Public Health Laboratories: A Critical Component of the Public Health Puzzle

Apr 26 2012 :: Published in Public Health Preparedness & Response

This week is National Medical Laboratory Professionals Week and National Environmental Laboratory Professionals Week.  APHL is honoring the many individuals working public health and environmental laboratories around the world.  Stay tuned for blog posts this week featuring the work of many of those unsung heroes working to protect the public’s health.

By Sikha Singh, MHS, Senior Specialist, Laboratory Response Network, APHL

Photographer: Jim GathanyDate:Description: CDC laboratory workerCategories: Health Occupations; CDC Buildings and Facilities; CDC Laboratorians Jim GathanyDate:Description: CDC laboratory worker

Despite ongoing budget decreases, public health laboratories continue to support prevention and population-based surveillance activities.  Each component of the public health system including first responders, sentinel laboratories, epidemiologists, clinical hospitals and the public health laboratory perpetuate the continuum of sustained population health.  These components of the system are greater than the sum of their parts, with each being an essential contributor to public health victories.  These victories include support offered during a variety of events including:

  • Pandemics like the 2009 Influenza A H1N1 pandemic
  • Deliberate attacks  like the 2001 Anthrax attacks
  • Resurgence of vaccine preventable diseases
  • Unintended consequence of natural disasters like the 2010-2011 cholera outbreak in Haiti following a massive earthquake

However, even in the absence of major events such as those listed above, public health laboratories work behind the scenes to perform daily activities ensuring that population health is maintained.  Business as usual, even during challenging economic times, involves public health laboratories performing a wide array of services including, but not limited to, newborn screening, emergency response, disease surveillance and detection, strain typing, identification of emerging diseases, environmental testing, and so on.

It cannot be stressed enough that public health laboratories keep the public safe and remain an essential element of the public health system.


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Hydraulic Fracturing and Laboratories: What Does it Mean for You?

Apr 26 2012 :: Published in Environmental Health

This week is National Medical Laboratory Professionals Week and National Environmental Laboratory Professionals Week.  APHL is honoring the many individuals working public health and environmental laboratories around the world.  Stay tuned for blog posts this week featuring the work of many of those unsung heroes working to protect the public’s health.

By Michael Heintz, Senior Specialist, Environmental Laboratories, APHL

With the increasing interest in our nation’s energy supply, natural gas mining is getting more attention. Advances in hydraulic fracturing, or “fracking,” now make it possible to reach and extract previously inaccessible stores of natural gas. The Energy Information Administration estimates there are 750 trillion cubic feet of natural gas locked in shale deposits in the lower 48 states. Fracking may allow recovery of up to 86% of that total; enough to meet the country’s demand for the next 100 years.

Drilling a Marcellus Shale well in the State Game Lands in Roulette, Pennsylvania

Originally developed in 1947, but becoming more widespread, fracking is a method of gas extraction that drills horizontal wells into gas-containing shale formations and injects millions of gallons of water, sand, and chemicals to create pressure pockets that fractures the shale. When the shale fractures, it releases the natural gas contained within the rock, which is then recovered through the well. Typically, fracturing fluid is 98% water and sand and 2% chemicals, although specific mixtures vary by location and operation. With up to five million gallons of fluid needed to fracture a well, 100,000 gallons can be chemicals.

Fracking fluid can contain any number of chemicals and solutions to aid in the fracturing process. Currently, 11 states require – or are proposing – registration of the chemicals in fracturing fluids used at individual wells. However, because formulas and compounds can be protected as trade secrets, registrations sometimes only include chemical families or CAS numbers, not the specific material or amount present in the fluid.  In addition to the chemicals used in the process, other liquid products return up through the well during drilling and fracturing, including brine, metals, and hydrocarbons. This “produced water” must be treated before recycling or disposal. Consequently, fracking is not without potential effects on human health and the environment, with groundwater contamination being the primary concern.

