By Lixia Liu, Deputy Director, Indiana State Department of Health Laboratories
Stephanie Dearth is a cheerful young supervisor with blond hair and black-framed eye glasses. This was her third week as the supervisor of the virology laboratory at the Indiana State Department of Health Laboratories (ISDHL). When she arrived at work on Wednesday, April 30, she felt lighter as she had submitted her portion of a grant application the day before. She thought she might be able to catch up on her many tasks that had been put on hold. She took a sip of her coffee and walked to the laboratory.
Stephanie put her things away and went to her desk inside the laboratory. Between responding to her emails, discussing training plans for the new hire in her area and preparing for an upcoming CLIA inspection, the day went by quickly. She finally sat down at her desk after many trips to the lab bench; the voicemail light was blinking on her phone.
Stephanie listened to the message. It was from Community Hospital in Munster requesting MERS-CoV testing. Recognizing the urgency of the request, she returned the call immediately and then sent an email to alert the ISDH respiratory epidemiologist about the request. Within an hour, the epidemiologist authorized the MERS-CoV test request from Community Hospital and held a teleconference with the ISDH (laboratory and epidemiology), CDC and the hospital. The specimens were scheduled to be delivered to the laboratory for testing the next morning.
When she told me the news I had goose bumps. I realized this may be the first MERS-CoV case in the United States. The weight of the situation was also felt by Dr. Omar Perez, the director of clinical microbiology. Stephanie, Omar and I stayed after the teleconference and discussed the plan for the next day. Although the MERS-CoV assay was in place, the last MERS-CoV run was performed more than a year ago when the assay was first validated. To be cautious, the team decided to use BSL-3 practice for the entire process. We also agreed that the most experienced senior microbiologist, Jamie Yeadon-Fagbohun, would be the best choice to run the test. Jamie, who was known for her high quality work, had over five years of experience at the ISDHL. She worked on the response to the H1N1 pandemic, the discovery of novel H3N2v and many other high-profile outbreak investigations. She had worked under pressure before, but nothing like this.
The next morning I updated Dr. Judith Lovchik, ISDH assistant commissioner of public health protection and laboratory services, on the testing plan and discussed the testing approaches. Meanwhile on the clinical microbiology floor, Stephanie, Omar and Jamie were detailing the testing plan. The same conclusion was reached by all: time was of the essence in this situation.
Immediately after the arrival of a nasopharyngeal swab and serum sample from the patient, Jamie took the specimens to the bioterrorism suite where she gowned-up, put on the respirator and began processing the specimens. She wiped all the surfaces that the specimens might come into contact with and took every precaution to prevent potential carryover. Around noon Jamie resurfaced from the BT suite, her face reddened by the pressurization in the lab and her respirator.
By 3:00 that afternoon, the test runs were completed. Despite the increased anticipation of the nation’s first possible MERS-CoV case, Jamie was not expecting positive results. “There is no way this would happen in Indiana. After all, Indiana is only a fly-over state,” Jamie thought to herself. After carefully reviewing the test results, Stephanie and Omar came to my office. I knew the results just by the looks on their faces. They told me that the serum sample was positive for all three genetic markers detected by the screening and confirmatory tests. As much as I was prepared for a positive result, I was still shocked to hear it. I immediately called Dr. Lovchik and broke the news to her. She was equally shocked.
The perceived pressure earlier in the day turned into real pressure that was building with every thought of the potential impact. The lab team – Jamie, Stephanie, Omar and I – met again to review the testing details such as how the samples were arranged in the run, where the controls were situated, etc. With all possible errors ruled out, the team was confident in the results and ready to share the news with the rest of the nation.
As planned, the nasopharyngeal swab and serum sample were shipped to the CDC lab on Thursday for final confirmation of the MERS-CoV results on Friday morning.
The ISDH, Community Hospital and various CDC teams reconvened to plan the response actions based on the public health lab’s test results. The response plan would be executed as soon as CDC’s confirmatory test results were made available, which was scheduled to occur around 1:30 pm on Friday.
First thing on Friday morning the lab team met to discuss the action plan for a potential surge in testing once CDC confirmed results from the first case. Each team member was assigned a task: ordering reagents and supplies, requesting laboratory information management system (LIMS) modifications for easier sample submission, identifying microbiologists from other areas for surge capacity, and others.
By noon, planning slowed, and the lab team had time to comprehend what the ISDH lab’s MERS-CoV results meant. But would the results be confirmed by CDC? The wait felt like eternity. I read every email that came across my computer screen. An email from CDC with the subject line “Confirmation” finally arrived at 1:43 pm. I felt like I was about to hear a courtroom verdict. I took a deep breath and continued to read the email: “CDC confirms Indiana MERS-CoV on 5/2/2014 at 1:30 pm.”
”WE DID IT!” I shouted with great relief. I couldn’t wait to share the news with the rest of the team. While it was not good news to hear that MERS-CoV had made its way into the US, it was extremely validating to know that our team quickly and successfully accomplished the task at hand. I was very proud of my colleagues.
After the detection of the first MERS-CoV case on May 1, the ISDH laboratory brought in two additional microbiologists, Stephanie Dalenberg and Brian Pope, to help with testing. During two consecutive 13-hour days, ISDH lab microbiologists, supervisors and directors tested a total of 124 specimens from all of the patient’s direct contacts, including health care workers and household contacts. All contacts continue to be observed, and there have been no additional cases to date.
The ISDH laboratory staff’s quick response, safe testing and accurate results were critical to detecting and containing MERS-CoV. Once again, our national laboratory first responders had quietly and effectively done their job to protect the public’s health.
Top Photo: Jamie Yeadon-Fagbohun in the BSL-3 laboratory
Bottom Photo (from left to right): Dr. Lixia Liu, Dr. Omar Perez, Stephanie Dalenberg, Stephanie Dearth, Jamie Yeadon-Fagbohun, Brian Pope, and Dr. Judith Lovchik
Photo credit: Indiana State Department of Health Laboratories staff