As hospitals across the country work to manage a constant influx of COVID-19 patients, their partners in public health are addressing critical community and statewide testing needs. While both the healthcare and public health systems are responding to the pandemic, their approach is different: healthcare systems focus on providing individual patient care while public health supports an entire population’s health. In this response, and like many before, the role of the public health laboratory in detecting and responding to threats has never been more critical. But public health laboratories are often only funded when there is a crisis such as Ebola, Zika, vaping and now COVID-19. This approach to federally fund laboratories while in emergency mode leaves the nation vulnerable.
Preparedness funding 101
Although public health laboratories receive funding support from their state and local governments, the federal government provides the majority of their preparedness and response funding. Via the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases Cooperative Agreement (ELC) and the Public Health Emergency Preparedness Cooperative Agreement (PHEP), the US Centers for Disease Control and Prevention (CDC) is the primary funder of state, local and territorial public health laboratories. For 25 years, the ELC has been a source of significant financial support that enables public health laboratories to conduct surveillance and respond to vector-borne diseases, food and waterborne diseases and other emerging threats such as pandemic influenza and COVID-19. In Fiscal Year 19 (FY19), which represents August 1, 2019, to July 31, 2020, total ELC funding was approximately $231 million, of which 43% went to public health laboratories to support testing and surveillance needs.
On an annual basis, approximately 90% of funding for public health preparedness and response efforts come from PHEP. Following the anthrax attacks of 2001, total PHEP funding to public health agencies peaked in 2003 at $970 million (unadjusted)—a year in which public health laboratories received $167.7 million for biological and chemical preparedness. Over the years, this funding has decreased considerably. In FY 2019 (July 1, 2019, to June 30, 2020), PHEP funding totaled $620 million. This was similar to 2018 when the jurisdictions received $620 million, of which public health laboratories received $81.5 million (Figure 1).
Funding has continued to lag for ELC and PHEP, creating challenges for laboratories to remain adequately prepared. ELC-recipient public health laboratories remain underfunded by 70% in personnel support while laboratory equipment and supplies, which are critical for detecting infectious diseases, face a shortage of 60%. Over 39% of ELC funding requests for health information systems went unfunded in FY19, resulting in $29 million less than health departments needed to sustain syndromic surveillance, electronic laboratory reporting and other systems necessary to track patient cases and limit the disease burden. Cuts to PHEP funding impacted preparedness activities as well. Up to half of state public health laboratories faced cuts over the past few years, resulting in the inability to expand capabilities for new assays and tests and hiring necessary staff.
Staying ahead of emerging threats
Funding shortages are most evident during a public health crisis. The federal government has largely responded to public health emergencies through just-in-time supplemental funding. The 2014 Ebola virus epidemic exposed significant gaps in US operational readiness to respond to a threat of its kind. Congress responded with millions of dollars, of which $110 million went to state, local and territorial health departments via the ELC. Approximately $21 million of these funds were provided to public health laboratories over a three-year period (extended in most cases to four years) to enhance biosafety and biosecurity, infection control and other urgent gaps. By enhancing outreach efforts, public health laboratories were able to engage clinical laboratorians and provide guidance on risk assessments, appropriate use of personal protective equipment, decontamination and other biosafety issues.
When the funding ended in 2018, many public health laboratories were forced to reduce biosafety staff and diminish outreach efforts. This presented challenges to recruiting and maintaining qualified staff as many worried about a subsequent loss of funds. The emergence of Zika proved similar to Ebola, with CDC issuing $97 million in supplemental funding via the ELC.
Response to COVID-19 is no different. Congress is appropriating billions of dollars and public health agencies now face a surge of funds at the height of a pandemic:
- At the beginning of the response, CDC redirected funds from its internal activities to state, local and territorial health departments via the Crisis Response Cooperative Agreement.
- An initial $10 million was distributed to select jurisdictions through the ELC.
- On March 5, the president signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (PL 116-123). This act provided funding to prevent, prepare for and respond to COVID-19. By March 16, CDC via the Public Health Crisis Response Cooperative Agreement awarded $569.8 million to 65 jurisdictions. On April 6, another $160 million was awarded to 34 jurisdictions. This included 27 jurisdictions with high COVID-19 case counts or evidence of rapidly accelerating case counts and seven US territories and freely associated states with unique COVID-19 response challenges.
- In addition, the Coronavirus Aid, Relief and Economic Security (CARES) Act, provided billions in supplemental funding, with a total of $631 million awarded via the ELC to state, local and territorial health agencies to increase testing capability and capacity, improve surveillance and additional efforts necessary for the US to successfully combat COVID-19.
Finding long-term solutions
While these additional funding sources are a welcome relief to underfunded public health systems, they do not provide a long-term solution for combating new threats. With each response, public health is behind—they have no ability to be ready to respond to novel and large-scale threats. This lag limits the ability for public health laboratories to quickly ramp up testing capacity needed to stay ahead.
Consistent and sustainable federal funding for public health laboratories is key to stay ahead of threats. Such funding provides:
- A warm base where laboratories are poised to quickly and safely respond, which encompasses highly trained laboratory scientists, biosafety professionals and other support personnel; high-throughput equipment and electronic data messaging tools; and communication systems and agreements in place with other laboratories such as commercial laboratories.
- The opportunity for scientists to validate and verify equipment and assays, ensuring timely, accurate results and sustained confidence in quality laboratory testing.
- Reagents and other laboratory supplies, including personal protective equipment, so that laboratorians can appropriately and safely perform testing and provide ample capacity within their jurisdictions.
- A national laboratory system comprised of private and public laboratories working side by side to protect the public’s health.