Staff Burnout in Flu Response: Tips from Montana

At the Montana public health laboratory, we are concerned about staff burnout. We don’t have enough staff cross-trained on the influenza test platforms, and our testing volume is highly variable depending upon the patterns of influenza and influenza-like illness circulating in the state. We are testing a representative sampling of specimens from across the state to detect seasonal influenza when it begins circulating. We anticipate that the volume of testing will increase when it becomes important--based on the different resistance patterns in seasonal influenza A--to know the influenza A subtype.

While I don't have great suggestions for reducing staff burnout, here are some measures that have helped us to cope. We activated a limited ICS structure and dedicated a single call-in line for questions about influenza testing. We also added staff to support critical tasks (e.g., today you will run the testing, process specimens, log in specimens, take telephone calls, etc.) and rotated responsibilities so that no one person had sole responsibility or the same responsibility for days on end. In addition, we stepped up our communications to staff and clinical partners via a weekly influenza update.

Susanne Norris Zanto, CLS(NCA) SM(NRM)Montana Public Health Laboratory

Public/Global/Environmental Health Leaders Among "Best Thinkers"

Foreign Policy Journal just published a special issue centered on the idea of the "Top 100 Global Thinkers."

As I was reading through my copy, I noticed that a significant number were chosen/noteworthy for public health, global health, climate change, or other environmental issues. While there is overlap (and a likelihood of "classification bias" by me) my review finds the following:

1.) 10 persons noteworthy for public health thought and initiatives...
2.) 5 persons for global health...
3.) 6 persons for climate change...
4.) 2 persons for other environmental issues.

Perhaps this might be of use/interest...or at least a diversion from H1N1. Additionally, several persons are further profiled on what they are reading, who they think are the "best thinkers," what their best/worst ideas were, etc.

Pat Luedtke, MD, MPH
Laboratory Director
Utah Division of Epidemiology and Laboratory Services

Toxic Chemical Policy Reform: Low-Hanging Fruit?

As Congress takes on some major issues, toxic chemical policy reform seems to be one that might be low-hanging fruit. It is a rare thing, when EPA’s principles for toxics reform line up with industry’s principles and environmental advocacy groups'. . . but as with health reform, the devil will be in the details. For example, industry wants to use terms like “safe for intended use” but it is not always the intended use that ends up resulting in exposures. From the laboratory perspective, all sides appear to agree that biomonitoring will play a key role in prioritizing chemicals for assessment. It will be important to take advantage of this opportunity to emphasize the need to build state and local biomonitoring capability.

PulseNet International: Detecting Global Foodborne Outbreaks

by Kristy Kubota, MPH, senior specialist for PulseNet Program, and Kara Watarida, temporary PulseNet program coordinator

Imagine an international outbreak of E. coli O157:H7. With the changes of the nation’s eating habits, the dynamics of the US population, increased international travel and the globalization of the food supply, global foodborne outbreaks do occur and may increase due to these factors. Thanks to PulseNet International there is a way to determine if an outbreak happening in your town is linked to an outbreak in Europe.

On November 12-13, CDC, APHL, WHO and PulseNet regional coordinators from around the world met in Buenos Aires, Argentina, for the 2nd PulseNet international Steering Planning meeting. This meeting brought together PulseNet coordinators from the United States, Europe, Canada, Pacific Asia, Latin America and Middle East to discuss issues related to protocols/next generation subtyping methods, regional updates and development of a strategic plan for the coming year.

One of the more interesting aspects of this meeting was learning about international outbreaks and how molecular subtyping has been applied for foodborne investigations worldwide. With all nations using the same standardized PulseNet protocols, DNA fingerprints are generated and can be “matched” across country borders. For example, in 2009 PulseNet Pacific Asia conducted an E. coli O157:H7 outbreak investigation associated with a steakhouse restaurant with possible links to U.S. imported beef. The link was dismissed upon sharing the subtyping information between the US and Japan.

The PulseNet network has come a long way since its inception in 1996, as a collaborative “project” between CDC, APHL and a few US states. It has now grown to PulseNet International -- United States, Europe, Canada, Asia Pacific, Latin America, Middle East and soon Africa. APHL will continue to support these partners in working towards a sustainable international foodborne diseases surveillance network.

Instant Re-Runs with DCET

by Dorelle Engel, product line specialist, On-Demand Products

Did you miss that scheduled teleconference or webinar training you wanted to see? No worries! APHL’s Department of Continuing Education and Training (DCET) has answered the call for the ever busy life of a laboratorian. With the growing presence of multimedia-enabled systems, archiving teleconferences and webinars has become a successful education and training modality. Previously recorded topics are available online, enabling registrants to watch at their convenience, 24 hours a day, 7 days a week while earning P.A.C.E.® continuing education credits provided by APHL.

