MERS-CoV: Why We Are Not Panicking

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

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

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

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

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

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

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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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Two Siblings Born With Isovaleric Acidemia: One Caught by Newborn Screening, One Wasn’t

May 21 2013 :: Published in Newborn Screening and Genetics

By Jana Monaco, Newborn Screening Parent Advocate

With spring in the air, the temperatures are climbing, the famous cherry blossoms have reached peak bloom and once again, the baseball and softball fields have come alive in Northern Virginia.  My very own sweet Caroline, age 10, has decided to try softball this year!  All decked out in her Shamrox uniform which includes fun socks covered with bright green shamrocks, she is eager and determined to play just like her dad and big brothers.

Caroline | Two Siblings Born by Isovaleric Acidemia: One Caught With Newborn Screening, One Wasn’t |

For most kids, it is a given that they will be on the field with the other kids in the spring, but for a child like Caroline, living with a life threatening inborn error of metabolism called isovaleric acidemia (IVA), it is a gift.  IVA is a disorder in which one’s body is unable to break down the amino acid leucine. Leucine, a by-product of protein, produces isovaleric acid that is toxic to the body.  Early detection of her disorder by newborn screening has enabled Caroline to have appropriate life-long medical intervention and management of her disorder, so that she has the strength and good health to play ball…something we never take for granted.

Through the joy of watching her run around the field, I am reminded that another season has come and someone else is missing on the ball field…her big brother Stephen.  He too has IVA, but due to a twist of fate, the disorder was not detected when he was a newborn as a result of lack of comprehensive newborn screening at the time he was born.  Despite my love for this time of year, springtime forever reminds me of a horrific time in our lives twelve years ago, leaving a permanent ache in our hearts.

Stephen | Two Siblings Born by Isovaleric Acidemia: One Caught With Newborn Screening, One Wasn’t |

On a beautiful May morning, much like the ones we are experiencing now, I found my happy, energetic little 3 ½ year old Stephen unresponsive in his bed with a strange odor permeating his room.  Just days before, he was playing in the dugout at his brother’s little league game and running the bases after the game.   He felt like a little, limp ragdoll as I picked him up and I could feel his little heart racing as I called 911.  By the end of the day, he was in a hospital pediatric intensive care unit (PICU).   Less than 48 hours later and two seizures, he crashed before our eyes and was left with swelling around his brain stem.  Stephen was in a coma on life support fighting for his life.  The diagnosis of isovaleric academia came too late to prevent severe brain damage.   Imagine being told “if your son makes it through the weekend, he won’t be the same little boy you knew” and having to tell your other children that their little brother is going to die.  Stephen remained in a coma on life support for three weeks and by the grace of God and excellent medical intervention, he survived his metabolic crisis.  However, it left him with severe intellectual and developmental disabilities, seizures, a gastrostomy tube and cortical vision impairment.   The devastation of what Stephen endured was compounded by the realization that it could have been prevented had he been screened for IVA at birth. However, it inspired me to become an advocate for expanded newborn screening at the state and national level to help prevent other babies and children from sharing Stephen’s fate.

Stephen | Two Siblings Born by Isovaleric Acidemia: One Caught With Newborn Screening, One Wasn’t |

After four weeks in the hospital and six weeks in a pediatric rehab center, we brought Stephen home to a very different life for all of us.  Somehow, we found a way to go on with life, welcoming Caroline just one year later.  We were now raising two children with a serious metabolic disorder including one with intellectual and developmental disabilities and two other sons who sought some sense of normalcy from the life we had.  Stephen has had many medical challenges over the past 12 years and we have all made incredible adjustments. Since 2011, Stephen has had four surgeries to include a major spinal surgery to insert two titanium rods and 27 screws.  In just a few short weeks, he will undergo another surgical procedure and diagnostic evaluation.  Despite four medications, we deal with weekly seizures that are difficult to explain.  It’s all a part of our roller coaster life where we savor the plateaus of status quo and brace ourselves with all of our inner strength for the approaching slopes and rapid descents of the next medical complication.

