapt to tighter, more consolidated spaces. FO&T can host the trainings at Ft. Detrick, but the mobile labs do travel well so trainings can come to you.

USAMRIID is truly instrumental in national biodefense history, response, research, and training, and has outstanding resources for APHL’s membership.

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Sarin Gas Attacks in Syria: What if it happened in the US?

Nov 19 2013 :: Published in Environmental Health

By Surili Sutaria Patel, Senior Specialist, Environmental Health, APHL 

“It is the worst use of chemical weapons on civilians in the 21st century,” said United Nation’s Secretary-General Ban Ki-Moon.

On the cool night of August 21st, residents of Ghouta, a suburb of the Syrian city of Damascus, were abruptly awakened by an explosion. In a region ravaged by civil war, explosions were unfortunately common; this particular explosion, however, was different.

An artillery rocket containing sarin gas had been released in the night, as the temperature dropped right before dawn. The cold, now-toxic air in Ghouta did not rise. Instead, the heavy gas circulated close to the ground and pervaded the lower levels of buildings where families rested for the night.

Almost immediately, many felt an onslaught of troubling symptoms: shortness of breath, disorientation, irritated eyes, blurred vision, nausea and vomiting. Many dropped into unconsciousness and over 1,400 people died, including 400 children, who would have been getting ready to go to school a few hours later.

Sarin is a volatile, man-made nerve agent used as a chemical weapon. First developed in Germany as a pesticide in 1938, sarin is a very toxic and fast acting gas. It is difficult to detect as it is a clear, colorless, tasteless and odorless vapor. Sarin enters the body through the eyes, skin, lungs or eating contaminated food. Instantly after exposure to the gaseous form and a few minutes after exposure to the liquid form the toxic effects of this chemical will present in humans. Sarin is a deadly chemical yet it is short-lived in the environment, presenting a very serious public health threat.

Given the symptoms (and the assumption that chemical weapons had been used), the UN stepped in to officially determine the cause of illness & death. They assembled an investigative team of scientists from Finland, Germany, Sweden and Switzerland to examine both environmental and clinical samples (blood, hair and urine).

A total of 30 environmental samples were collected from two impact sites and analyzed by two laboratories. Concurrently, a clinical investigation advanced: in addition to conducting medical examinations, 34 victims were selected to provide blood and urine samples for further investigation. Nearly 85% of the blood samples tested positive for sarin. The investigative team reported back with great confidence that the chemical weapon used was in fact, sarin.

The world mourned for these innocent people, so devastated by such an atrocious crime. The large-scale use of such weapons against civilians led to increased international attention on chemical weapons of mass destruction: their possession, storage, destruction, and use. Not only did the global community call for Syria to disclose and destroy their chemical weapons, but many countries examined their own system for responding to such an attack.

Sarin Gas Attacks in Syria: What if it happened in the US? | www.aphlblog.org

While it is painful to think of, what if this reprehensible act of terrorism had taken place on US soil? Americans are protected by the CDC-funded Laboratory Response Network (LRN) which maintains an integrated network of laboratories that can respond quickly to acts of biological or chemical terrorism, as well as all the other wonderful first responders that skillfully approach such a scene.   The Laboratory Response Network for Chemical Threats (LRN-C), comprises 54 public health laboratories at the local, state, and territorial levels, and has protocols similar to the UN investigative team: from the systematic method used to select individuals for clinical testing to the chain of custody protocols practiced when collecting and shipping the samples to the appropriate laboratories. LRN-C operates as a network of laboratories designated Level 1, 2 or 3 laboratory capabilities.

  • Level 3 laboratories work with hospitals and first responders for clinical specimen collection, storage and shipment.
  • Level 2 laboratories employ chemists trained to detect various toxic chemical agents, including nerve agents such as sarin.
  • Level 1 laboratories use high-throughput analysis to serve as surge-capacity laboratories for CDC, in case CDC is overwhelmed by the number of samples. These labs also have the capability to test even more chemicals than the Level 2 laboratories.

The LRN, with funding and assistance from CDC, serves as a global, national, state and local asset. Its staff remains crucial to any chemical response in the United States and even abroad.

