New Lab in Iowa Shaping a Healthier Future For All

By Scott Becker, Executive Director, Association of Public Health Laboratories

On Wednesday, May 5, a dedication ceremony was held for the new State Hygienic Laboratory at the University of Iowa. The three-story, 113,900-square-foot facility, which replaces one constructed in 1917, houses the states’ environmental and public health laboratory.

The opening of the state-of-the-art facility marks the culmination of years of work by the lab’s staff who identified the need for a new building, worked tirelessly to secure the funding, and directed design and construction of the enormously complex edifice.

The Hygienic Laboratory is responsible for conducting tests to detect diseases and contaminants in the environment. It also monitors for the presence of diseases and for contaminants in Iowa's waterways and air. In emergencies, such as the Iowa floods of 2009, it serves as the state’s laboratory first responder.

The facility will allow for new collaborations, including those to study interactions between human health and the environment, and to evaluate emerging laboratory technologies that could save lives and money. Who knows? Scientists here could uncover indicators linking infectious and chronic disease or develop methodologies that will revolutionize laboratory diagnostics.

The people of Iowa are the immediate beneficiaries of this state-of-the-art health resource. Yet, because no public health laboratory works in isolation, this new facility actually benefits those of us in the rest of the country as well. Its presence represents another step toward our shared mission--shaping a healthier future for all.

Suspicious Powder Sample Sent to Arizona State Lab for Testing

The Laboratory Response Network (LRN) and its partners maintain an integrated network of laboratories that are fully equipped to respond quickly to acts of chemical or biological terrorism, emerging infectious diseases, natural disasters and other public health threats and emergencies.  The LRN became operational in 1999 and has since performed essential public health services, notably including responding to the Anthrax attacks of 2001. 

Most recently in Phoenix on Tuesday, the State Department of Health (Arizona Bureau of State Laboratory Services, an LRN member laboratory) similarly acted to test a white powder letter addressed to Governor Jan Brewer.  The letter was opened by a staff person in the State Capitol sending the hazmat team scrambling to lockdown the building. 

In situations such as this, the FBI will deliver the suspicious sample to the LRN laboratory.  The LRN lab’s highly trained staff will then run a panel of tests (standardized across the LRN, specific to BioTerrorism and Public Health threats) in a very secure and safe environment to determine if there exists an agent of interest within the suspicious sample.  The testing methodology is robust and redundant, with verification and confirmation tests run for any positive samples.  All data specific to threat samples received and tested by the LRN labs are then reported to CDC as well as to the FBI.

Currently the FBI is awaiting results on the samples in Arizona.

Lab Week Comes to a Close -- A Message from Scott Becker

As National Laboratory Professionals Week comes to a close, APHL is proud to honor all of the public health laboratory professionals who work tirelessly to protect the health and safety of the public. You are each to be commended for the high quality work you deliver day after day-- despite budget cuts, furloughs, staff down-sizing, antiquated facilities and all the other challenges that confront laboratorians in 2010.

So today, raise a purple-gloved hand high in a salute to you and your colleagues. Few people can say that their work saves lives, but you can. I extend my sincere thanks on behalf of the people you serve and the association that is fortunate to represent you.

Scott Becker
Executive Director, APHL

Celebrating Earth Day and Lab Week

Happy Earth Day! This year marks the 40th anniversary of this celebration, a day designed to inspire awareness and appreciation for the Earth's environment. While we have come a long way in improving our environment – no more rivers so contaminated that they regularly are consumed in flame, for example – we still have a long way to go, as evidenced by recent findings of contaminants in dog food, baby bottles, and children’s toys.

Did you know that laboratories are vital to protecting us from harmful contaminants in our environment?

Public health laboratories measure contaminants once they get into our bodies, while environmental laboratories measure contaminants in the environment itself (in the air, water or soil).

To better illustrate the importance of the lab’s role in protecting us from environmental contamination, here is a fictional but realistic scenario:

A group of six young men, all apparently friends, arrive at a local emergency room with similar symptoms: nausea, vomiting, headache, fatigue and weakness. The ER immediately takes blood and urine specimens, sending them to the hospital labs for screening while simultaneously contacting the state Poison Control Center for advice.

Tests indicate cell and tissue decomposition and the Poison Control Center suspects radiation sickness. They recommend calling the state public health lab for guidance. Meanwhile, all of the patients and medical staff who came into contact with these men (receptionists, nurses, and physicians) enter quarantine. The men’s clothing is secured.

The public health lab contacts the local FBI field office, which immediately sends agents, while the Department of Defense’s Civil Support Team begins processing the men’s townhome. A suspicious white powder is found along with documentation on a laptop linking the men to a recent theft totaling over $75M in radiopharmaceuticals. Following confirmation of radioactivity, the scene is evacuated and cordoned off.

Meanwhile, the FBI locates a storage unit rented by one of the men under an assumed name. Upon search of the unit they find more of the white powdery substance as well as containers of paint remover, concentrated sulfuric acid and hydrogen peroxide. In addition, the unit contains laboratory equipment (glassware, distillers, mixers, an ice bath and filters).

Ultimately, the white powder is determined to be Triacetone Triperoxide (TATP), a powerful, highly unstable homemade explosive. Apparently, the men were trying to build a dirty bomb and were exposed to the radioactive pharmaceutical they had stolen.

People who came into contact with these men remain concerned about their potential exposure, so the state public health lab tests their urine. The results reassure the medical staff and the men’s neighbors that they need not worry. The state environmental laboratory tests soil and water samples from around the storage unit and the men’s townhome; much to local policymakers’ relief the results show no reason for concern.*

Thanks to the coordinated response between the hospital, the Poison Control Center, the Civil Support Team, the public health laboratory, the environmental laboratory and the FBI, the terrorist plot was foiled. Public health and safety were protected!

