Could funding cuts to food safety programs make you sick?

Jul 23 2014 :: Published in Food Safety, Public Policy

By Michelle Forman, senior media specialist, APHL

Could funding cuts to food safety programs make you sick? | www.aphlblog.orgWhen public health works, no one sees it.

That’s a common adage at APHL and is most frequently used when referring to the gross lack of – and ever plummeting – funding for valuable public health programs. But what does it mean? When do we see public health and when does it vanish into the background?

The public health system comprises many areas from healthy eating to smoking cessation to biomonitoring to newborn screening. To answer this question, we’re going to focus on food safety – something that impacts every person in the United States – by following the journey of peanuts as they pass through the food system and into your lunch bag.

(Note: Peanuts were chosen to make a point. They are not inherently risky. As of the original date of this post, there is no current known outbreak associated with peanuts. This journey could feature any food item.)

Our peanuts were grown on a large farm that distributes its harvests for use in many different products.

After being roasted, they are shipped to another facility to be ground into a paste. That paste is then used to make peanut butter for cookies, crackers, ice cream, dog treats and many other products.

In a perfect situation, our peanuts are grown using the safest growing practices; thoroughly roasted to kill pathogens acquired on the farm; processed in facilities that ensure utmost safety and cleanliness in accordance with all food safety guidance provided to them; sent to stores, restaurants and other food service facilities where they will be purchased and consumed by families trusting that they are receiving peanut butter crackers free of Salmonella. Public health has worked in the form of inspectors, guidelines, regulations, sample testing, quality assurance, staff training and public education to ensure that a perfect situation can and will exist most of the time. Although you never saw public health working to prevent you from getting sick, it was there.

Even when all goes right – even when there are not blatant safety oversights along the way – sneaky Salmonella can find its way in. What then?

Our peanuts have picked up Salmonella after roasting (there’s likely no more heating to kill that nasty pathogen) in the processing facility. They are then mixed with more and more peanuts, shipments from other farms, passing through machine after machine, being ground into peanut paste, infecting huge lots of peanuts along the way. Our peanuts are now causing a silent outbreak deep within the processing facility.

The lots of infected peanut paste – soon to be peanut butter – go unsuspected and are sent to the next phase of processing where they will become cookies, crackers, ice cream, dog treats, etc.

Suzy Public loves peanut butter cookies, so she picks up a package during a routine grocery store visit. Two days later, Suzy is very sick.

Vomiting takes a turn to more severe symptoms so Suzy does the right thing and heads to her doctor. In keeping with clinical care guidelines, Suzy’s doctor orders a stool sample which is then sent to a clinical lab where it tests positive for Salmonella. This is obviously important information for Suzy’s doctor who needs to determine the most effective treatment, but it is also important for the public at large, especially for those in her community.

Additional testing at the public health laboratory could link Suzy’s Salmonella to other cases in her area or across the country.

While clinical labs must submit a report alerting epidemiologists of Suzy’s Salmonella, many states don’t require clinical labs to submit isolates (a sample of the Salmonella that made Suzy sick) to the public health lab. The report allows epidemiologists to gather initial exposure information on cases, but identifying potential outbreaks among sporadic cases can be tough without additional information. An isolate allows the public health lab to subtype or get DNA fingerprints from the Salmonella (more on this below), providing greater information and more rapid outbreak detection. So why wouldn’t states require these isolates be submitted? There are likely different reasons for this; one common reason is simply that the states lack resources. Some states can afford to have a courier pick up and deliver those isolates, but not every state is able. It is hard to mandate that the clinical labs handle shipments on their own time and dime. Additionally, some states simply cannot process all of those isolates at their current funding level. Requiring all clinical labs to send those isolates would put an enormous workload on already understaffed public health laboratories.

Once the investigation has been opened, an epidemiologist or public health nurse will contact Suzy Public to begin the investigation to nab the culprit. The first question they will ask Suzy is to list everything she consumed in the week or so prior to getting sick. These interviews allow disease detectives to track patterns in sick individuals’ diets. If everyone ate peanut butter crackers, they can target their investigation.