While we hope for that day where the potential for such atrocities no longer exists, we recognize the need to remain vigilant and prepared. Most importantly, our hearts and thoughts remain with the people of Ghouta, and Syria at large.

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Looking Back at Superstorm Sandy: Preparedness for the Public Health Laboratory

Oct 29 2013 :: Published in Public Health Preparedness & Response

By: Scott Hughes, PhD, Chief of Emergency Preparedness & Response, New York City Public Health Laboratory; and Christopher Chadwick, MS, Specialist, Public Health Preparedness and Response, APHL

Public health laboratories work tirelessly to protect our nation from a multitude of threats—suspicious powders, foreign viruses, and even molasses spills. But how do the laboratories protect themselves in the face of danger? As we mark the one-year anniversary of Superstorm Sandy, we’re reminded exactly how they do so.

Looking Back at Superstorm Sandy: Preparedness for the Public Health Laboratory | www.aphlblog.org

On October 22, 2012, Tropical Depression 18 slowly churned in the southern Caribbean. Despite an inconspicuous start, the tropical depression amped up to become Tropical Storm Sandy and then Hurricane Sandy just two days later. Within a week, Hurricane Sandy marched up the east coast to meet a cold front thus creating Superstorm Sandy, an epic rain, wind, and snow event, which had only ever existed in Hollywood blockbusters. On Monday, October 29th Sandy struck New York City.

While Sandy began its havoc in the Caribbean, the New York City Department of Health and Mental Hygiene ramped up its preparations and activated the Incident Command System on Friday, October 26th.  Would the storm actually hit New York City?  As we now know, the storm was devastating.  Much of Lower Manhattan flooded. Fortunately, the New York City Public Health Laboratory avoided severe damage but only had emergency power in certain areas — a limitation that didn’t stand in the way of performing essential testing.

The lab had work to do despite what was happening around them. On Wednesday, October 31st, just two days after Sandy struck New York City, the laboratory’s bioterrorism staff was sent a suspicious powder for testing, a task that is commonplace for them.  But the circumstances were quite different – this was a challenging Halloween treat for the staff! Despite facing the apocalyptic storm, working with limited power and Internet connectivity, and lacking many staff members who were unable to get to work, the New York City Public Health Laboratory maintained bioterrorism testing as an essential function.  The testing was completed quickly as usual, demonstrating how resilient our public health laboratories are during crises. (Testing showed the powder was negative for potential biothreat agents.)

By November 5, the New York City Public Health Laboratory was fully functional and resumed all testing.

Early decisions were critical for the laboratory to protect itself and its staff. Continuity of Operations Planning (COOP) can be a vital resource for all laboratories when making decisions such as what testing should be maintained, what testing can be shared (e.g., the New York State Department of Health in Albany helped out with tuberculosis testing during Superstorm Sandy), and which staff are essential. Public health laboratories are trained to expect the unexpected, and with the help of COOP, the laboratories continue offering essential public health services, which is a true reward of proper preparedness.

Reminder: Hurricane season lasts until November 30th. Preparedness is a continuous process, so be sure to get a kit, make a plan, be informed, and get involved!

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What Exactly Does the Shutdown Mean for Public Health?

As we face day three of the federal government shutdown, we are hearing more about the deeply felt impact on our federal partners.  While we can be grateful that local and state public health agencies are still hard at work, the federal portion of the continuum is minimally staffed and operating a bare-minimum of essential programs that ensure the public’s health and safety.  Below are some of the negative effects we are hearing from the Centers for Disease Control and Prevention (CDC), the United States Department of Agriculture (USDA), the Food and Drug Administration (FDA), and the Department of Health and Human Services (HHS).

What Exactly Does the Shutdown Mean for Public Health? | www.aphlblog.org

Reference Testing Services Will be Delayed or Absent

CDC provides highly specialized reference testing for rare pathogens and for rare instances of drug resistance. Although CDC will maintain many of these services, the number of staff performing these tests will be greatly reduced. The result will be a delay in delivery of potentially lifesaving test results.