Because the wells necessarily pass through aquifers to reach the deeper shale deposits, opinions differ on whether there are impacts to groundwater resources. EPA is studying fracking and groundwater resources, but the results are years away. There are reports of groundwater contamination near mining operations, but connecting the drilling directly to the contamination is difficult. In the meantime, some say keep drilling, while others say stop until we better understand the issues. In addition to groundwater contamination, there are other potential impacts, including air and dust emissions from the drilling equipment, produced water overflows from surface tanks and storage ponds, and well casing leaks.

Environmental and public health laboratories already find themselves involved with the issue. As fracking becomes more widespread, laboratories will increasingly be asked to test groundwater, surface water, soil and air samples in the areas around drilling sites. Moreover, laboratories may not be able to avoid the developing political debate. In Pennsylvania, for example, doctors may ask to see fracking fluid recipes, subject to confidentiality agreements, but are not allowed to share the specifics with patients. Is this a gag order on doctors or trade secret protections? Where will laboratories find themselves in the discussion?

Fracking will continue to dominate the energy and environmental debate. Until the science catches up with the technology, we cannot know the true costs and benefits.


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Using Technology to Combat HIV/AIDS in Swaziland

Apr 25 2012 :: Published in Global Health

This week is National Medical Laboratory Professionals Week and National Environmental Laboratory Professionals Week.  APHL is honoring the many individuals working public health and environmental laboratories around the world.  Stay tuned for blog posts this week featuring the work of many of those unsung heroes working to protect the public’s health.

Computerized information systems make work easier in many fields, including laboratory practice. But can a laboratory information system (LIS) help make a dent in one of the world’s worst HIV epidemics?

Laboratory and health experts in the Kingdom of Swaziland are betting the answer is yes.

Swaziland, a geographically small, landlocked nation bordering South Africa and Mozambique, has been home to human inhabitants since at least the early Stone Age 200,000 years ago. Today, however, the country’s population of 1.2 million is seriously threatened by the highest HIV prevalence rate on the African continent. An estimated one of every four adults is infected with HIV, and many of those are co-infected with TB or multi-drug resistant TB, both of which are also highly prevalent.


Health experts know that HIV prevention, education, testing, counseling and treatment programs are essential to reverse such a daunting public health crisis. Swaziland has responded with a campaign to reduce HIV transmission by circumcising HIV-negative men aged 15-49, and with greatly increased access to testing at voluntary counseling and testing centers and other Ministry of Health (MOH) laboratories. Yet these efforts have been complicated and slowed by reliance on paper-based systems.

Marie-Claire Rowlinson, PhD, a former senior APHL global health specialist, said an electronic LIS “is important for quality of testing and therefore for the quality of patient services.” She continued, “It enables laboratory technicians to test samples more efficiently and with fewer errors in the testing process. For example, because the LIS is integrated with testing instruments, there are fewer manual transcription errors, and quality control procedures can be monitored more easily.”

All of this has a positive impact on testing quality, speed and volume. Technicians are able to spend more time generating potentially life-saving test results, rather than entering data by hand. And the test data can be retrieved in seconds.

Rowlinson added, “A common issue for the labs in Swaziland is that patients will get the same test two days in a row when they only need one, which wastes much needed resources. With a paper-based system, it is much harder to track what tests a patient is getting, but with an electronic LIS this can be monitored.”

Fortunately, the advantages of electronic information management will be coming to Swaziland Ministry of Health (MOH) laboratories soon. APHL completed a laboratory assessment in Swaziland last year and is assisting the MOH with development of an LIS strategic plan for the country. Previously APHL helped MOH stakeholders in the selection of an LIS software vendor.

In 2012, the new electronic LIS system will be installed in the national reference laboratory, the Mbabane Government Hospital National Reference Laboratory, and five other MOH laboratories. It is hoped that the new LIS system will eventually be installed in all 18 MOH laboratories, and the current stand-alone systems made interoperable to enable real-time data exchange.