Could funding cuts to food safety programs make you sick? |

Delays in testing or reporting will delay these disease detectives, and that means Suzy and the others who were made ill may not remember so far back. Even if they do remember and the disease detectives can identify a common food item in their diets, that product may already be off the shelves and in more people’s homes thus exacerbating the outbreak. Additionally, departments of public health face staff shortages that mean overloaded epidemiologists and public health nurses. Their ability to conduct thorough interviews requires ample time – and time is limited when staff are carrying a workload suited for several people.

If that isolate was sent to the public health lab, additional testing is done to confirm Salmonella and to subtype the pathogen. There are over 2,500 subtypes of Salmonella, so the first step in outbreak detection is determining which type has made this individual sick. PFGE testing delves further into the identification of the pathogen by identifying its DNA fingerprint. For example, there could be multiple outbreaks associated with Salmonella Typhimurium at the same time but that doesn’t mean it is the same culprit. Isolating the DNA fingerprints is like a detective pulling fingerprints from a crime scene – when there are multiple offenses committed, fingerprints can link them to the same perpetrator. The DNA fingerprints are then entered into the PulseNet database, a system used to detect clusters nationally. This information is used by epidemiologists to further target their investigation.

But staff shortages in public health laboratories mean not all isolates can be tested, and those that are tested could be delayed. That means less information is making its way into the PulseNet database or it is being entered too late.

Delays or gaps in information make the investigation extremely difficult.

The case of the contaminated peanuts is a complicated one. We know the contaminated peanut butter used to make Suzy’s cookies caused her illness, but identifying those cookies as the source is only the beginning of the investigative process. Was it the flour, sugar, salt, eggs, peanuts, or one or more of the other ingredients that made Suzy sick? And what about the people who were sickened by peanut butter crackers? Or energy bars? Finding the common denominator – and drilling all the way down to where contamination occurred – is very difficult. These complicated investigations can last upwards of a year, but they are being closed without resolution simply because public health departments don’t have the means to keep them open. No resolution means contamination at the processing facility could continue and more people could become ill. It also means the rest of the industry cannot learn from the outbreak and implement changes to improve product safety.

Rapid detection leads to faster recalls of contaminated products. That means fewer people get sick. But our public health system does not have the means to investigate every case of foodborne illness. There are not enough resources to follow up on every cluster.

Without question, more outbreaks would be found if there were sufficient resources to detect and investigate them all. Simply put, funding cuts are ultimately causing more people to get sick.

Advocates continue to work hard to convince decision makers that increasing funding for the public health system is a very good investment in our population. Healthy people are better for every aspect of society. While the advocates are working, public health professionals continue to seek more ways to improve the system with fewer staff and fewer resources. Whole genome sequencing, for example, could provide more information to better understand outbreak clusters, and that could mean less follow up testing which could mean operating with fewer staff. However, implementation of advancements such as whole genome sequencing requires time and money that the system simply does not have.

Every day that you wake up without foodborne illness, thank the public health system. Waking up healthy did not happen without the dedicated men and women working hard to prevent the spread of dangerous bacteria.

When public health works, no one sees it… but it still needs adequate support to continue protecting our health. The disease identification system described above operates on only $40 million annually and is in immediate need of at least an additional $10 million as indicated in the 2015 budget request. To realize significant improvements, CDC funding for food safety should be doubled at a minimum.

Tell Congress that more money is needed for food safety! Follow these two simple steps:

  1. Here is a letter telling Congress that more funding is needed for public health. Complete the information and it will be sent to your elected officials.
  2. Copy the following sentence and paste it into the letter to draw attention to the specific needs for food safety: I am especially concerned with the need for funding to improve our nation’s food safety system. CDC’s food safety office is in immediate need of an additional $10 million as indicated in the 2015 budget request. Without this funding, more Americans will get sick from foodborne illness.



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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? |

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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Federal Public Health Programs and Employees are Essential Despite Label

Oct 02 2013 :: Published in Food Safety, General, Infectious Diseases, Public Policy

By Scott J. Becker, executive director, APHL

It is day two of the federal government shutdown.