These archived teleconferences and web conferences have been put into an appealing format, providing the viewer with the ability to listen to the speaker and see the presentation onscreen in high quality. In addition, a sequenced presentation bar is available to allow for moving ahead or rewinding to specific points of viewer interest. This APHL On-Demand product provides public health and clinical laboratory scientists the ability to maintain as well as strengthen core competencies in laboratory practice while delivering up-to-date information and new technological advancements. DCET continues to develop innovative online delivery systems as well as improve and enhance all On-Demand products. Currently, some of the most popular of our previously recorded teleconferences and webinars include 2009 Influenza Update, New and Updated Diagnostics for the Mycology Laboratory, Yeast Identification Update: “New Ones and Old Ones with New Names,” TB Interferon Gamma Release Assays, TB Molecular Diagnostics and Using AST (Antimicrobial Susceptibility Testing) to Tame the Fungal Elements.

What is Your Laboratory’s Approach to STEC Testing?

by Sharon Shea, MHS, MT(ASCP), director, infectious disease and food safety programs

If you have followed clinical microbiology listservs, attended ASM’s General Meeting or listened to enteric disease talks in the past year, you may have been anticipating the October 16 release of an MMWR Recommendations and Report issue, “Recommendations for Diagnosis of Shiga Toxin-Producing Escherichia coli Infections by Clinical Laboratories.” These guidelines were developed by CDC in collaboration with APHL and a host of clinical, academic and public health partners. The report highlights the importance of prompt and accurate diagnosis of STEC infections for both proper patient treatment and effective public health control. Detailed guidelines for STEC testing in the clinical laboratory are provided, including the recommendation that all stools submitted for routine testing from patients with acute community-acquired diarrhea be simultaneously cultured for O157 STEC and tested with an assay that detects Shiga toxins (to detect non-O157 STEC). Such testing will be a major change in practice for some hospital laboratories and could represent an increase in laboratory costs. Who will bear the cost of this testing? How much of that cost can be reimbursed to the lab?

We in public health need to support our clinical partners as they adopt the new recommendations. Is your laboratory ready to accept isolates and/or broths from laboratories in your state/county? Who will pay for the packaging and shipping? What will you do with those samples once they are received? How can this work be supported at a time of severe cutbacks in public health spending, without additional federal support?

APHL’s STEC work group, in conjunction with state and federal partners, is developing guidelines for receiving and characterizing STEC isolates and specimens in public health laboratories. These companion guidelines will be released in early 2010. Your input on that document or the impact of the new STEC diagnostic recommendations is welcome.

World Rabies Day, September 28th, 2009

by Brian Remortel, senior specialist, emerging infectious disease

The inaugural World Rabies Day was held on September 8, 2007, and witnessed the participation of hundreds of thousands of individuals from more than 70 countries. This annual event is dedicated to raising awareness about rabies and enhancing prevention and control efforts globally. On September 28th, I had the pleasure to attend a World Rabies Day symposium at the Centers for Disease Control and Prevention (CDC). This years’ symposium was held in memory of Dr. George Baer, who was the long time chief of the Rabies Laboratory in the Division of Viral and Rickettsial Diseases at the CDC. Dr. Baer has been proclaimed as the “father of oral rabies vaccination,” which enabled successful mass fox vaccination campaigns throughout Canada and Europe.

Dr. Baer was a former Epidemic Intelligence Service Officer, who initially became interested in rabies during his assignment at the New York State Health Department in Albany. Throughout the nation, APHL member laboratories make significant contributions to the prevention and control of rabies. Public health laboratories routinely perform diagnostic tests that play a vital role in the rapid identification of the rabies infections which provides vital information to assist in post-exposure prophylaxis efforts. In addition, the results of rabies diagnostics provide vital surveillance data to improve control efforts in endemic wildlife populations. APHL member laboratories provide a critical service in protecting our nation from this 100 percent preventable disease.

Who Will Help Build Food Safety Partnerships?

by Mike Smith, specialist, food safety program

APHL is holding the 13th Annual PulseNet Update Meeting in Utah this week. In the spirit of partnership, this year’s meeting is being held in conjunction with the 5th Annual OutbreakNet Meeting. Holding these meetings together is allowing professionals in the fields of epidemiology and laboratory science to exchange ideas and information as we improve a U.S. food safety system that some believe is faltering.

Michael Taylor, the new senior advisor to the commissioner of the Food and Drug Administration, presented the keynote address. In his speech, Taylor emphasized the need to “construct a whole new level of partnership to prevent foodborne illness.” He went on to state that “it must be a partnership that empowers the full range of people working on food safety at federal, state and local levels to succeed in their common cause of preventing foodborne illness.” Taylor stressed that these partnerships will be key if the prevention-focused vision for food safety in the U.S. set forth by FDA and Congress is to be successful. It’s going to take adequately-funded public health professionals across a range of disciplines at the federal, state and local levels working in harmony to effectively implement and execute FDA’s public health prevention vision. Now that there seems to be a real opportunity for change, let’s hope that our lawmakers provide more than just lip service to support this ambitious endeavor.

