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? |

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 |

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? |

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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Massive Molasses Mess and the Laboratory Response

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


By Megan Latshaw, Director, Environmental Health Program, APHL

“It was shocking because the entire bottom is covered with dead fish. Small fish, crabs, mole crabs, eels. Every type of fish that you don’t usually see, but now they’re dead. Now they’re just laying there. Every single thing is dead. We’re talking in the hundreds, thousands. I didn’t see one single living thing underwater.” ~ Roger White, a diver (Massive Molasses Spill Devastates Honolulu Marine Life, NPR)

Massive Molasses Mess and the Laboratory Response) |

We’ve all heard of killing someone with kindness, but who knew that sweetness could deal such destruction? The sweetness comprises almost 250,000 gallons of molasses, spilled into Honolulu harbor on September 9th as it was being loaded into a ship via pipeline.

Because the greatest priority relates to public health, the Hawaii Department of Health is leading the response rather than the US Environmental Protection Agency or the US Coast Guard.

Their State Laboratories Division will be doing bacteria testing (enterococci, clostridium and total).  Since this spill is relatively unprecedented the first two bacterial tests were chosen because 1) Hawaii has a lot of data on them and 2) they are currently used to monitor water quality. Scientists are not sure how the spill will affect these indicators but they theorize that the dead fish and the nutrient-rich liquid could lead to unusual growth in marine algae and harmful bacteria. These data plus some chemistry and physical parameters will help them figure out when things are starting to get back to normal.

Meanwhile, the laboratory expects to run out of supplies for this valuable testing.  They have called upon their peer network to borrow and replace consumables from their labs, on the outside possibility that their suppliers cannot provide them with the necessary materials quickly enough. Such outreach emphasizes the importance of building relationships through networks such as the Laboratory Response Network and the Environmental Response Laboratory Network.

Click the image above for an interview with Hawaii’s public health laboratory director and many of their staff.

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Public Health Preparedness in the Age of Social Media

Sep 03 2013 :: Published in Public Health Preparedness & Response

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


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

One of my earliest childhood memories is of being woken up during nap-time at daycare.  I was about four, and my parents were bringing me home early because a hurricane was approaching the coast.  While I can’t remember now which storm it was (though Hurricane Bob is the most likely), I do remember that my parents kept the radio on for the entire drive home, paying meticulously close attention to the constant stream of weather updates. Even before the age of the smartphone, it was crucial to know what was happening.

That need for timely and accurate information will never change but technology has come a long way since 1991, and thanks to social media we have many more tools available to us to plan for and respond to emergencies.  For laboratories, this means new ways to expand on their Continuity of Operations Plans (COOP) to keep employees and the public safe and well-informed.

Public Health Preparedness in the Age of Social Media |

To share information, many organizations are leveraging existing social media platforms such as Facebook and Twitter.  You might think these services are for bored teens sharing pictures of their lunch, but a quick Facebook search yields hundreds of emergency management groups, and Twitter has even more.  Both platforms are quick and easy ways to push out information such as the status of the local drinking water or whether or not a public health laboratory is diverting samples to other laboratories due to storm damage.  It’s also an opportunity to ask for assistance during emergencies and share information on outbreaks….just search for Cyclospora and you’ll find current news on the number of cases and possible source. I’m far more likely to hear about a major news story from Twitter than from the local television news station, and I know I’m not alone there.

Like most social media sites, these services aren’t reliant on any specific computer and messages can be sent by any laboratory employee with the correct password, making it even easier to communicate.  I admit some of this could be accomplished through text messages as well, but social media messages have a tendency to go viral (meaning people share the messages to different groups of people) that texts can’t match.  When the message concerns issues such as contaminated food or water, the more people that see the information, the better.  Laboratory employees could also use these services to check in when phone lines are tied up, letting supervisors know what their personnel capabilities are in real-time.