“In addition to improving quality and expanding test volume, the LIS can be used to centralize data and support MOH decision making,” said Ralph Timperi, MPH, a senior advisor for laboratory practice and management at APHL. He explained, “You can put personnel data on a central database so you can see where your technicians are, their ages and education. You can determine whether you need to provide training for people in one location or if key people are nearing retirement.” He added, “You can store supply information and equipment information, so you know: Where is the equipment? How old is it? An LIS gives you the ability to accurately keep track of things in real time. That’s a very helpful thing.”

In the end, said Timperi, it all comes down to one critical trade-off that can indeed make a difference in a HIV epidemic:  “Putting out quality test results versus moving paper.”


Other Lab Week blog posts: 

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Flu Vaccine: How it finds its way into the needle

Apr 24 2012 :: Published in Infectious Diseases

This week is National Medical Laboratory Professionals Week and National Environmental Laboratory Professionals Week.  APHL is honoring the many individuals working public health and environmental laboratories around the world.  Stay tuned for blog posts this week featuring the work of many of those unsung heroes working to protect the public’s health.

By Stephanie Chester, MS, Senior Specialist, Influenza Programs, APHL

When you get your annual flu vaccine, chances are you roll up your sleeve, feel a small prick and go on about your day without thinking any more about the shot. Yet there is a lot of work that takes place behind the scenes to determine what’s in that injection.

Fortunately for you, the US has a system for national influenza surveillance. Data from across the US is collected to identify which flu viruses are circulating, if the current season’s vaccine is a good match, and which viruses should be included in the next year’s vaccine.

This is CDC Clinic Chief Nurse Lee Ann Jean-Louis extracting Influenza Virus Vaccine, Fluzone® from a 5 ml. vial.According to the product text, the intramuscular route of administration is recommended, vaccinating adults and older children in the deltoid muscle using a needle ? 1 inch in length in order to penetrate the muscle tissue.

Did you know that preparations for next season’s flu vaccine start at the beginning of each flu season? In fact, it is the specimens collected at the beginning of each new flu season that help inform vaccine virus selection for the next year. So how does this work exactly? Well, it is a complicated process but one in which public health laboratories play a critical role.

Let’s say you come down with a fever, cough, sore throat and other generally crummy symptoms. You decide to give in and go to the doctor who will likely test you for influenza. Some doctors act as sentinel providers which means they regularly submit specimens collected from patients with flu-like symptoms to public health laboratories for influenza surveillance. Public health labs can also receive specimens from a variety of other submitters including hospital/clinical laboratories, university student health centers, long-term care facilities, commercial laboratories and many more.

Now here’s the part that APHL staff really like to talk about: the public health lab role! The public health lab will test the submitted specimens for influenza.  They will then characterize the influenza virus down to the specific flu subtype using a real-time reverse transcriptase PCR (RT-PCR). These test results are reported to CDC and help inform what specific types and subtypes of influenza are currently circulating in the country and locally. This helps CDC and state/local public health officials determine if this year’s vaccine is effective at protecting us from what is actually circulating.

The public health lab then selects a subset of specimens to submit for national surveillance.  This subset is grown up in virus culture and further characterized to determine exactly which influenza viruses are predominant and thus should be included in next season’s vaccine. Each February, CDC, in collaboration with the World Health Organization and other countries, uses real-time RT-PCR data, sequencing analysis and viral isolate characterization results to determine which viruses to include in the Northern Hemisphere’s vaccine for the next season.

As you can see, a lot of effort goes into national influenza surveillance and vaccine virus selection, and public health labs are integral in this process. Even with this season being so mild and slow to start, the diligent work of public health labs and their health departments ensured that specimens arrived at CDC consistently and on time to help inform vaccine virus selection.

As we celebrate Lab Week, I for one am very grateful for the hard work and dedication of all the public health lab personnel and public health officials who consistently perform exemplary work to support our national influenza surveillance system. Their work on influenza alone impacts all our lives, from informing our communities and physicians about circulating flu viruses to helping to determine what goes into that annual prick in our arm. They deserve to be celebrated! Happy Lab Week!