To highlight the theme of partnerships that Taylor so eloquently spoke about in his speech, I would like to close with the following analogy. The current U.S. food safety system is a very complex machine much like the engine of a car. And like the engine of a car, the U.S. food safety system consists of many pieces working in unison. If even one piece of the food safety engine malfunctions, the whole machine breaks down. In the past, when these pieces have broken, the lawmakers and leaders of this country have been too eager to replace the needed precision components with discount parts. Worse yet, it seems they neglected the maintenance of the machine altogether. As evidenced by foodborne illness outbreaks over the past 15 years, we can’t afford to let this machine falter any longer. It’s time that we start investing in the whole machine, maintaining it so that we don’t continue to experience these costly, and far too often deadly, outbreaks. The opportunity for change is now. Are the lawmakers ready to take this issue seriously? For the sake of this country’s well-being, let’s hope so.

The Power of APHL

by Karen Rogers, senior specialist, communications

The American Society of Association Executives (ASAE) recently interviewed APHL’s executive director, Scott Becker, as part of a new campaign, “The Power of A,” which showcases examples of collaborative problem solving at associations. ASAE is the national association representing trade and professional associations.

During the interview, Becker discussed members’ response to the novel H1N1 virus and their dedication to APHL as well as the urgent need to build national capacity for electronic reporting of laboratory data. The video is available on YouTube and on ASAE’s The Power of A website.

Cross-Border Influenza Preparedness

by Chris Mangal, director of emergency preparedness and response

On August 31-September 1, 2009, in Winnipeg, Canada, APHL's leadership and infectious disease, preparedness and global health staff met with key officials from the Canadian Public Health Laboratory Network (CPHLN) to discuss collaborative activities, such as lessons learned from the recent H1N1 outbreak and planning for a tri-national cross-border preparedness summit. In addition, APHL staff toured the Emergency Operations Center of the National Microbiology Laboratory and learned about their Incident Command Structure used to respond to infectious disease outbreaks.

Following the meeting with CPHLN, APHL staff (Scott Becker, Mary Shaffran, Chris Mangal and Natalia Machuca) attended the first conference of its kind in Canada, “Severe H1N1 Disease: Preventing Cases, Reducing Mortality,” organized by the Public Health Agency of Canada (PHAC).

Dr. Graham Tipples from PHAC served as the Master of Ceremonies, welcoming key public health officials, including the Honorable Leona Aglukkaq, Canada's Minister of Health. The minister noted that this conference was the first of its kind to bring together clinicians, laboratorians and key public policy officials. She mentioned that the conference will help Canada to better prepare for and respond to the upcoming influenza season. The minister also mentioned that continued monitoring and surveillance for H1N1 along with consistent collaborations, information exchange and strong partnerships will be vital to keep the population healthy and prevent and manage the spread of H1N1.

The Manitoba Minister of Health, the Honorable Theresa Oswald, welcomed participants to Winnipeg, but stated, “I really wish you weren't here." This statement is a reflection of the growing concerns about the upcoming flu season and the potential for H1N1 to be more widespread, affecting the general population and overwhelming the healthcare systems globally.

Dr. David Butler-Jones, chief public health officer, PHAC, addressed the dilemma of managing and measuring H1N1. He noted that "you can't manage what you don't measure," but also mentioned that the fluidity of H1N1 cases makes it difficult to measure and as such public health officials must be creative in responding to this pandemic.

Dr. Frank Plummer, chief science advisor, PHAC, further explained the objectives of the conference, noting that he hopes participants leave with a better understanding of epidemiology and severity of the disease, clinical care and management issues, intensive care unit challenges and strategies to manage H1N1 cases. He also encouraged further connections among hospitals, infection control and public health.

Dr. Charles Penn, Global Influenza Programme, World Health Organization (WHO) addressed the current status of the pandemic and WHO efforts to facilitate communications globally, mobilize resources and provide access to vaccines and antivirals. Several additional sessions, including in-depth discussions on modeling scenarios, provided participants with more information on Canada's efforts to prepare for and respond to H1N1.

APHL will continue our collaboration with Canada and look to build stronger linkages with Mexico to ensure that there are robust laboratory systems in place to detect and respond to infectious disease outbreaks globally.

A New Frontier for Public Health Laboratories

by Norman Crouch, APHL Emeritus Member, Guest Blogger

Dr. Norman Crouch, is a well known figure in the APHL community. Earlier this year, after 16 years with the Minnesota Department of Health, Dr. Crouch announced his retirement. As laboratory director and assistant commissioner, Dr. Crouch worked closely with APHL, serving as a member-at-large and secretary/treasurer on APHL’s board of directors, APHL president from 2003-2004, and a member of numerous APHL committees. The post below is adapted from the keynote address he gave at APHL’s 2009 Annual Meeting.