For example, the Division of Tuberculosis Elimination performs sequencing to detect mutations associated with drug resistance to rapidly identify persons with drug resistant TB.  It is the only laboratory in the country that is currently utilizes this method (which provides a high level of detail) for public health investigations.  Delayed results will lead to delays in delivering optimal treatment to patients and mounting an appropriate public health response.

National Disease Surveillance Will Be Weakened

CDC collects data on infectious diseases from all 50 states, local jurisdictions and territories.  The compiled data tracks how diseases are spreading and helps scientists to identify multi-state outbreaks.  One of the best examples of this function is influenza surveillance.  Flu season is upon us; CDC monitors the flu virus strains that are circulating nationally, keeps track of any resistance to drugs, and determines how well this season’s flu shot will work against circulating strains, and sends national alerts to public health professionals when things look out of the ordinary.  It shares the data generated from this activity with state and local health departments, providing them with a “big picture” view of flu activity across the country. Armed with this information, they can prepare effectively for potential outbreaks in their area. But a prolonged government shutdown will reduce the clarity of the big picture view, since less data will be collected.

CDC Support of Local Outbreak Response will be Limited

CDC services like advanced testing and consultation to state and local public health programs facing cases or outbreaks of relatively rare diseases. Because these diseases are so rare, many jurisdictions rely heavily on subject matter expertise at CDC for advice and information when responding. Although CDC’s skeleton crew of staff will do its best to assist, state and local public health departments will be largely on their own when it comes to responding to outbreaks of relatively rare diseases like measles or mumps.

Food Safety Will be Negatively Impacted – More People Could Get Sick

  • If you and others who ate the same food become ill from certain types of foodborne bacteria, you may never know the cause of your illness, as CDC will not be analyzing all of the data submitted, and FDA and USDA will not be following up on those leads to track the source of the illness.  These are necessary steps to ensuring fewer people get sick.
  • CDC will delay assessing the proficiency of state and local laboratories that participate in PulseNet.  This bi-annual assessment may be pushed back for several weeks, even if the shutdown only lasts several days.
  • State and local scientists who want to begin submitting DNA fingerprints to PulseNet will not be allowed to, as CDC certification of new PulseNet participants will be on hold.
  • In normal operating status, state and local food regulators do not have enough resources to properly inspect all retail food establishments and restaurants.  With federal inspection personnel on furlough, even fewer establishments will be inspected to make sure that they are following the regulations.
  • CDC’s IT staff have been furloughed. PulseNet IT staff are not present to aid public health laboratories if they are unable to connect or submit data to the national databases. If the system fails, national outbreak detection could come to a halt. If communication list-serves fail, there are few remaining staff with the know-how to repair these critical national communication tools.

Select Agent Program Has a Delayed Response

Due to the absence of either an FY 2014 appropriation or a Continuing Resolution for HHS and USDA, the Federal Select Agent Program, which oversees the possession, use and transfer of biological select agents and toxins that have the potential to pose a severe threat to public, animal or plant health or to animal or plant products, is not fully staffed and thus unable to provide timely regulatory compliance support to state and local entities. These regulatory gaps could have serious implications for safety and security.

Laboratory Response Network Anticipates Delays

Because the CDC is operating with minimal staff throughout, the Laboratory Response Network, which is the nation’s premier system for responding to potential bioterrorism, chemical terrorism and other public health emergencies, is down to just a few staff with anticipated delays in responding to requests for assistance from state and local public health laboratories and no support for daily reagent shipments.

The larger impact is the lack of federal support for state and local public health. While these state and local agencies continue to conduct routine surveillance and monitor the nation’s health, they rely on their federal counterparts to provide the big picture of disease spread, potential releases of biological threats as well as scientific guidance and methodologies to detect novel threats, like the MERS-coronavirus.

Newborn Screening Laboratory Quality Assessment Delayed

Closing CDC has delayed the fourth quarter assessment of newborn screening laboratory quality. If the delay is extended, then these laboratories will not be able to rely on the assistance of CDC to maintain their compliance with Clinical Laboratory Improvement Amendments, the federal law known as CLIA. Newborn screening depends upon high complexity laboratory operations that are governed by the requirements of CLIA, which include an independent external review to provide quality assurance – and is provided by CDC in the case of newborn screening.