 Other Lab Week blog posts:

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All in a Day’s Work

Apr 23 2012 :: Published in General

This week is National Medical Laboratory Professionals Week and APHL is honoring the many individuals working public health and environmental laboratories around the world.  Stay tuned for blog posts this week featuring the work of many of those unsung heroes working to protect the public’s health.

By Chris N. Mangal, MPH, Director, Public Health Preparedness and Response, APHL

For a few days I pondered what to say in this blog post that would help folks to have a better appreciation of laboratorians… Why should people care about laboratorians? After all, they only get results.

Yes, that’s it! Laboratorians get results which play a key role in medical treatments and overall population health.

Public Health Laboratory, Richmond, VA

Think about it – when you feel sick, you go to your doctor’s office or your local hospital depending on the intensity of the symptoms.  The physicians do their best to temporarily treat your symptoms and they quickly get some samples from you. Off they go… ever wondered where your samples went? Probably to the in-house hospital laboratory or a local commercial laboratory.  These laboratories then work closely with public health laboratories so they can quickly identify what’s making you sick. Is it a chemical? Other toxic compounds? A super bug which is resistant to antibiotics? In certain instances, other public health officials get involved to monitor the extent of the illness in a population. Just think, all of this started with a laboratory result!

Much of this work is happening behind the scenes to get you the correct and best medical treatment and to reduce the spread of diseases in a population.

Laboratorians aren’t the best at tooting their own horn so organizations like APHL must play a role in promoting their valuable work. On a daily basis, APHL staff work side-by-side with laboratorians to protect global health.

Laboratorians from across the globe ensure that your water is safe to drink, your food is safe to eat, your sunscreen actually works and provides appropriate protection from the sun (more about this at a later date) and they’re also there when you get ill to quickly detect the culprit and inform your treatment. So, the next time someone takes a sample from you, remember the thousands of highly qualified laboratorians who are quietly working behind the scenes doing their routine – all in a day’s work – to keep you safe and healthy!

Thank you to all of the exceptional people who work in or on behalf of laboratories.


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Killer Outbreaks — Public Health Saves the Day

Apr 28 2011 :: Published in Public Health Preparedness & Response

By Sikha Singh, MHS, Senior Specialist, Laboratory Response Network, APHL

Animal Planet has a fascinating new show called Killer Outbreaks that chronicles real-life episodes involving deadly diseases. Anthrax, E. Coli 0157, hantavirus, rabies, West Nile virus, monkeypox, salmonella, valley fever, meningococcal disease, SARS and MRSA  all star in this series.

While many think these diseases reside far, far away, the show emphasizes the fact that nearly anyone can fall victim to these pathogens with potentially lethal consequences. We live in a world where frequent plane travel leaves no corner of the globe untouched and where hazards resulting from biological terrorism and natural disasters threaten to compromise public safety on an alarmingly regular basis.

Public health laboratories detect, diagnose, control and mitigate these threats, serving as a bridge between small town doctors in community hospitals and top scientists at the Centers for Disease Control and Prevention (CDC).

The season opener contrasted a naturally-occurring anthrax infection with the 2001 terrorist attacks that killed five Americans and sickened 17 others.  A middle-aged African dance instructor becomes infected after building drums from contaminated hides, engendering an intensive investigation by CDC and the New York City Department of Health and Mental Hygiene to identify the source of the infection before others became ill. Ultimately, the victim makes a full recovery after successful treatment when CDC decides to try an antibody called “immunoglobulin” which had never before been tried.  And how did the investigatory team know to pursue this particular disease agent?  The answer: the lab. New York City had a new high-security laboratory that opened in 2004. Dr. Thomas Frieden, the city health commissioner at the time (now the director of CDC), said that the new lab was working around the clock to test the dozens of samples collected.  Yet again, the lab was successful in protecting the lives of millions of people living in New York City.