Every day, before I leave for work, I walk our family dog around the neighborhood.  The weather is beautiful today, just as it has been for the last couple weeks.  What’s different about today, however, is that my neighborhood is full of cars on the street and people milling about. It just dawned on me that I live in a nonessential neighborhood.  My neighbors are government employees.

Federal Public Health Programs and Employees are Essential Despite Label |

APHL is headquartered in Montgomery County, Maryland, an ethnically and socioeconomically diverse area; our school system is known for being one of the top in the nation but today it’s known for having children from 70,000 families whose family members’ jobs are considered nonessential and are now furloughed.  Among those furloughed are the security guards who check IDs at the National Institutes of Health (NIH); our nation’s top scientists who are looking for cures for childhood cancer; the researchers doing work on influenza viruses; the food service workers who are usually hard at work by now helping to feed the many employees at the National Institute of Science and Technology (NIST); and the Maternal and Child health specialist at the Health Resources and Services Administration (HRSA) who supports the newborn screening programs in our public health labs.

Despite being given a “nonessential” label, they are all essential to us.

Public health is a local, state and federal continuum where all parts work together to ensure we have a healthy American populace. The public health system can’t work very well – or, I should say, doesn’t work very well – when one part of the system simply isn’t engaged. That’s the situation we face today on the second day of the federal government shutdown. Local public health is still hard at work, state public health is still hard at work, but the federal portion of public health is minimally staffed. If the local or state systems need technical assistance or laboratory support, they are largely on their own.

The federal portion of the continuum is essential.  In some ways you can think of it as the glue that holds the system together.  Public health laboratories and epidemiologists are busy tracking down disease outbreaks all the time. They do a great job in their local or state jurisdictions detecting diseases and other pathogens that can harm us. But it is the role of the federal government – the Centers for Disease Control and Prevention (CDC), in this case – to come up with a national picture of disease outbreaks. It’s the job of the CDC to knit together the mystery of how outbreaks unfold across the country, all with the goal of stopping them as soon as possible so that lives can be saved.

Take a foodborne outbreak for example. On any given day CDC is reviewing up to 30 (and sometimes more) clusters of foodborne illness across the country. We have an incredible system called PulseNet, which is essentially a DNA fingerprinting system for bacteria that cause foodborne outbreaks.  It’s those DNA patterns that are uploaded to a large database at CDC. It is then CDC’s role to review that data and to look for matching patterns across the country so that multistate outbreaks can be detected, the product pulled from market, the outbreak stopped and people can regain their health. What I just described isn’t only CDC’s role, it also involves the FDA. It’s their responsibility to test products that have been implicated in outbreaks and ensure they are pulled from the market. But because of the shutdown, only a skeleton crew of CDC disease investigators and FDA investigators and regulatory specialists are at work.

It’s also the beginning of the annual flu season. Public health laboratories around the country are busy collecting specimens and analyzing them to determine what influenza strains are circulating. That information is then shared with CDC so they can do their job of reviewing the information nationally to determine where flu outbreaks are occurring.  But because of the government shutdown there is no one at CDC able to review these reports.  That means we are likely to see influenza reported in each state but we will not see a national picture. While  that’s not devastating in the short run, if we go a few weeks or longer we will miss out on seeing what’s happening with influenza this year which will impact our knowledge base on what strains might be put into the flu vaccine for next year potentially compromising  the health – and possibly lives – of many.

I could go on and on but my point is really that public health remains an enterprise; as I said above, it is a local, state and federal continuum. The federal role in public health is essential. It is the part that holds together the other pieces and we are less safe when the federal contributions to public health are missing in action.

Congress must act soon; public servants deserve better and the American public deserves better.