The shutdown will force newborn screening laboratories to seek out non-traditional sources for external review, establish a working relationship with them – possibly at some expense, and pursue activities to meet the CLIA quality assurance requirements. This will not only be inefficient, cumbersome and potentially costly, it will also result in a greater degree of uncertainty because it has never been done.

As CDC’s website details, “The Newborn Screening and Molecular Biology Branch, Division of Laboratory Sciences, operates the Newborn Screening Quality Assurance Program (NSQAP). NSQAP is a voluntary, non-regulatory program to help state health departments and their laboratories maintain and enhance the quality of test results. The program is operated in partnership with APHL. The program provides services to more than 85 domestic newborn screening laboratories, 31 manufacturers of diagnostic products, and laboratories in 67 countries. NSQAP has been the only comprehensive source of essential quality assurance services for dried-blood spot testing for more than 33 years.”

The shutdown will add an unnecessary burden and additional complexity to one of the most successful public health programs in the United States.

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Leveraging Public Health Laboratory/First Responder Partnerships

Sep 11 2013 :: Published in Public Health Preparedness & Response

This month is National Preparedness Month.  Follow APHL on our blogTwitter and Facebook for preparedness information and discussions all month!

 

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By: Christopher Chadwick, MS, specialist, Public Health Preparedness & Response, APHL

Since the morning of September 11, 2001, the American view on terror has changed drastically, and with that, so has public health preparedness and response. Over this last decade, terrorism has become not only a household word but also a public health priority. As we enter Preparedness Month, we’re reminded of the events 12 years ago that caused public health preparedness and response to focus on both natural disasters and intentional attacks.

The fall of 2001 was a defining time for public health laboratories. It was the anthrax letters mailed to several media outlets and United States Senators that brought this form of bioterrorism in the U.S. to the forefront of national news. Still in its infancy, the Laboratory Response Network (LRN), which was created in 1999 to increase bioterrorism and chemical terrorism response capabilities, established itself as a key force for national security as the anthrax letters circulated. In fact, a Florida LRN laboratory was one of the first to recognize inhalational anthrax from a sick person, thus beginning the influx of human samples and laboratory tests conducted by the LRN. These events highlighted the importance and strength of the LRN, and although it wasn’t a household name, the LRN certainly became a name that the public health world knew and valued.

Testing for anthraxFast-forward to 2013 and public health laboratories have added a variety of gadgets to their utility belts to uphold their public health preparedness and response core function (they actually have 11 core functions total that support all of public health). The laboratories continue testing for anthrax but also other potential bioterrorism and chemical terrorism agents, including the recently infamous ricin toxin. These utility belts contain not only actual gadgets (e.g., advanced diagnostic technologies) but also active partnerships comprised of an intense network of players, including hospital and private laboratories, law enforcement, fire departments, and federal programs.

In 2001, the partnerships between the public health laboratories and first responders (e.g., police, fire, hazardous materials teams) facilitated the anthrax response, and since then, these partnerships have only grown stronger. Daily, states continue to see letters and packages containing suspicious powders. And although these powders are typically of the powdered sugar or baby powder varieties, first responders and public health laboratories continue to respond as rapidly as ever. Who knows when the next suspicious powder with an actual threat will emerge (this year’s ricin letters showed us that this form of terrorism is still quite popular), but what we do know is that the public health laboratory/first responder partnerships will always be leveraged to ensure that the nation’s security is upheld.

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Big Changes for the District of Columbia Public Health Laboratory

Jul 17 2013 :: Published in Member News, Public Health Preparedness & Response

By Kara MacKeil, associate specialist, Public Health Preparedness and Response, APHL

According to recent census estimates, Washington DC has a population of 632,323 people. On a workday, however, there are at least 800,000 additional people in the city due to commuters who live in Maryland and Virginia. Add all of the tourists visiting the nation’s capital, and daytime DC is a city of more than 1 million people. Although only roughly 100 square miles, daytime DC has more people than Vermont (626,011), Wyoming (576,412), Alaska (731,449), South Dakota (833,354), or North Dakota (699,628), and is about equal with Rhode Island (1,050,292) and Montana (1,005,141).