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Be Prepared [for a Nuclear Crisis]

Apr 28 2011 :: Published in Environmental Health, Food Safety

By Jennifer Pierson, MPH, Senior Specialist, Environmental Health, APHL

The Japan Fukushima Nuclear Power Plant accident following the March earthquake and tsunami raised fears of radiation exposure and sickness in the US. Many Americans who were not in favor of nuclear power prior to this accident are using Fukushima as an example of the safety issues associated with this technology. While the safety issues can be fiercely debated, laboratory testing capability and public health safety should be black and white.

VOA Herman - April 13 2011 Fukushima Nuclear Power Plant-03

A small plume of radioactive materials from Japan did make it to the US as confirmed by the results from analyses of air, precipitation and milk samples. Public health laboratories and federal agencies worked in concert to analyze environmental samples ranging from air to milk for radioactive materials in order to determine the levels that reached our shores.  The sample results did not indicate levels of concern for the public’s health.

While the plume may have been unexpected, imagine a worst case scenario where a US nuclear power plant faced a similar accident as Fukushima. If this power plant happened to be within 50 miles of a major metropolis, say New York City, millions of people would be affected and thousands or even hundreds of thousands of people would seek testing.

If such an event occurred on US soil, there might be enough capacity to test environmental and food samples thanks in large part to federal agency support.   This support includes an EPA grant program and a program within the FDA and USDA collaborative network called the Food Emergency Response Network (FERN). Both EPA and FERN have programs in place to expand radiation testing capabilities in state public health laboratories. EPA is pilot testing radiation analyses in state public health laboratories and the FERN funds five laboratories to test food for radiation. However, the 2012 President’s budget proposed drastic budget cuts for both programs and, if implemented, both EPA and FERN would have to halt funding to the state public health laboratories. We can only hope the Japan incident is a reminder of the importance of funding laboratories. We do not want to be left scrambling if an event happens closer to home.

Despite CDC’s efforts to develop rapid screening methods, capacity to test humans for radionuclide contamination lags behind. Congress even acknowledged the gaps in radionuclide testing during a hearing in 2007. Yet, they have not appropriated funds to CDC to enhance testing capabilities or to expand current methods to state public health laboratories, who would act as surge laboratories during a large scale event.

The solution is clear. The US needs to find a better balance of funding for our public health programs to do what they do best: protect the health of the public. Large-scale nuclear accidents may be rare but that does not mean we should not be prepared. Learn more about radiation and APHL’s efforts during the Japan response from this fact sheet or on our website.

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Confronting Measles — Part 2

By Travis Jobe, Senior Specialist, Laboratory Systems & Standards - Vaccine-Preventable Diseases, APHL

So where do the public health labs enter the story on measles?

One of the key components for identifying measles cases is laboratory diagnostics.  This can be especially important when immunized persons become sick with measles but don’t present with typical symptoms due to their partial immunity.  However, the limited number of assays available to public health laboratories for measles diagnostics limits their abilities to detect the disease.  Also, because a laboratory rarely gets a chance to run the test on real cases, it may be hard to be confident in any given assay’s performance.  The APHL Recovery Act-funded Vaccine-Preventable Diseases (VPD) project has attempted to confront the question of performance of measles serology assays by offering public health laboratories the opportunity to participate in a pilot proficiency testing-like exercise.  Anyone who hasn’t worked in a diagnostic laboratory probably doesn’t know what proficiency testing, or PT, is.  But, essentially, PT is a panel of positive and negative samples sent to a laboratory to test and see if they get the correct results.  PT is a vital part of the work that public health laboratories perform to assure that they are competent in the results they report – results that impact the treatment of people like you and me.