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What We’re Reading – Cyclospora Edition

Aug 08 2013 :: Published in Food Safety, Infectious Diseases, What We're Reading

By Jessica Monmaney, Associate Specialist, Food Safety and Infectious Diseases, APHL

What We’re Reading – Cyclospora Edition |

Cyclosporiasis, the infection of Cyclospora, is rare in the U.S., so when the Iowa Department of Public Health (IDPH) found six cases from June 28th to July 3rd (after experiencing only ten cases prior to 2013) the state issued an alert that there was a possible outbreak. As of this morning, the Centers for Disease Control and Prevention (CDC) reports that the most recent total of illnesses has reached 504 confirmed cases across 16 states and New York City*. (Check CDC’s website for the most up-to-date numbers).Thanks to the heroic efforts of laboratorians and epidemiologists at IDPH from the start of the outbreak, the source of the illnesses has been identified in Iowa and Nebraska, though investigations continue in the remaining 14 states and New York City. Below, you’ll find a list of articles we’ve been reading this week to stay informed on the progress of these investigations.

*The number of states refers to the number of state health departments reporting cases. In this case, there are 16 state health departments plus the New York City health department which reports directly to CDC. New York state is also included as one of the 16 states reporting.

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What We’re Reading — Measles Edition: One of Ms in MMR

Aug 01 2013 :: Published in Infectious Diseases, What We're Reading

By Laura Iwig, Senior Specialist, Infectious Disease Program, APHL

For many people, the word “measles” conjures up memories of the series of MMR vaccines – that’s measles, mumps and rubella – they received as a child. Measles, as you may know, is a viral infection spread by contact with droplets from the nose, mouth, or throat of an infected individual. The disease can have serious health consequences, notably in infants.

Since the development of the measles vaccine 50 years ago, there have been few cases in the United States. In fact, in 2000 it was thought that the US had eradicated indigenous measles. Unfortunately the disease has resurged in recent years with outbreaks in Texas, New York, Washington, Michigan, and most recently, New York City and North Carolina.

While it’s discouraging that measles is making a comeback in cities across the country, there are positive developments at public health labs, which are leveraging national and state resources to respond to such outbreaks. North Carolina, for example, was ready to respond to an influx of measles specimens in spring 2013 because it had signed up as a submitting laboratory for APHL’s Vaccine Preventable Disease Project. North Carolina also had the benefit of services provided by one of the Vaccine Preventable Disease Project’s Reference Centers, Wisconsin State Hygienic Laboratory. Wisconsin tested 10 specimens associated with the outbreak, three of which proved to be positive. More such collaborations can be expected as state health departments continue to ramp up surveillance and detection of emerging diseases and of those, like measles, that boomerang back from obscurity.

Measles in the News:

A possible measles exposure was reported in Washington due to visitors from out of state. Individuals are encouraged to call a health care provider if they develop any symptoms of the illness.

The Florida Department of Health in Orange County recently confirmed a case of measles in a tourist. The infected individual visited many local attractions. Individuals who attended area attractions at the same time as the infected individual are encouraged to contact a health care provider if they develop symptoms.

The Brooklyn Measles outbreak that went on from March to June was officially declared over in mid-July. This outbreak resulted in 58 cases of measles in Brooklyn, NY.

Travelers may have been exposed to measles at the Dulles Airport on June 7. A warning from the Loudon County Health Department was issued to all travelers who were in Concourse A or B, the International Arrivals building or the baggage claim level of the main terminal. 

For more information:

Information about measles including current outbreaks and preventative measures is available here.

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A Look Back at the New Hampshire Hepatitis C Outbreak

May 16 2013 :: Published in Infectious Diseases

By Celia Hagan, Manager, HIV, Hepatitis, STD, TB Programs, APHL

A Look Back at the New Hampshire Hepatitis C Outbreak |

People often associate hepatitis with intravenous drug use or getting tattoos or piercings at dirty parlors.  They think it’s something that can’t happen to them. However, recent health-care associated outbreaks in Oklahoma and New Hampshire show that hepatitis is something that we all need to be aware of.  The New Hampshire case, in particular, demonstrated how a rapid public health response can identify a hepatitis C outbreak and stop transmission.