Big Changes for the District of Columbia Public Health Laboratory | www.aphblog.org

In public health terms, this means a greater emphasis on emergency preparedness and response in addition to the everyday management of core public health laboratory functions, such as testing for sexually transmitted infections, foodborne illness and more. For the past few years, the DC Public Health Laboratory has dealt with everything that came its way while working out of a small temporary facility. Fortunately, in the fall of 2012, the staff moved into a larger, brand-new, state-of-the-art laboratory.

Part of the reason for this move is that the public health laboratory has been transferred from the Department of Health to the newly created Department of Forensic Sciences. The new facility, located in the heart of DC not far from the Capitol, also houses sections of the police department, the Chief Medical Examiner, and other agencies within the mayor’s office. The main motivation for the move is that the old lab space was just too small to meet the testing demands of a public health laboratory serving more than a million people.

The APHL public health preparedness and response team toured the new facility last May with Dr. Alpha Diallo, deputy director, DC Public Health Laboratory, and other senior members of the DC laboratory. The APHL team had visited the facility once before, during construction in the summer of 2012, and were very impressed with the finished facility.  The building is LEED Gold-Certified, meaning construction materials and furnishings are sustainably produced; appliances, computers and other machines were chosen for conservative energy use; and there’s a focus on conscientious use of resources. One of the most visible features of the LEED principle is the bank of cantilevered window shades on the exterior of the building, covering the glass wall that exposes workstations on most of the floors, including the public health laboratory. These dark glass shades are controlled by sensors that open or close them depending on available sunlight, conserving heat and energy and helping to maintain a steady temperature inside the building.  LEED building techniques are becoming very popular in laboratory construction, as they save significant amounts of funding and resources over the long term and create beautiful, highly functional working environments.

Now that the move is complete, laboratory leadership is well positioned to improve their capabilities and increase their staff, taking best advantage of the new space. There are high hopes that the improved facilities will attract lots of new talent and student interns.

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Shifting my perspective: Why I love working for the public health lab

Jul 09 2013 :: Published in Public Health Preparedness & Response

Shifting my perspective: Why I love working for the public health lab; Royden Saah, North Carolina Public Health Laboratory Bioterrorism Coordinator | www.aphlblog.org

By Royden Saah, North Carolina Public Health Laboratory Bioterrorism Coordinator

It was the summer of 2001.  I had defended my master’s thesis in microbiology about a year and a half prior when I noticed an open position in the state public health laboratory in the area of bioterrorism.  My preconceived opinion of public health microbiology was not great.  Spoiler alert: Converts make the most ardent advocates!  I thought public health microbiology was dull; I thought public health microbiology was monotonous; and I thought public health microbiology was not for a research-minded bacteriologist.  But this position was in bioterrorism!  Maybe it was worth a look.

September 6, 2001 – five days before my 33rd birthday – I had two job interviews on the same day.  My nine o’clock was at the public health lab; my 11 o’clock was at a start-up company in the Research Triangle Park.   Both interesting positions, both were associated with great teams, and both interviews went very well.  Of course, I immediately weighed which job I would accept if I got two offers.  It was truly a toss-up since there were some really nice points to each position.  The tie-breaker came on my birthday, September 11, 2001.  The tragedy of that day made the service aspect of the public health position outweigh the benefits of working with a start-up (i.e., higher compensation, less bureaucracy).  Unfortunately, the wheels of authorization do move slower in government.  On September 13th, I received and declined the start-up position offer without assurances of being selected for the public health lab position.  I was making a leap of faith that was ultimately justified after the first wave of anthrax letters was discovered.  My journey into public health had begun as it continues – chaotic, eventful and wholly fulfilling.

The initial long hours of work responding to the anthrax attacks delayed my discovery of the field of public health laboratories, but as the turbulence of late 2001 subsided, an unexpected world was opened to me.  My prejudices – my judging without knowing – regarding those tedious areas of the public health laboratory were destroyed by my observations around the lab.  By talking to my colleagues in the different sections of the lab, I discovered the fascinating complexities of the public health laboratory science area.  While they weren’t making basic scientific discoveries with which I had been previously involved at the university, the public health laboratory discipline held a myriad of questions waiting to be answered.  Indeed, seeing the application of the ongoing science (trouble shooting, novel assays, even process management!) was surprisingly more satisfying to me than the basic research.  I had a Green Eggs and Ham moment.  I could not get enough of hearing about the issues in the TB lab or knowing my baby’s bloodspot card was rapidly working its way through the newborn screening lab.