I believe these are exciting times for state and local public health laboratories. Despite current difficulties caused by severe budgetary reductions that impact operations, as well as workforce training and recruitment, our laboratories in public health have entered a new frontier. Major changes are occurring to accommodate advanced technology and address increasingly complex health threats caused by natural, accidental, and deliberate public exposure to infectious or toxic biological and chemical agents. Today, our public health laboratories play a key role in emergency preparedness and response, food and water safety, and the expansion of newborn screening. It is becoming increasingly clear to both governmental and private sectors that our health laboratories play a unique and essential role in protecting the public.

Based on experience as a state public health laboratory director, I believe this new frontier embraces a significant change in laboratory culture. In the past, most public health laboratories were described as being independent, focused on providing routine and rare laboratory services to support public health-related programs. As the role of the public health laboratory has changed in response to technology and need, the laboratory culture has become one of interdependent connectivity and high expectation. There’s been a shift from the independent analytical testing of the past to an innovative culture of communication, collaboration, and cooperation with a multitude of essential partners. Today’s partners include (1) infectious disease and environmental epidemiologists, (2) sentinel clinical laboratories, (3) local and state first responders, (4) other state agencies, (5) numerous federal agencies, and (6) state and local health officials. This connectivity, I believe, will be a major strength for our public health laboratories in the future. Such connectivity will result in better understanding of the public health laboratory’s value, giving our laboratories a priority status not experienced in the recent past, which will foster robust inter-partner advocacy essential for sustaining laboratory operations relevant to public health and safety.

To convince key partners of the value of our public health laboratories, we must continually demonstrate that our mission is markedly different from other laboratories, and that our laboratories are indispensible in the broad scheme of health protection. To be convincing, our laboratories must show their value, not just say it is so. We must show our partners strong professional leadership, our worth to the public health cause, and our willingness and ability to go beyond expectations.

In a sense, this is a “golden time” for public health laboratories. With recent national food borne disease outbreaks detected by our PulseNet laboratories, with our laboratory response to rapid introduction of the novel H1N1 influenza virus, with the widely recognized critical role of our national Laboratory Response Network in biological and chemical surveillance, with our leading effort to expand newborn screening, and with the construction of new, high-tech laboratory facilities, public health laboratories are in the spotlight. Even the public now awaits identification or confirmation of an unknown biological or chemical agent in samples sent to the public health laboratory for analysis. They know this is critical information that determines what actions will be taken to protect their health and keep them safe. Additionally, each state now recognizes the importance of expanded newborn screening to detect treatable inborn errors of metabolism and congenital defects.

With this current visibility, I believe our public health laboratories are viewed with respect and high expectation. By continuing to demonstrate that our unique operations are indispensible for local, state, and national health protection, our public health laboratories will survive and thrive in this new frontier.

What is Public Health?

by Karen Rogers, senior specialist, communications

This question circulated among of group of public health professionals at the Second Annual Public Health Branding Coalition meeting yesterday. Scott Becker, executive director, Leigh Slayden, director of marketing and member services, and I represented the Association of Public Health Laboratories at the meeting, which was organized by the Association of State and Territorial Health Officials, the American Public Health Association (APHA), the Association of Schools of Public Health (ASPH), the National Association of County and City Health Officials (NACCHO) and the Society for Public Health Education.

The meeting’s goal was to move toward developing a brand for public health. According to participants, branding public health would have a myriad of benefits: inspiring the current and future workforce, increasing recognition, creating demand, improving advocacy and improving public health outcomes.

So what is public health?

Past campaigns have sought to help answer that question.

In 2006, NACCHO developed a national identity for local health departments. The logo they developed touted the theme “Public Health: Prevent. Promote. Protect.”

ASPH launched the “This is Public Health” campaign in 2008. This innovative movement used stickers to “brand” public health by pointing out the many (often unrecognized) ways that public health works to keep up safe and well.

The Alliance to Make US Healthiest created a video as part of its Healthiest Nation campaign. If you work in public health, this video will remind you why you do. If you don’t work in public health, this video may inspire you to learn more.

In 2009, APHA launched “Healthiest Nation in One Generation.” This motivating viral video campaign shows the many ways that public health touches our lives.

What does public health mean to you?

APHL Staff Explore Emerging Technologies

by Sikha Singh, specialist, Laboratory Response Network

Recently, APHL staff met with a bioMérieux representative to gather more information on an advanced microbial genotyping system. This emerging technology, called Diversilab, is geared toward rapidly tracking the spread and source of microbial infection, contamination and foodborne outbreaks. In some aspects, the Diversilab system may be comparable to Pulsed Field Gel Electrophoresis (PFGE), a DNA "fingerprinting" method that is the gold standard for subtyping bacteria. This type of technology may be used in the future to analyze and monitor foodborne disease outbreaks. APHL staff continue to monitor emerging technologies that could benefit our member laboratories in their efforts to quickly detect pathogens and improve public health response. BioMérieux is an APHL Silver Level Sustaining Member.