As we coast our way through life, we are constantly reminded of the endless “what could have beens” with Stephen, while cherishing those first 3 ½ years when we watched Stephen grow and develop his fun, loving personality, strong independence and infectious charm.  Rather than dwell on the loss, we have chosen to embrace the opportunity to take the series of events in his life and see a greater purpose…one that has and will continue to impact endless children and families in the years to come nationwide.  Together, Stephen and Caroline are a clear representation of the importance of newborn screening and the dramatic consequence with and without…a forever reminder every baseball/softball season.

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Newborn Screening: Parents are the Best Advocates

Apr 04 2013 :: Published in Newborn Screening and Genetics

By Thalia Wood, MPH, Specialist, NewSTEPs, APHL

I came to the Association of Public Health Laboratories after 11 years as the Newborn Screening Program Manager for the State of Alaska. I was the follow-up coordinator who ensured infants who screened positive received diagnostic testing and treatment as appropriate. Part of my role there was to establish the Newborn Screening Advisory Committee and conduct regular meetings to review procedures and policies, write position papers, and discuss ways to improve the newborn screening process.


Newborn Screening -- Babies

In 2002 a baby was born in Alaska with maple syrup urine disease (MSUD) at a time when many states were not yet screening for this condition.  The infant’s parents became advocates for newborn screening, writing letters to providers who felt newborn screening was not necessary due to the rarity of the disorders. They also wrote a short story which was printed on the newborn screening brochure that Alaska provided to parents.

This same mother became a member of the Alaska Newborn Screening Advisory Committee and an advocate for expanding the newborn screening panel when the state added tandem mass spectrometry conditions in 2003.  She joined me on a local Public Radio show called Line One: Your Health Connection to discuss newborn screening and its benefits to families.

Increasingly, families with children with newborn screening conditions are sharing their stories. These stories have become a powerful advocacy tool by putting a face on these conditions.  Family stories emphasize how early treatment can make a significant difference in a child’s development, and are often used as part of educational presentations to medical staff and in materials distributed by the Alaska Department of Health and Social Services to expectant families.

Other families in Alaska have also become vocal advocates for newborn screening, particularly for expansion efforts. In 2006 the father of two children with cystic fibrosis (CF) joined Alaska’s Newborn Screening Advisory Committee.  When CF was being considered for addition to the state’s newborn screening panel, he shared his family’s story to emphasize the value of the addition.  Thanks to his contribution and that of other families, cystic fibrosis screening was added to Alaska’s panel in 2007.

Recently a young mother who lost a child to severe combined immunodeficiency (SCID) presented a very passionate plea for the addition of this condition to the screening panel to the Alaska advisory committee; the committee agreed to begin screening as soon as possible. The date of implementation will be determined by Oregon Public Health Laboratory (OPHL) which handles screening of Alaska’s bloodspot cards.

There is no more compelling testament to the value of newborn screening than family stories.  Families in Alaska, like others from across the U.S. who have shared their experiences, do so because they value newborn screening and how it has saved them time, money, frequent hospital visits and, most importantly, their children’s lives.

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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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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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What We’re Reading — A Month of Blog Posts

Sep 27 2012 :: Published in What We're Reading

National Preparedness Month and Newborn Screening Awareness Month

As you probably know, this month has been both National Preparedness Month and Newborn Screening Awareness Month.  And as you may have noticed, our blog has been BLOWING UP (don’t worry, we were prepared) with fantastic posts honoring each of those months.  Just in case you missed any of these great stories, here is a rundown of posts by APHL staff, members and partners:

National Preparedness Month:

My Path To Public Health Preparedness and Response by Christopher Chadwick, MS, Senior Specialist, Public Health Preparedness and Response, APHL

System Built for Responding to Bioterrorism Confirms Plague in Colorado Girl by Larry Sater, MS BT/CT Coordinator, Colorado Department of Public Health & Environment Laboratory Services Division