In the spring of 2012, the New Hampshire Department of Health and Human Services, Division of Public Health Services began investigating a cluster of four people who were recently diagnosed with hepatitis C and who had been treated at the same hospital. The public health laboratory initially coordinated blood draws and performed hepatitis C virus (HCV) testing. Additionally, the public health lab performed DNA sequencing on the non-structure 5B region of the HCV genome to subtype the virus and sequenced the hypervariable region 1 of the HCV genome to determine if individuals who were infected were part of the same outbreak. When sequencing was performed on the initial cluster, the four individuals had matching HCV viral sequences indicating a common source of infection.

As the outbreak unfolded over the next few weeks, mounting evidence suggested that the mode of transmission was a drug diversion by a cardiac catheterization laboratory technologist at Exeter Hospital. The technician is accused of stealing Fentanyl syringes intended for patients, injecting his own arm, refilling the empty syringes with a saline solution, and returning the used syringes as if they were untouched. Those dirty needles were then used on patients.

Dr. Christine Bean, New Hampshire’s public health laboratory director, and Dr. Fengxiang Gao, New Hampshire’s public health laboratory virology and special testing program manager, said that in the initial phase of the investigation, where the primary concern was focused on testing patients who received care at the cardiac catheterization laboratory of Exeter Hospital, the laboratory tested 1,072 specimens. This was well over their normal testing volume of about 200 specimens per month. All testing was performed at the public health laboratory and positive specimens were sent to CDC for additional testing.  When the investigation expanded to other units in the hospital that the technician had access to, an additional 3,300 patients needed testing. Community testing centers were set up to assist with rapid blood draws. In addition to the routine testing done at the public health laboratory, the clinics offered rapid HCV testing on site and also trained sentinel laboratories on rapid testing to help with the volume. Ultimately, 32 patients were identified as part of the NH outbreak, in addition to the infected technician. As the outbreak investigation expanded to include other states where the technician had previously worked, additional cases were found.

The Molecular Diagnostics group at New Hampshire's Public Health Laboratory.  This group did the hepatitis C (HCV) sequencing during the 2012 outbreak to determine the HCV subtype and HCV genetic relatedness. |

The overall response to the outbreak from the laboratory was phenomenal.  Quick detection may have prevented additional infections. Dr. Bean emphasized that their success in responding to the outbreak depended on a strong public health laboratory system—the public health laboratory and epidemiologists working together and the public health laboratory’s capability and capacity to perform both serology and molecular tests for HCV.

In the May 10, 2013 issue of MMWR, CDC released Testing for HCV Infections: An Update for Guidance for Clinicians and Laboratorians. The updated guidelines emphasize identifying persons with current HCV infections as opposed to those who have had past infections that have been resolved and encourage laboratories to utilize newer testing technologies. The new recommended testing sequence includes an initial test with an FDA-approved test for HCV antibodies, followed by an FDA-approved nucleic acid test (NAT) intended for the detection of HCV RNA in serum or plasma if the initial serology assay is reactive.

May 19, 2013 marks the second National Hepatitis Testing Day during a month that is already dedicated to raising the awareness of viral hepatitis. The day is committed to testing people at risk for hepatitis and to educating providers and the public about chronic viral hepatitis and testing.

To find a Hepatitis Testing Event near you or to register your event, click here.




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World TB Day: What’s in a name?

Mar 24 2013 :: Published in Infectious Diseases

By Will Murtaugh, Specialist, Infectious Diseases, TB Programs, APHL

Robert KochWorld TV Day, you say?!  Sorry, unfortunately not. But since you’re here – let’s talk about World TB Day!  So hit pause on Contagion (you know you’ve already seen it umpteen times), take a look at this guy, and read on.

This German man with the enviable uber-beard once gave an uber-exciting lecture titled “Über Tuberkulose” describing how he discovered the bacilli that causes tuberculosis (TB). He eventually won a Nobel Prize for his discovery, and now, on World TB Day, we’re supposed to celebrate!