I discovered that public health laboratory operations touch the lives of every person in a lab’s jurisdiction – this had a profound impact on me.  From the safety of drinking water, to the screening of all infant children for serious diseases – public health labs directly affect my family and my community!  I found it easy to be passionate about my new field… “Zealous” may be a better adjective.

I hope that sharing my experience and my shift in perspective encourages others to explore the activities and careers of their local or state public health lab.  You may find that a career helping to improve the health of a population is something that interests you – it did for me!

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British Invasion – My Career in Public Health

Apr 23 2013 :: Published in Member News, Public Health Preparedness & Response

By Andrew C. Cannons, Ph.D., HCLD (ABB), Laboratory Director, Florida Bureau of Public Health Laboratories, Tampa

“What do you want to be when you grow up?” In England, students have to make these decisions early on, and at 14 my answer was a doctor or a chef. If you asked me back then what public health was I would have said “the health of the public!”

Andrew Cannons as a child

I was not to become a doctor, due to poor study habits as a child and I did not become a chef (except in my own kitchen), but I did get to university where I acquired a good tutelage in Eastern culture at the city of Bradford –known more for its excellent authentic curries and high volume of pubs than education. Four years later, I graduated with a degree in applied biology. I had a thirst for research, but no acquaintance yet with public health.

Having discovered I was good at research I stayed on at the University of Bradford to complete my Ph.D. in biochemistry, and followed that with a four-year post-doctorate at the University of Wales in Swansea where I also picked up a Welsh accent. I was trying to determine what I wanted to do, and quite frankly I drew a blank. As luck would have it, I soon met one of my field’s most world-renowned scientists at a conference in Spain.  He offered me a three-year post-doc opportunity in his lab at the University of South Florida (USF) in Tampa. I was excited, flattered and thrilled at the offer. And guess what… USF has a college of public health! I was getting closer to where I wanted to go without knowing it.

I had a blast for the first two years I was at USF, so much so that I wanted to stay. After a lot of work and a lot of payments to an immigration lawyer, I received my green card. But I was not really sure that research was my true vocation anymore. I had been an assistant professor in biology for five years and proved to be a good teacher, but it wasn’t fulfilling enough. During this time I met the assistant director of the Florida State Public Health Laboratory in Tampa. He was doing his Ph.D., and asked me to be on his dissertation committee. We became good friends and I started to find out more about public health, albeit at a very superficial level.

The turning point for my career in public health came one October morning. It was 5:00 AM on October 6th, 2001, three days after the index anthrax case was identified in Boca Raton and I received this message –“Can you help us at the public health lab? We are expecting an onslaught!”  No kidding.  By 6:00 PM that day we had processed 40 suspicious samples for Bacillus anthracis. I was tired and hungry, but more importantly, I was hooked. This was important, meaningful, critical work. Sign me up! Not so easy as there had to be a job.

Andrew Cannons -- adult

The following year I was asked if I had considered a career in public health, and specifically about directing a state public health laboratory. I had the Ph.D., the administration skills, and a research background. I just lacked some (a lot!) public health knowledge, and there was the small issue of a Florida Clinical License. So I spent the next eight years directing the research lab, volunteering in the public health lab, studying and building up my clinical licensure one level at a time. I also joined the Association of Public Health Laboratories (APHL) as an individual member and applied for and became a member of the Emergency Preparedness and Response Committee (now the Public Health Preparedness and Response Committee).  This was a really smart thing to do.  It was such an eye opener to understanding more about public health laboratories, the Laboratory Response Network (LRN) and a host of other partners as well as their operations! This was a tremendous education and learning experience for me. Joining APHL became crucial to honing my public health knowledge and skills. In addition to serving on the Public Health Preparedness and Response Committee, various sub-committees and participating in the national meetings, in 2010 I was given the chance to be a member of the APHL Emerging Leaders Cohort III, which seeks to engage APHL members who will play a crucial role in sustaining future leadership in the public health laboratory system. This was a tremendous opportunity to 1) network and share operational experiences with other emerging leaders; 2) enhance my professional development; and 3) collaborate to deliver a product that promoted public health laboratory science.