Firearms, Explosives and Bullets -- Oh My!: Public Health Partnerships with the FBI

by Anthony Barkey, specialist, emergency preparedness and response

To quote Moe Sullivan: “Early on, working with the FBI was a different experience, but it doesn’t hit you until you realize your partner is carrying a gun. That's a whole new experience for public health."

On a recent visit to the FBI Laboratory in the Quantico Marine Base, I was privileged to gain insight into the breadth of FBI's role in preparedness and response. Joining me in this experience were APHL staff Chris Mangal, Sikha Singh and Gavin Gollehon. The APHL team met with FBI representatives to discuss the development of chain of custody and moot court trainings for Laboratory Response Network (LRN) laboratorians. During these discussions, we were able to make much progress in developing the curriculum and should have some great training opportunities available in the near future. While at the facility, the APHL team were able to see not only an impressive collection of firearms, but also explosives displays and the famed Hogan’s Alley. Overall, the laboratory and Quantico experience was very eye-opening and strengthened our partnerships with the FBI.

Experts Cite Lack of Resources for Public Health Laboratories as Impediment to Response in Foodborne Outbreaks

A lack of resources at state and local public health laboratories slows response to foodborne outbreaks, according to experts at a national meeting of food safety professionals. Participants in a panel at the International Association for Food Protection identified adequate laboratory staffing and provision of testing materials as critical to rapid response in a hypothetical multi-state outbreak of E. coli O111.

This statement will come as no revelation to those in public health. Disease control measures are based on a definitive laboratory-confirmed diagnosis. If you don’t have the test results, you can’t track down the pathogen that’s contaminated the food in your community. It’s that simple.

But this simple message seems to be lost on the funders of the governmental laboratories that conduct testing for E. coli O111 and other foodborne diseases. Laboratories continue to reel from cuts in state and local budgets. Yes, dedicated staff will work long hours during a crisis—as they did during the Salmonella outbreak in peanut products and the novel Influenza A/H1N1 outbreak—but this only goes so far. In a prolonged outbreak, staff has to be rotated or the quality of test results will be compromised. You just can’t make two people out of one, no matter how hard you try.

The same principle applies to lab instrumentation and supplies. Too often the assumption seems to be that lab testing is like cooking: if you have more specimens, you just put more pots on the stove. Unfortunately it doesn’t work that way. Laboratory “through-put”—the number of specimens that a laboratory can test in a day—depends upon the capacity of its instrumentation: If a lab has bigger and faster equipment, it can test more specimens faster. If it doesn’t, then laboratory diagnosis, and response time, will lag. And, of course, no testing can be conducted without test kits, reagents and other essential supplies. But with recent budget cuts, inventories are low, and resources to purchase additional supplies limited.

One wonders what will happen in the event of a sustained, foodborne disease outbreak – or the next wave of novel H1N1.

APHL at White House: Obama's Food Safety Working Group Adopts Public Health Approach

by Scott Becker, APHL Executive Director

On July 7, 2009, I had the pleasure to attend a White House event for President Obama’s Food Safety Working Group. The event was hosted by Vice President Biden. He, along with Health and Human Services Secretary Kathleen Sebelius and Secretary of Agriculture Tom Vilsack, announced the key findings of the Working Group, which are partially based on information gathered at a White House listening session at which APHL was ably represented by John Besser, Peter Kyriacopoulos, and Michael Smith. These recommendations take a public health-focused approach to food safety and emphasize three core ideas: prioritizing prevention; strengthening surveillance and enforcement; and improving response and recovery. To advance these key concepts, the working group announced specific actions including: developing tougher safety standards for eggs and poultry products to reduce Salmonella contamination; strengthening enforcement in beef facilities and improving protections for produce to reduce E.coli contamination; implementing new traceback and response systems when outbreaks do occur; providing improved safety alerts to consumers; creating new positions within the key food safety agencies; and allowing for a continued oversight role for the Food Safety Working Group. I’m looking forward to greater collaboration with FDA, given the terrific new leadership in place. Read more.

HIV Testing & Public Health Laboratories

According to a CDC estimate, close to 250,000 Americans are unknowingly infected with HIV. CDC recommends HIV screening as part of routine patient care for all people between the ages of 13 and 64. Yet despite improvements in care, social stigma and lack of awareness still prevent many from receiving tests for HIV.

Rapid detection of new HIV infections and successful linkage of HIV-positive patients into care are crucial factors in breaking the transmission cycle. In an effort to improve outreach and access to testing, CDC is targeting resources to high-risk communities. But while community outreach is integral part of the fight against HIV, fast and accurate laboratory diagnostics also plays an important role.

