Notes from the President: Preventive Laboratory Services

By Dr. Patrick Luedtke, M.D.; President, APHL; Director, Unified State Laboratories, Utah Department of Health

Notes from the President will be a regular series.

Currently public health laboratories focus on infectious disease. Recently an APHL member and fellow lab director asked me for my thoughts on branching out to testing related to chronic disease prevention. I have given a good deal of thought to how public health labs will or could fit into a new prevention-based health system, which seems to be bounding down the healthcare highway toward us at a high rate of speed.  While I certainly have no solutions, I have no shortage of ideas and concerns.

It seems to me the roles of public health laboratories in a prevention-based health system could be made to fit into four broad categories:

1. Provision of test results

Public health laboratories could begin or continue providing a panel of prevention-based testing that perhaps focuses on CDC director Dr. Thomas Frieden’s “winnable battles.”  Testing could include fasting blood sugars, lipid panels, and others.  Some of APHL’s local laboratory members already perform this testing on a regular basis.  For others, it seems to me adoption of this type of testing would be quite dependent on local/state politics.

2. Prevention-focused research

I envision public health laboratories could play a meaningful role in prevention-focused research.  For example, we are approaching 80 million American adults with hypertension, 95% of whom have no known cause for their high blood pressure.  Additionally, it is well known that high blood levels of calcium and potassium as well as low levels of sodium produce significant decreases in many with high blood pressure. That being said, very little is known about body-burden of select metals/chemicals at birth and the resulting development of hypertension.  The same could be said of other common diseases of public health import.  Therefore, given the public health laboratory’s role in newborn screening (NBS), it is not a stretch to imagine an expansion of the NBS panel to include heavy metals, other select chemicals, etc. with the aim of identifying “at-birth risks” for chronic disease development.  

3. Regulatory systems

It seems to me that traditional public health laboratory roles of oversight in the clinical lab arena will likely not change substantially in the future.  In fact, they may expand as point-of-care testing increases and direct access testing labs proliferate.

4. Health outcomes partnering

I believe public health laboratories have an opportunity to move from the old “program evaluation” and internal “quality improvement initiative” paradigms to become active members in systems that focus predominantly on the final impact an intervention has on patient outcome.  This is an area that clinical medicine is rapidly moving into, and an area I feel that public health laboratories need to seriously study.

-- The opinions expressed here represent those of the author and not APHL.

“Perfect Storm” Prompts FL DOH to Open Workforce Office

By Nancy Maddox, MPH

Recent news from the Florida Department of Health (DOH) offers hope that upper echelon government leaders are waking up to a looming public health workforce crisis.

A Florida DOH brief notes that the agency is approaching a “’perfect storm’ in maintaining a competent workforce,” given a wave of retirements, noncompetitive wages, an ill-prepared pool of applicants and job-related stresses that compound hiring difficulties.

The brief wisely notes, “In times of funding constraints and reductions, there is an even greater need for a better educated workforce that is always learning the most efficient and effective methods of running state government.”

They do seem to understand the situation.

In response to these concerns, the agency has created a special workforce development office to assess and improve workforce competencies. In fact, the office’s task list includes some of the activities carried out by APHL’s own training programs and National Center for Public Health Laboratory Leadership (albeit for a broader state public health workforce), so we know it is on the right track:

• Establishing succession plans, mentoring programs and an in-house leadership program.
• Maintaining a catalogue of state trainers and training resources.
• Sharing best practices across divisions.
• Developing self-paced training modules.
• Coordinating development of a first-in-the-nation clinical management practice institute and training program and a first-in-the-nation financial administration certification program.

We hope the state’s efforts will translate into real improvements for the Florida Bureau of Laboratories.

Those interested in more information can contact Shannon Hughes, workforce development director, at 850.245.4444, ext. 3409 or Shannon_Hughes@doh.state.fl.us.

First Day Back in Haiti: Notes from January 22, 2010

By David Doherty, APHL Consultant

Just had an aftershock as I was beginning to type this message. Here is a very brief synopsis of the site visits from today:

1) Bernard Mevs
- no damage to hospital or lab
- no electricity but a 100kW generator is supposed to arrive from Jamaica tomorrow AM
- they have Sysmex but no automated chemistry; Drs. Bitar (Jerry and
Marlon) are desperate to get up and running to do haemograms and blood typing; they are doing as many as 20 surgeries an hour
- all lab techs survived but are homeless; spoke with two of them this afternoon; one is in Miragoane and is willing to return to work on Monday; another is sleeping outside in P-ville and will be returning to Hinche to accompany the older members of her family out of the city

2) HUP
- some damage to lab and hospital; mostly horizontal cracks on non-load bearing walls; all beams seem to be intact
- no electricity in lab
- Sysmex but no automated chemistry
- spoke with lab supervisor and Drs. Fontilus and Sant Fleur; all technicians are ready to report to work once they open the lab; she has requested one of the APHL techs if we get them a Vitros

3) Hopital Carrefour
- no damage to infrastructure; MSF has taken over the hospital temporarily; they will be moving to a new site on Monday and Carrefour will resume independent operation
- inverter and generators are intact; only concern will be availability of fuel
- no automated hematology except Hb and white cells using Point Care instrument; no automated chemistry
- spoke with the medical director, Dr. Dauphin; Ms. Barolette, the lab supervisor, had just left; all his technicians survived and are available as soon as he gives the word

4) Fame Pereo
- major structural damage to second floor; lab is intact but unsafe due to the unstable mass of concrete above
- inverters are damaged but functional Sysmex and Reflotron operational
- all technicians are available for work except one who returned to Gros Morne; spoke with her this evening and she is ready to return once she has a place to work
- spoke with the medical director, Dr. Pean; she is looking for another building to house the clinic temporarily; she will require some funds to get the lab set up if space is located

5) Maternite Isaie Jeanty
- no major structural damage to hospital or lab; hospital opening half days for emergency cases only
- lab was operating with power during the visit
- no automated hematology except Hb and white cells using Point Care instrument; no automated chemistry

Did not attempt to visit HUEH because it has been taken over by the US Military and PIH.

We need to help CMMB unload a plane tomorrow morning. I will visit NPFS if there is time while we are in the neighborhood. Hoping to get to Leogane tomorrow afternoon to see Sanatorium Sigueneau and St. Croix. (Ran into a team of US doctors on the plane to Miami; they were being posted to the latter site.)

Taking a team of orthopedic surgeons and anesthesiologists to Jacmel on Saturday morning. I will check out St. Michel and Marigot. Don't think I will have time (or a road) to get to Bainet and Lavalee.

We will resume visits to the remaining sites in the West on Monday (Grace, St. Fracis de Sales, IMIS, etc.). We will not schedule a visit to the GHESKIO main campus as they are overwhelmed.
Lastly, went to the Petionville Club to speak with Coty Reinbold. (He is managing the relief camp there, currently 53,000 people.) The situation for Vitros DT60 is as follows:
a) he has two instruments for GHESKIO that have not been installed
b) he has two instruments for PIH that have not been installed
c) AIDS Relief has 5 or 6 instruments at the warehouse in Delmas that have not been installed; I will be meeting with Olivia tomorrow to confirm that those could be made available for the relief effort if needed; their office and storage depot were not damaged.

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.