There are also a number of mobiles applications (apps) on the market that can assist in planning for and responding to disasters.  The Red Cross is one of the best-known in the business, with a suite of apps that instruct users on how to prepare their homes and workplaces for disasters like tornados, wildfires, and hurricanes. The apps also push out location-specific updates on shelters, weather updates, and other essential information.  Louisiana’s Office of Homeland Security and Emergency Preparedness has another great group of apps called Get a Game Plan, which guides users through making readiness plans for different situations and provides Louisiana-specific information on evacuation zones and shelters, weather alerts, and maps.  Both are accessible from the web for those without smartphones. While these apps are primarily targeted towards families and individuals, it would be relatively easy for a laboratory to include use of these apps in their COOP as a reference point for when certain steps should be taken.  For example, the decision to evacuate or call in extra personnel could take up-to-date information from one of these apps into account.

Good responses to emergencies also require good planning beforehand.  Most laboratories have excellent disaster-response plans in their COOPs, but even the best COOP will be clotheslined if employees aren’t prepared at home.  In addition to the apps above, FEMA’s is a great resource for planning personal disaster readiness, and I’d advise everyone to take a look.  You might be surprised when you realize just how much stuff you’d need to keep your family (and your pets!) safe and comfortable for a few days of shelter-in-place.  We all know how critical public health laboratories are.  In the interests of keeping your laboratory functioning in a disaster, it might be a good idea to have a home-readiness information session at work to be sure that employees are fully equipped to deal with emergencies and keep essential services running.

Of course, no app will protect you if you’re stranded without supplies.  Easy ways to make contact are no substitute for having a readiness kit and a plan in place, and everyone should make the time to ensure they’ll be ready if disaster strikes.  I bet my parents would have loved to have some of these tools back in 1991!

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Dogs Ease Work Stress and Great Lab Continuing Education Does Too

Aug 14 2013 :: Published in Workforce & Professional Development

By Beaker, Your Lab Training Partner

I don’t know if you remember me, but I’m Beaker, APHL’s unofficial mascot for its laboratory training program.  You may not know me personally, but I am your lab training partner!  I know that you are always looking for good continuing education programs to help you and your staff keep up to speed on what is happening in laboratory science… and believe me, a lot is happening!  APHL has put together a variety of webinars this fall that ease the stress of where to find the continuing education that everyone in your lab needs.  Who exactly are these webinars for? Those of you working in clinical, academic, reference, veterinary, research, public health, environmental laboratories – any labs that do any type of analysis on humans, animals or environmental specimens. If that’s you, keep reading!

Dogs Ease Work Stress and Great Lab Continuing Education Does Too |

Did you know that APHL training webinars are available to your entire staff at one reasonable, low price?  The registration fee includes one-line access to the webinar on the broadcast date, access to the webinar for all those who want to listen in at your site AND six months’ access for the rest of your staff.  And, yes, that does include continuing education units (CEUs) as well.  What a bargain!  If I were you, I’d be happier than if my friends and had ended up in a room full of fire hydrants!

And did you know that you can register your site for the archived webinar for six months after the live training?  If the date doesn’t work for you, don’t worry!

Coming up this September is a webinar on the new OSHA Chemical Standard that outlines what EVERY lab needs to know about the new standard and the new safety data sheets which you may already be seeing in your laboratories.  OSHA mandates that all employers conduct training by December of this year to get their employees up to speed, and this webinar will satisfy that requirement.  The program, on September 19 at 1:00 ET, will be presented by Eric Clark, the Safety Officer for Los Angeles County—can’t get a better safety expert than that!

Speaking of safety, APHL also has two other webinars in September on safety issues. The first covering laboratory-acquired infections, will be presented by Karen Byers, the Biosafety Officer for the Dana Farber Cancer Institute in Boston on September 17.  Risk Assessment for Clinical Microbiology Laboratories  also is scheduled for September. Mary DeMartino from the State Hygienic Laboratory at The University of Iowa will be the speaker.  With all of these safety webinars, your laboratory a safer place to work. But I know safety is only one of your stressors and must-haves in professional education.