Public health laboratories support HIV treatment and prevention initiatives in multiple ways. They not only provide timely diagnostic tests, but many also conduct surveillance for drug resistance and offer tests for patient care and disease management. Public health laboratories implement advanced testing technologies as they become available to detect infections earlier and confirm infections more accurately.

The observance of National HIV Testing Day this past Saturday highlights the role of community outreach and increased testing in fighting the HIV epidemic. But behind the scenes, the daily work of public health laboratories plays an essential role in the speedy diagnosis of infection and the vigilant surveillance of disease.

FERN Microbiological Cooperative Agreement Program Grant

FDA's Food Emergency Response Network (FERN) has recently announced that it will be using its Microbiological Cooperative Agreement Program Grant mechanism (U18) to solicit applications from institutions/organizations that would like to become part of the Microbiology Cooperative Agreement Program (CAP).

The Microbiology CAP is intended to select state and local FERN laboratories to provide surge capacity testing in the event of a large-scale foodborne illness outbreak or other food emergency situations. The CAP will also be used to implement standardized analysis results through the use of standardized methods, equipment platforms and reporting.

For full Program Announcement (PAR-09-215) and details, please visit here. Applications must be submitted electronically through grants.gov. The deadline(s) for submitting grant applications is 5:00 pm local time on July 29, 2009, July 29, 2010, July 29, 2011.

National TB Conference

Representatives from US public health laboratorians have converged in Atlanta, GA, this week for the 2009 National TB Conference, June 15-18. The meeting, formerly known as the “National TB Controller’s Workshop,” examines topics of interest to TB controllers, nurses, physicians, researchers and laboratorians. More sessions for laboratorians have been added to this year’s program. Topics include rapid detection of TB in clinical specimens, case studies in implementing Interferon Gamma Release Assays (IGRAs), success stories in laboratory-program collaboration and molecular detection of drug resistant pathogens.

APHL’s electronic laboratory self-assessment tool, “Mycobacterium tuberculosis: Assessing Your Laboratory,” was discussed in a session on Monday presented by David Warshauer, PhD, D(ABMM), Deputy Director, Communicable Diseases, Wisconsin State Laboratory of Hygiene. This tool gives public health, clinical and commercial TB laboratories a means to assess the quality of their TB practice and to institute quality improvement measures. The online assessment tool represents a significant improvement over the original tool published in 1995 as a spiral-bound notebook. Within a few weeks, laboratories will be able to employ the tool to locate the latest diagnostic technologies and apply this information to improve their operations. Look for the link here.

CIFOR guidelines released

Within the next couple of weeks, expect to see a copy of the recently completed Guidelines for Foodborne Disease Outbreak Response, a comprehensive best-practices document, published by the Council to Improve Foodborne Outbreak Response (CIFOR). The report focuses on improving detection and response to foodborne outbreaks, and is a comprehensive resource for federal, state and local agencies involved in investigating foodborne outbreaks.

The Guidelines are the product of a three-year collaboration between public health and food safety partners from all levels of government, and technical experts from a variety of associations and academic institutions. The Guidelines map out and discuss all of the steps involved in foodborne disease outbreak response, including preparation, detection, investigation, control and follow-up.

The Guidelines also discuss the roles that key organizations play during outbreak response, describe strategies for improving inter-agency communication and coordination during multi-state outbreaks, and identify benchmarks organizations can use to compare and critique their performance during response activities.

While the Guidelines are indeed a comprehensive source of information, they’re not a replacement for existing procedure manuals. Rather, they serve both as a complimentary resource to improve and update already established procedures and as a training tool for staff.

As mentioned earlier, the Guidelines are the product of many hours of collaboration among a large number of partners including APHL. We’re proud to have been involved with this project from its inception, and we have provided both technical expertise during the development phase, as well as assistance with marketing and distributing the final document.

However, the Guidelines are just the first step. It’s now up to everyone with a role in foodborne disease response to use the Guidelines correctly. With proper implementation, the number of people affected by foodborne illnesses each year can be greatly reduced.

Flu Appropriation Update

Great news! The Senate Appropriations Committee has recommended approving $900 million in emergency flu funding. Even more importantly, the Committee has recognized the importance of hiring PHL staff. Taken from the report itself:

“The Committee notes that the economic downturn has forced States and local governments to lay off public health laboratories and other public health professionals.”

The House Appropriations Committee has already taken similar action by adding $350 million for State and local government capacity building in its version of the emergency flu funding bill. Their report also references the impact of the lay offs.

You can see the full text of the Senate report here and the full text of the House report here.

2010 Proposed Federal Budget

President Obama recently unveiled his proposed 2010 federal budget. Unfortunately, it was disappointing to see that the budget generally maintained, but did not increase, the levels of funding for most governmental public health priority programs. The budget for CDC was approximately $6.6 billion, a 0.4% increase from 2009’s budget of approximately $6.3 billion.