Thirty-five public health laboratories from 30 different states participated in this measles serology PT exercise.  As it turns out, the results did point out some variances in the assays public health laboratories use for measles serology testing.  It just goes to show that not all assays may work perfectly for laboratory diagnosis, which shouldn’t be news to anyone in the medical or public health field.  But as long as the laboratorians themselves know about and understand these limitations, the proper interpretation of laboratory results can be communicated to the epidemiologists and doctors who are confronting the measles cases – real patients – directly.  Travelers with measles continue to return to the US this year from Europe and other areas of the world with ongoing measles outbreaks.  The laboratories that participated in the PT exercise are already putting to use this increased knowledge of their assays’ performance as they are called upon to perform the testing for these cases.  This includes the public health laboratories of Minnesota, California, New York, Pennsylvania, Washington, Texas, Florida, New Mexico, and New Jersey – just to name a few of the states that have seen imported measles this year.

For the general public, not only does the public health response prevent further illness by limiting disease transmission, it also helps to save further expenses – real money.  In the US, the cost to society is estimated to be well over $100,000 per measles case!  This includes not just the cost of treating the sick patient but of protecting the public from further spread of disease.  This doesn’t even include the cost to businesses for parents’ time off to attend to sick children and other private-sector expenses.  Nor does it include the costs of raising and supporting individuals permanently injured by the disease.  By immunizing the population and responding quickly to imported measles cases, further costs – and potentially deadly or debilitating illness – can be prevented.  Laboratories are but one link in the chain of the public health response.  Confidence in the performance of laboratory assays is a key component of that link.

At the same time, not all public health laboratories can be expected to perform all tests for measles – or any other disease for that matter.  No laboratory has unlimited resources, and public health labs are faced with limitations coming from federal, state, and local budget constraints.  So, in the public health laboratory community, we need to work together to support each other where needed.  Of course, the US Centers for Diseases Control and Prevention (CDC) have historically provided the extra support and reference testing services that public health laboratories rely on.  But with current fiscal cutbacks, laboratories cannot always count on that to be the case.

To discuss these issues is more depth, with a specific focus on measles testing included, APHL’s VPD project hosted a meeting of experts in March to discuss various national laboratory capacity models that may help confront the challenges of VPD testing.  The meeting participants noted that currently many public health laboratories utilize a shared-services model for mutual support; but they also acknowledged the lack of sustainability of this type of model.  Having a national laboratory capacity model where each public health laboratory can maintain the baseline testing capability that they desire, while having the ability to access additional non-CDC reference services for complex testing and surge capacity, was seen by the meeting participants to be an acceptable, if not urgently needed, solution.  The existence of public health laboratory resource centers for this type of support for reference testing, additional PT programs, and subject matter expertise, are seen as universal needs for all types of VPD testing.  This type of collaborative national effort to confront existing VPD testing challenges can help public health laboratories support each other and maintain a level of preparedness that will allow them to be ready to respond to many emerging public health threats, such as importation of measles.

The World Health Organization has targeted measles for worldwide elimination.  For this disease to begin a comeback in the US due to a lack of relatively small investments would be an embarrassment and a national shame.  Elimination of measles is not a goal of just some poor countries overseas where the disease is still endemic.  We in the public health system in the US are all part of this effort as well, whether we realize it every day or not.  Now is not the time to be complacent by cutting back funding for prevention and control efforts, because to do otherwise would risk catastrophic situations and massive inputs of resources.  Of course, by resources, I mean money – money that state governments currently cannot afford to spend on preventable situations.

APHL and the VPD project are doing their part within their role to maintain vigilance against measles.  I hope that my efforts in this project help make our roles be successful.  Now, I don’t expect my grandmother from Arkansas, or the street vendors I encountered in Livingstone, Zambia, to understand all the work that I do calculating standard deviations for PT results, reviewing laboratory testing algorithms, or analyzing the factors of various laboratory capacity models for public health laboratory resource centers.  But I hope they do understand the value that these efforts have on society as a whole, helping to keep us all healthy – and happily ignorant of this devastating disease.

As I said, I have never seen a case of measles.  With the continued great efforts of all my colleagues in the public health field, I hope I never do.

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