Since regulatory issues are always on your mind, APHL is partnering with the American Society for Clinical Laboratory Science (ASCLS) to present a webinar, CLIA Summer Update on Hot Topics 2013.  Judy Yost of the Centers for Medicare and Medicaid Services (CMS) will be just back from the summer Clinical Laboratory Improvement Advisory Committee (CLIAC) meeting and will discuss (among other hot topics) the latest breaking news on competency assessments, quality systems and a pilot project for education of CLIA-waived laboratories.

That’s just the beginning of APHL’s training line-up!

I’ll leave you with one last bit (or kibble) of information:  Since I am your best friend, I know that working in a laboratory can be stressful.  Fortunately, CDC has resources that can help you deal with stress.  Check them out today! And did you know that owning a dog or having one at work with you (I know that’s impossible for you!) alleviates stress?  And as reluctant as I am to admit it, cats can help too (but probably not as much as dogs)!  At Harvard Medical School, they even have a resident pooch at their library to help students, staff and faculty relieve stress.  Good stuff!

Have a GRRRReat August and September—we will talk again soon!  By the way, if you need to ask me any questions, I am available by email.  I’ll have to get one of my humans to translate, but feel free to contact me!

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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 |

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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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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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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Nanotechnology and Public Health: Part 2/2

By: Michael Heintz, Senior Specialist, Environmental Laboratories, APHL

This is the second in a two-part series on the implications of nanotechnologies on public health. See Part 1 for an introduction to nanotechnology and nanomaterials. Part 2 delves into how this emerging field may impact various parts of public and environmental health.

Nanotechnology and Public Health

Nanomaterials provide new opportunities for detection, remediation and protection. Laboratories, in particular, need to understand the uses of nanomaterials because the small particles with very different properties and reactivity will affect laboratory operations.

- Environmental Health: Nanomaterials may provide significant new remediation tools, while also presenting contamination concerns. As consumer goods use nanomaterials more often, the potential for accidental exposure or release increases. Disposal from nanomaterial-containing goods, such as cosmetics and paint, could cause increased soil and water contamination as the nanomaterials leach. In some instances, nanomaterials are small enough to permeate the liners of landfills and other barriers, providing exposure pathways into groundwater and other environmental resources. Similarly, accidents or other releases can cause direct environmental harm. Additionally, nanomaterials appearing in sunscreens may be small enough to pass through the skin and into the biological system of people.

Of particular concern for laboratories is that nanomaterials may begin appearing in both clinical and environmental samples. Without proper controls, nanomaterials may cause unknown impacts on results. And, given the higher reactivity at lower concentrations, test methods may not accurately reflect the presence of nanomaterials leading to confusing or illogical test results.

- Food Safety: Food safety issues may be the largest area of concern when it comes to nanomaterials. Nanotechnology is employed in a large portion of the food chain including agriculture (pesticides and sensors), processing (nanocapsules and flavor enhancers), packaging (sensors and spoilage barriers), and supplements (vitamin sprays). On the other hand, the potential for longer food preservation, more efficiency in nutrient uptake, and disease resistant crops provides significant benefits to society. In addition, nanomaterials may allow for rapid pathogen testing in food sources. Such tests could potentially avoid outbreaks and recalls before food is moved to the market.

- Preparedness: For emergency response preparedness, the products using nanomaterials are largely the same as in other industries. Nanosensors and testing platforms used in the environmental sector are available to emergency responders for contamination warning and rapid analysis using handheld equipment (lab-on-a-chip). However, because the reactivity of nanomaterials is not widely understood in an emergency context, preparedness may be impeded by adding variables to emergency response situations. For example, nanomaterials age during environmental oxidation, but there is no information on how this aging process will change the properties of the materials.

In addition to these potential benefits and risks, the overarching issue remains uncertainty. Without clear direction as to the limits of nanotechnology, industry will continue to operate in a vacuum, products will continue to be developed and sold, and research will be left to catch up.

For more information on nanotechnology issues and areas of concern, see the following:

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