A few key laboratory areas did, however, receive greater funding:

▪ FDA funding for food safety was increased. However, there was no sizable increase for CDC activities, most notably PulseNet. To ensure America’s food supply is protected, it’s important that all elements of the food safety infrastructure are adequately funded.
▪ There was a $51 million increase in HIV/AIDS funding, most of which was primarily for point-of-care programs and not for laboratory testing.
▪ It was the third year running that newborne screening activities received dedicated funding.

For more information about the budget, please browse the online document.

APHL Corporate Partners Assist Lab Community During Outbreak

APHL has a long history of collaboration with corporations associated with laboratory and public health practice. Corporate partners have sponsored events at our conferences, assisted with training programs for the clinical laboratory community and included us in initiatives to build the under-staffed laboratory workforce. Since APHL established its sustaining membership program in 2005, corporate support for member laboratories has been enthusiastic. We are pleased to have 24 companies as current members.

With the emergence of the novel Influenza A (H1N1) virus, several sustaining members have stepped up to assist member laboratories in ramping up capacity to identify and characterize the virus. One, Applied Biosystems, made contributions long before the virus made its appearance in the United States.

In 2008 Applied Biosystems collaborated with CDC to bring the 7500Fast PCR platform to FDA for clearance with the CDC 5-target influenza assay, which detects circulating strains and the H5N1 virus. Fortunately, APHL had trained public health laboratories on use of the platform and panel prior to the emergence of H1N1, but unfortunately, some did not have the required instruments. Enter Applied Biosystems. The company worked tirelessly to ship and set up equipment 24/7 in labs across the country while providing around the clock technical assistance via phone. To complement this fine work, BioSearch Technologies—whose Black Hole Quencher dye label is used for the probe technology in both the CDC 5-target influenza and novel H1N1 assay—increased production to meet international demands for the test reagents.

Another sustaining member, Luminex, assisted and continues to assist member laboratories that have requested its viral influenza panel and equipment for rule-out of the presence of novel H1N1. Again, the company has worked hard to provide support and technical assistance to aid labs in obtaining equipment and reagents.

Finally, when APHL needed assistance in publicizing the hard work of public health laboratories during this event, we reached out to Fleishman Hillard, a respected national public relations firm with whom we had worked on the Labs Are Vital campaign (www.labsarevital.com). They offered to help us pro bono and have provided insightful advice and much needed support to APHL’s Communications staff.

We are a proud to be a part of this remarkable, extended public health community. The challenges we faced during this outbreak would have been much greater without the support of our corporate partners. We salute you for your efforts and extend our sincere thanks.

Lab Capacity Model

The CDC-APHL State Lab Capacity Modeling Analysis model, developed to generate data on laboratory processes over the course of a pandemic, allows for states to refine their pandemic plans based on their individual resources and needs. Information generated from running the model identifies resource gaps and bottlenecks that may occur during a pandemic surge. Further, it allows for optimization of strategies for increasing respective capacities. Data entered into the model can be easily reconfigured, to determine how adding or removing resources affects throughput.

The recent and ongoing 2009 Novel Influenza A H1N1 (swine-like) outbreak offers a real-life scenario with which to assess the predictive value of these models. Compilation of data and of measurement evaluations continues, particularly as this event constantly evolves. Preliminary evidence proves, however, that the bottlenecks predicted by the model have proven to be true. Specifically, North Carolina, with seven confirmed cases and thousands of samples tested, reports that the model proved correct when predicting that the accessioning, extracting, and reporting stages would result in bottlenecks.

The feedback from the state—that the model was correct—is indicative of the fact that such practices are useful and carry value. We anticipate receiving feedback from other states, and are optimistic that this tool can be utilized in the future for more effective planning and capacity assessment purposes.

Flu Appropriation

The House of Representatives pushed through a $350 million appropriation for desperately-needed federal funding for state and local government public health organizations.

This funding will help combat many of the cuts government public health labs have had to make during the current recession. A recent APHL survey found that in 2008 alone, labs laid off or left unfilled almost 430 full-time positions, and expected to see another 230 positions empty in 2009. This proposed budget appropriation will go a long way to restoring vital lab capacity—it is critically important that labs retain and reclaim their highly trained workforce.

Despite severe workforce gaps, in the past few weeks, government labs still managed to test thousands of samples and keep the H1N1 outbreak just that—an outbreak—and not a pandemic. However, we’re not out of the woods yet. While things have certainly quieted down in the media, the H1N1 outbreak underscores the need to strengthen public health surveillance and detection of any novel flu strains that may appear.

Yet, that proposed $350 million in funding may still die—unless the Senate acts quickly and decisively. As it stands now, the full Senate will not begin actively debating the proposed appropriation until next week. If the Senate does not match the House with this funding, public health infrastructure will continue to erode in the wake of continued budget cuts.