In 2011 I became qualified as a High-Complexity Clinical Laboratory Director through the American Board of Bioanalysis (ABB) and received my Florida Clinical Laboratory Director License. I was ready, and in April 2012 I assumed the position of Laboratory Director, Bureau of Laboratories (now Bureau of Public Health Laboratories), Tampa.  I acquired a great facility and a wonderful group of dedicated, hardworking and loyal staff, which has made this move so much easier and more fulfilling.

Since transitioning to a director of a major public health laboratory, I have worked on large-scale national events such as the Republic National Convention.  As a 14-year-old boy, I never thought I would end up partnering with the US Secret Service, the Federal Bureau of Investigation, the Department of Homeland Security, and the Centers for Disease Control and Prevention to protect the public’s health from all sorts of threats. Public health was the perfect career choice for me even though it took several forks in the road for me to get here.

Through it all, I’ve held to the motto: Keep Calm and Carry On!

 

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Anthrax in Minnesota? The Laboratory Response Network Springs Into Action

Mar 05 2013 :: Published in Public Health Preparedness & Response

By Kara MacKeil, Associate Specialist, Public Health Preparedness and Response, APHL

Picture a small rural hospital in northern Minnesota.  A man walks into the emergency room late in the afternoon complaining of flu-like symptoms. He’s admitted and at first seems stable, but rapidly deteriorates.  As he is transported by helicopter to a larger hospital for advanced treatment, his condition plummets en route and survival seems increasingly unlikely.  The backstory: The man was three weeks into a road trip and could have passed this fast-acting, apparently lethal bug on to any number of people.  Sounds like the script pitch for Contagion 2, right?  Mystery illness in Minnesota, I can see it now.*

But while it sounds like a script pitch, this actually happened in the fall of 2011, with Bacillus anthracis, as the causative agent of anthrax, as the starring villain.  There was one very important change to the storyline though.  Thanks to the efforts of the laboratorians at Lake Region Healthcare in Fergus Falls, Minnesota, and the Minnesota Department of Health Laboratory Response Network (LRN) staff, the mystery bug was identified in time to provide treatment, and the patient is alive and well today. Maureen Sullivan of the Minnesota Public Health Laboratory told us the story of the legwork that went in on the laboratory side, and it would definitely make for a pretty good movie!

First, a word on the LRN.  The LRN was developed in 1999 by the Centers for Disease Control, APHL, the Federal Bureau of Investigation (FBI) and the Department of Defense.  Today, there are two main arms of the LRN: chemical and biological threats preparedness and response (LRN-C and LRN-B), which provide a strong, unified system of laboratories that can respond to any threat.  There are standard protocols for everything, and regular trainings to keep everyone up-to-speed. In the LRN-B, Sentinel Level laboratories like the Lake Region Healthcare Laboratory can rely on reference laboratories such as the Minnesota Public Health Laboratory, and the Minnesota Public Health Laboratory, in turn, can call on resources within the CDC. Further, the Minnesota Public Health Laboratory can leverage partnerships with the local law enforcement, FBI and the National Guard Civil Support Team.  From the first culture to the final treatment, the Minnesota anthrax case was a perfect illustration of what dedicated laboratory and first responder professionals can do with the strength of the LRN behind them.

Testing for anthrax

Back to our story.  The patient in question was a 61-year-old Florida man who had been driving through the northern plains states for the past few weeks with his wife, taking in your standard tourist attractions and enjoying the scenery. (Can’t you picture the opening montage of our movie?)  He had a previous history of pneumonitis and had been exposed to Agent Orange in the Vietnam War, but was otherwise healthy.  When he arrived at Lake Region Healthcare on a Thursday afternoon, there wasn’t anything to suggest that he might be infected with a deadly biological agent, so the hospital began its standard protocol for flu-like symptoms and sent blood cultures to the laboratory.  These cultures were examined that Friday morning and, after finding all four to be positive, the laboratory technician followed LRN sentinel protocols and plated all four to watch for growth.  Normally samples like these would have been checked again at about noon on Saturday, but the laboratory technician was suspicious and made a point to look at them again later Friday afternoon.  Cue the ominous music and enter the Minnesota Public Health Laboratory, an LRN Reference Lab, at camera left, because those plates had growth!