Not yet convinced to throw on that party hat? OK, so he’s no Jude Law and maybe this wasn’t the blockbuster climax you were looking for – but the story of “Über Tuberkulose” is far from over…

Imagine that you were this shrewd-looking man surrounded by people who still believed they lived in a “miasma” filled world that caused 1 in 7 people to die with a combination of symptoms including fever, weight loss, and a prolonged productive and bloody cough.  What if this was happening to 7,000,000 people worldwide every year?  What if it was believed incurable and treatment involved being sent away in isolation to a “sanatorium” with a prescription of more fresh air?  You’d surely say,

“…my words have been unheeded. It was still too early, and because of this they still could not meet with full understanding. It shared the fate of so many similar cases in medicine, where a long time has also been necessary before old prejudices were overcome and the new facts were acknowledged to be correct….”

Or something like that – right?

This was the reality of 131 years ago.  But you can thank your lucky pipettes for a “19th Century scientist giving a speech about discovering germs in a laboratory” that the miasma fog has lifted and exposed the road to TB elimination we continue down today; one in which we can demand, “Stop TB in my lifetime”.  Specifically, you can thank Dr. Robert Koch for revealing to the world on March 24, 1882, in an oft romanticized speech, still considered one of the greatest in medical history, that TB was caused by an identifiable infectious agent, Mycobacterium tuberculosis.

So, what’s in a name?

In the case of M. tuberculosis, an infectious bacilli likely as old as mankind itself, a lot. So don’t throw on your party hats just yet.  Part of observing World TB Day is that we recognize we are still a long way from TB elimination. In 2013, we face a different set of challenges than those of 1882:

  • An increasingly mobile global community in which one-third of its population are believed to be carriers of M. tuberculosis.
  • The emergence of Multi-Drug Resistant (MDR-TB) and Extensively Drug Resistant (XDR-TB) strains of M. tuberculosis induced by improper use as a result of an expensive and long-term treatment program.
  • Systemic societal issues, including marginalized high-risk populations such as persons co-infected with HIV, foreign-born persons, the homeless and those in America’s prison system.

We recognize the progress of science, medicine and public health that has contributed to the global reduction of TB and remember Dr. Koch’s fundamental contribution in naming M. tuberculosis. Specifically here at APHL, we recognize its impact on the development of TB diagnostics used in our public health laboratories today.  Koch contributed to the development of a widely used test for detecting TB infection, the tuberculin skin test (TST, also known as PPD or Mantoux test).  Additionally, he successfully developed a method to both grow and visualize M. tuberculosis that was so valuable similar methods are still used by our public health laboratories to aid in the diagnosis of TB.  As our Mycobacteriology laboratories progress forward, detecting M. tuberculosis with faster, and more advanced technologies, they evaluate many of these tests against the methods pioneered by Koch.  Furthermore, laboratories are developing the capability to “name” M. tuberculosis in greater detail, revealing important information such as the strain responsible for an outbreak and the presence of MDR and XDR-TB.  The value of these laboratory capabilities is becoming increasingly apparent as we overcome the evolving and often overlapping challenges. Important instances of the laboratories’ continued relevance in TB control in the United Stated can be found in still ongoing events such as the outbreak in a largely homeless population in Los Angeles’s Skid Row and the detainment of a Nepalese man in McAllen, TX diagnosed with XDR-TB.

So not to worry, Dr. Koch, with the help of those funny lenses of yours, our public health laboratories see the way forward.  Party hats on!

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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The Newest SuperBug: CRE

Mar 21 2013 :: Published in Infectious Diseases

By Laura Iwig, Senior Specialist, Infectious Disease Program, APHL

What is this new antibiotic-resistant superbug that is flooding the news streams these days?  Nightmare bacteriaTriple threat?  What is this monster?

On March 5, 2013, CDC’s Vital Signs featured a report describing the newest superbug circulating health care facilities around the world: Carbapenem Resistant Enterobacteriaceae (CRE). It has targeted patients in health care facilities receiving care that requires devices such as ventilators, urinary catheters, or intravenous catheters.  People receiving these treatments are immunocompromised and more susceptible to other infections.  Symptoms can include gastrointestinal illness, pneumonia, or, in serious cases, infections of the bloodstream or other organs.

Hospital bed

CRE is unlike other antimicrobial resistant bacteria.  As Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, stated “They’re resistant to nearly all antibiotics. They have high mortality rates, killing half of people with serious infections. And they can spread their resistance to other bacteria.”