Despite Outbreak, Work Continues

The recent outbreak of novel Influenza A H1N1 and the subsequent laboratory response have shed light on the work of state and local public health laboratories. But while this rapid response has been grabbing headlines, laboratorians continue work behind the scenes to address a wide range of public health threats.

Through active surveillance, public health laboratories can often detect infections before they become widespread outbreaks. While the media was transfixed by H1N1, the PulseNet system detected a spike in Salmonella serotype Saintpaul infections. Subsequent investigation and testing rapidly identified contaminated alfalfa sprouts as the culprit. Aided by advanced laboratory techniques and improved surveillance, public health laboratories continue to monitor for diseases like E. coli and Salmonella to ensure the safety of our nation’s food.

Public health laboratories are also responsible for screening 97% of newborns in the United States—in the past week alone, government labs have screened close to 80,000 babies for as many as 55 separate conditions. Newborn screening lets clinicians rapidly identify genetic and metabolic disorders, which without prompt treatment may lead to lifelong disability or even death. While many focus on the roll-out of the new influenza assay to states this week, thousands of newborns continue to be tested in the public health laboratory system.

The nation’s public health laboratories provide a diverse range of services to protect the public’s health. Disease diagnosis and surveillance, drug susceptibility testing, newborn screening, chemical exposure and environmental monitoring continue, even while laboratories operate at surge capacity to address the ongoing flu outbreak.

The importance of electronic messaging

A crucial element in response to a large-scale outbreak, such as the novel H1N1 virus, is rapid reporting of laboratory test results. Lab test results must reach the right people at the right time. Without this information, important public health decisions cannot be made.

Public health labs lack a single, standardized way to exchange laboratory data electronically. Right now, only a handful of state labs can send their H1N1 results electronically to CDC—most rely on some combination of sending spreadsheet attachments through email, uploading results to a secure website, calling in or faxing their results. These limitations apply to CDC as well as public health labs.

Some progress has been made through the Public Health Laboratory Interoperability Project (PHLIP), a joint undertaking by APHL, state public health laboratories and CDC. PHLIP aims to link government labs nationally to provide fluid electronic dialogue among laboratories and CDC. PHLIP's key goal is interoperability—the ability for different types of systems, including computers, networks, operating systems and applications, to work together effectively to exchange information in a useful manner. Essentially, this means systems talking to each other.

Much more needs to be done.

Many federal task forces have identified the need for electronic laboratory reporting; however adequate funding for this activity has not been identified. An expert panel convened by ANSER estimates the cost to develop and maintain electronic laboratory messaging capability at state and local public health labs is at least $200 million in federal funding annually. Without this investment, lab results will continue to be trapped in local, state and federal silos where we cannot protect America's health.

Hardworking Workforce

Over the past year, public health laboratories, their budgets ravaged by state and local cuts, have lost funding for operations, instrumentation and staff. Since January 1, 2008, an APHL survey shows the extent of the damage: labs have lost close to 500 full-time positions out of a total workforce of only 6500, and more losses are anticipated. Entire laboratory programs have been eliminated, because there were simply no funds to sustain them.

Yet, despite a bleak outlook and limited resources, laboratories, when thrust into the latest crisis with the H1N1 outbreak, have responded with skill, ingenuity and grit. In the first week of the outbreak, they subtyped nearly 300 suspect specimens for referral to CDC for final confirmation.

This week public health labs in some 65 locations across the country will assume responsibility for confirmatory (definitive) testing for the novel H1N1 virus, thus accelerating delivery of test results and implementation of disease-control measures. This eases some of the pressure on CDC laboratories but the demand for testing remains intense at the state and local level. Laboratory scientists, administrators, IT specialists and other staff are all racing to keep pace, working late into the night and on weekends.

This level of response isn’t surprising, however. We saw it earlier this year during the Salmonella outbreak when thousands of human and environmental samples poured into PulseNet labs for testing. We saw it in 2008 during the Iowa floods, when laboratorians worked to keep up with the increased demand in water testing. And we saw the same response after hurricanes Ike and Katrina pummeled the Gulf coasts, during the Anthrax attacks in 2002 and following the World Trade Center attack in 2001, to name a few examples.

The staff working flat out in our labs have opted to stay in the field of public health to help people. If money was a primary motivating factor, they would have left long ago! Instead they work to guarantee that emerging diseases and other health threats are detected promptly and that health officials have the information they require to mount an effective response.

It is a testimony to their dedication and hard work that they are continuing testing for other key public health functions—newborn screening, drinking water testing and analysis of foodborne pathogens, for instance—while managing the burgeoning load of H1N1 testing.

Introduction and Welcome

Welcome to the launch of LabLog, the blog for the Association of Public Health Laboratories (APHL), a membership organization of federal, state and local government laboratories that provide testing of public health significance. LabLog will feature posts by APHL staff and members, as well as outside experts. We hope that LabLog will be a valuable source of information on laboratory science and policy, and provide a forum for lively discussions. We strongly encourage questions and comments.