National Preparedness Month and Serendipity by Jim Garrow, Guest Blogger, Operations and Logistics Manager for the Bioterrorism and Public Health Preparedness Program at the Philadelphia Department of Public Health

Newborn Screening Awareness Month:

It’s all about the babies by Pat Blake, Strategic Communications Director, State Hygienic Laboratory at the University of Iowa

Happy Birthday to Ary — 10 years of Living With Sickle Cell by Michelle Forman, Senior Media Specialist, APHL

Raising Baby Caroline: Life With PKU by Michelle Forman, Senior Media Specialist, APHL

Breathing a Sigh of Relief Thanks to Newborn Screening by Elizabeth Jones, MPH, Specialist, Newborn Screening and Genetics, APHL

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System Built for Responding to Bioterrorism Confirms Plague in Colorado Girl

Sep 13 2012 :: Published in Member News, Public Health Preparedness & Response

By Larry Sater, MS BT/CT Coordinator, Colorado Department of Public Health & Environment Laboratory Services Division

When the Laboratory Response Network (LRN) was established in 1999, the goal was to establish accurate, rapid testing methods to confirm or rule out dangerous bacteria, viruses and toxins that bioterrorists might unleash on the American public.  However, those same laboratory tools and trained staff do not sit idle waiting for a bioterrorist threat. A great success of the LRN is the day-to-day use of these resources in detecting the presence of select agents in people, pets, livestock and food during everyday life.  If you do not believe me, speak with a seven-year-old Colorado girl and her parents.

Colorado Bioterrorism Lab

Each year, and especially during the summer, the Colorado Department of Public Health & Environment Laboratory Services Division (CDPHE) laboratory is busy testing for West Nile Virus, rabies, plague and other diseases in both clinical and environmental samples.  On August 27, 2012, the lab received another one of these calls, but this one was very different.  A seven-year-old girl was critically ill and determination of the cause of her illness was critical to quickly proceed with appropriate treatment.  A courier from Presbyterian/St. Luke’s Rocky Mountain Hospital for Children delivered the specimens to the state laboratory just before noon on that day.

This was the story: While at a Colorado campground, the little girl found a dead squirrel and insisted on giving it a proper burial.  In the process, it is suspected that fleas containing the plague bacteria left the squirrel carcass and contacted the girl, inflicting several bites. The child soon became ill with a fever of 107 and required airlifting to St. Luke’s.  There, an alert physician checked both symptoms and the literature, concluding bubonic plague was a possible culprit.

The hospital collected specimens for culture and could not rule out the presence of Yersinia pestis, the bacteria causing plague.  At this point, the Laboratory Services Division was contacted and specimens collected from the girl were sent to us for confirmation testing.

Before the LRN, bacteria had to be grown in a culture for at least 1-2 days before the organism could be detected and colonies sampled for testing. However, thanks to rapid technologies adopted by LRN laboratories, the DNA for the plague bacteria was detected and identified within 2 hours of receipt of the specimens using a method called polymerase chain reaction (PCR).  A second rapid test, direct fluoroimmunoassay (DFA) which uses the antibody to the suspected bacteria, confirmed the presence of Yersinia pestis.

Thus within hours, the cause of the girl’s life-threatening illness had been identified as a presumptive positive and a confirmation test conducted that supported the physician’s suspicions.  Samples of the specimens were cultured overnight with microscopic observation of the organisms. Other tests confirmed the presence of the agent and the fact that it was still alive.

Earlier that month, two human cases of brucellosis were confirmed by the CDPHE laboratory, as well as several cases of plague in rabbits discovered in communities across Colorado.

Such specimens come in routinely to the CDPHE laboratory—all part of a day’s work for the staff.  While the LRN Network was established to rapidly confirm the presence of biological and chemical agents that could be employed in a terrorist attack, it has offered a bonus to the American public, protecting them from naturally-occurring health threats every day of the year.

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