Most health departments are only beginning to look for CRE.  Many report health care-associated infections only when there is an outbreak.  As indicated in the MMWR article, only six states require facilities to report CRE infections!  This means that the true impact of CRE is not known.

What are public health laboratories doing in response?

Depending on the presence of CRE in their state, public health laboratories are either working to respond or preparing for an influx of testing orders.  The Colorado public health laboratory, for example, has collaborated with state epidemiologists to implement CDC screening procedures for CRE in response to an outbreak at a Colorado hospital.  To date, the lab has screened a total of 126 swab samples for the presence of CRE, and validated and implemented detection of two CRE genes to support identification of the nightmare bacteria.

At the same time, APHL is assisting public health labs to build CRE testing capability.  In August 2012, the association, in collaboration with CDC, selected the Indiana State Public Health Laboratory and Michigan Public Health Laboratory to develop non-automated antimicrobial susceptibility testing capability for CRE to provide confirmatory testing for clinical laboratories.  These critical projects are well underway; it is in the public’s interest to ensure that they are sustained.

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Presenting APHL’s New Animated Video!

Oct 31 2012 :: Published in General

What is a public health laboratory? Hopefully this will help answer that question. If you cannot see the video below, click here.

Thanks to Digital Bard for their hard work on this video!

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Beware of the Nose Pickers

Oct 16 2012 :: Published in Food Safety, Infectious Diseases

By Kara MacKeil, BA, Senior Technician, Public Health Preparedness and Response, APHL

Let’s all stop and think for a moment about why you, personally, should wash your hands.  We all agree that washing your hands is a good thing; according to the US Agency for International Aid, good hand washing can reduce death from diarrheal disease by almost half.  But you may notice that “I know I should wash my hands” often does not equal “I DO wash my hands.” (Feel free to read this if you don’t believe me.)  So in the interests of public health, I’m going to do my best to scare you all into picking up the soap.

Nose Picker

Picture the handle on the front door of your workplace (if yours doesn’t have one, skip ahead to the elevator buttons).  Who might have used this handle before you arrived this morning?  What have they all been touching before they came to work? Many have small children at home; conceivably they changed a diaper or dealt with an accident before they left the house.  Almost certainly they used the bathroom themselves.  There are numerous pet-owners, perhaps they did the morning walk or scooped a litter box. It’s cold season, so quite a few have been coughing and sneezing, and just as many have spent the last hour sitting in traffic with their index fingers shoved firmly up their nostrils.  They might have hit the sink, they might have used hand sanitizer, but they all touched that handle before you did.

Go inside and walk to your desk.  Notice that the cleaning crew has thoughtfully dusted underneath your various pencil holders, convention toys, and other objects.  How nice!  I’m sure they washed their hands before they picked up the mouse you’re about to spend all day holding. The rest of the day passes as usual.  You touch buttons on the copy machine and objects on your desk.  You pick up a pen, and wonder idly how you came to own it, since you didn’t attend the convention it advertises.  Someone must have left it on your desk.  Wonder what they touched?

Lunchtime hits, and you eat with your co-workers.  Hopefully everyone washed their hands, especially the one passing out cookies.  After lunch it’s more buttons, more objects, more mystery pens.  Someone coughs in the background, jolting you from your post-lunch stupor, and you hit the candy jar for a boost.  Just be sure to get to it before the cougher does.

You use the bathroom.  Uh-oh, there’s another door handle.  Are you sure you heard the sink when the last person finished?

Work is done, so it’s time for errands, or maybe the gym. Whatever you do, you’ll be touching things. More door handles, more objects, more nose pickers. On the way home, you realize your EZ pass isn’t in the car, and you’ll have to use cash.  Amazing how long a coin lasts, I bet THOUSANDS of people have touched that!

Here’s your front door, safe at last!  It’s late, so crawl into bed, maybe read a few pages of that great book you snagged from the secondhand bookstore.  As you drift off, try not to think about how many things you have touched today, and all the hands that touched them first. Pay no mind to all those times you touched your face.

Wash your hands!


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