Realizing what she might have on her hands, the sentinel laboratory technician made a call to the MN public health lab to let them know what was happening, and then personally packaged the samples and drove them to the delivery drop box to ensure they would arrive at the state laboratory the next day. Thanks to her diligence, the plated samples arrived at the state laboratory about 24 hours early, at 11 AM Saturday morning, and Sullivan says when the on-call molecular biologist opened the box, “she looked at the colonies, closed it right up, went and called her husband and said ‘I think I might be here for a while.’”

Sullivan got the call with positive results for B. anthracis spores at 2:30 PM that afternoon (while on a family vacation, I might add) and started making phone calls.  The submitting hospital had to be notified so treatment could begin as soon as possible, but positive anthrax findings don’t stop with identification.  Because anthrax is so dangerous, the Minnesota LRN-B’s next task was to determine whether this patient was deliberately infected.  This is the point in our script where the military enters, in the form of the National Guard’s 55th Civil Support Team (CST).  The Minnesota laboratory conducts regular trainings in conjunction with the 55th CST, and they have a great working relationship. In conjunction with the National Institute for Occupational Safety and Health (NIOSH), the 55th CST and two representatives from the Minnesota laboratory (Sullivan included) spent a day combing over the patients rental car, removing anything that might give them a clue as to where the spores had come from.  Altogether they collected over 50 samples, including the patient’s boots and a set of deer antlers.  While none of the samples collected from the car tested positive, Sullivan notes, “It was a very good collaboration with the CST team and with our partners at CDC to put the environmental sample plan together.”

Testing for anthrax

Meanwhile, the patient’s condition had deteriorated.  On Sunday, he was loaded into a medevac helicopter and sent south to a larger hospital for treatment. Despite a nail-biting collapse en route, doctors were able to stabilize him, and the following day a team from the CDC administered emergency treatment.  It’s important to note that this treatment would not have happened without the positive B. anthracis identification from the Minnesota State Public Health Laboratory. That treatment, coupled with the early changes to the patient’s antibiotic regimen after the positive identification, is likely the reason the patient recovered completely.

Like any good movie, this story leaves a few questions behind.  First, where did the anthrax come from? While the movie version of this story would probably end with some hint at nefarious origins in order to create a sequel, the truth is it was probably a complete coincidence.  Anthrax is found naturally in all seven continents and lies dormant in soil for hundreds of years.  The spores can reactivate when they are kicked up and inhaled, commonly by grazing animals.  Our patient had spent some time on his road trip collecting rocks from riverbeds, and at one point drove past a large herd of grazing buffalo.  It’s probable that he inhaled some spores (and it would only take one) in one of these locations, but we will truly never know. You may also be wondering why the patient’s wife didn’t get sick, despite being in all the same places and presumably getting the same exposures.  It’s possible that the patient’s history of lung problems might have made him more susceptible, but again, there is no way to know.  She may have just been very lucky.

Despite these questions, the reality remains that without the smooth functioning of the LRN-B, this could have been a very different story.  But thanks to the dedication of a wide variety of people, the patient was on the road to recovery a mere four days after the initial blood cultures were drawn.  “I think what this really showed us was that all of the efforts we’ve put forth for our training really have made a difference,” says Sullivan. “All of those things really came together and we had a very successful response.”

In conclusion, Contagion 2: LRN in Action.  Get the popcorn!

*Speaking of Contagion, my friends in Minnesota would probably like me to point out that this case study does an awesome job of refuting the movie Contagion’s very unflattering portrayal of Minnesota public health and emergency response systems.  Despite what Steven Soderbergh may have you believe, when trouble arrives in real life, Minnesota is on its game!

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