* Note that there is no national program for radioanalytical laboratory preparedness and response. Some states are better able to test for radioactivity than others, some not at all.

For more information on environmental health and laboratories see www.aphl.org/eh

For more information on Earth Day see:

• Top Ten Actions Individuals, Organizations, and Businesses can Take in Reducing Their Contribution to Global Warming
• Commit to taking action or sign up for daily green tips

Laboratory Systems & Standards: Building the Foundation for Quality Testing

In honor of Laboratory Professional Week, APHL would like to highlight some of the activities that it conducts on behalf of members. The Laboratory Systems and Standards (LSS) program works with public health and laboratory partners to build the foundation for quality testing: comprehensive standards and integrated public health laboratory systems.

Vaccine-Preventable Disease Project

As the incidence of Vaccine-Preventable Diseases (VPD) decreases in the US, the capacity and capability of state and local public health laboratories to perform VPD testing has declined, becoming increasingly inconsistent. While some labs are quite proficient in VPD testing, others are eliminating testing altogether. However, timely and accurate diagnosis of VPDs is essential to identify and control outbreaks and to provide the information needed to improve vaccines and vaccination programs. To address gaps in testing capacity for VPDs, APHL was recently awarded funding through the American Recovery and Reinvestment Act of 2009 (ARRA) to provide training programs and quality improvement activities for VPD testing in public health laboratories. The association is partnering with CDC to develop and present these programs.

The first initiative is a series of teleconferences targeted to public health laboratorians. To date, CDC subject matter experts have presented new diagnostic testing methods for several VPDs, including Bordetella pertussis (whooping cough), Streptococcus pneumoniae, measles virus and mumps virus. The mumps educational teleconferences have been especially timely in light of the ongoing mumps outbreak in the northeastern United States. State public health lab staff are being trained in the new mumps assay developed at CDC. Access to this assay will enhance patient diagnosis and epidemiological investigations in participating states.

In response to a recent survey of public health labs’ training needs for VPDs, more trainings and quality improvement activities are planned, including hands-on workshops, proficiency testing exercises and assay comparison studies. By working together on these activities, APHL and CDC look forward to helping public health laboratories to improve their capability to quickly and accurately detect cases of VPDs.

Voluntary Accreditation Program

“Continuous quality improvement” is part of the laboratorian’s credo. Assays and equipment must meet precise quality standard before they can be utilized in the laboratory. Now APHL is developing voluntary standards specific to public health laboratories that will be used to assess the quality of the laboratory itself and specifically its operations and functions. These new standards will not supplant CLIA, but be used as a complement to the federal regulation.

The accreditation program will be voluntary, and will integrate standards from existing domestic and international sources as well as those outlined in the Core Functions of Public Health Laboratories.

Incorporation of the public health laboratory standards will be proposed to the Public Health Accreditation Board (PHAB) for incorporation into their accreditation process. Accreditation will signify that the laboratory has met agreed-upon standards of quality and that it ascribes to them as a measure of its services.

APHL is convening a Think Tank with PHAB at the end of April to discuss how the program should look, be structured, and what elements should be included in such a partnership. Information from the Think Tank will be shared with membership on the APHL web site and through reports in Lab Matters.

Laboratory System Improvement Program (L-SIP) Assessment

To make it easier for labs to find quality improvement and performance-related materials, APHL provides a one-stop-shop for resources to improve the quality of state public health laboratory systems. One of those tools is the Laboratory System Improvement Program (L-SIP) assessment tool. During an L-SIP assessment, representatives of the state public health laboratory system and partners convene to assess the performance of state public health laboratory system. This program provides a user-friendly process, including a performance assessment tool for assessing and establishing a baseline measure of performance.

Most recently, South Dakota has scheduled our Laboratory System Improvement Assessment for April 29th. We have closely followed the recommendations of the APHL L-SIP Assessment Tool User's Guide, a document that walks the coordinators through the assessment preparation process and includes sample materials such as letters to participants and agendas. For this lab and the others who utilize the L-SIP assessment tool, they find that it offers a means for strengthening relationships with public health, clinical and other laboratories and partners that comprise the broader laboratory system, as well as a framework for continuous improvement of public health laboratory systems.

We are looking forward to convening our system partners later this month to discuss our state public health laboratory system and what we can do to improve it.

Rebuilding Haiti’s Labs: Governance, Policies and Systems Before Bricks and Mortar

At a March 31 United Nations special session on rebuilding Haiti, countries responded with pledges of significant funding for the decimated nation; however, funding alone will not rebuild Haiti, and certainly not its battered laboratories.

First, Haitian leaders must find the courage and commitment to confront corruption and inefficiency within their government. Without a fundamental shift from opportunism to public service, donors will not be willing to sustain the long—and costly—process of recovery.

Photo: A typical lab in Port-au-Prince, Haiti

Second, the international donor community must adopt new operational models that are less dependent on the services of ex-patriots. Good models are available. Paul Farmer at Partners in Health and Jean William Pape at GHESKIO/ Weill Cornell Medical College, for example, have shown that impoverished communities with few resources can combat diseases and improve health care. Their approach—like that of APHL's project in Haiti—is to build long-term partnerships with local groups and to help train their doctors and healthcare professionals.

Third, Haiti’s laboratories need to be reconceived and rebuilt as part of an integrated national laboratory network operated under a strong quality management system. A precursor to this is development and implementation of a revised national laboratory policy and strategic plan to guide the orchestration of the necessary resources, including a trained and competent workforce.

Yet the reality at the moment is that there isn’t a comprehensive and forceful Haitian laboratory policy, strategic plan or network, only the commitment of the country’s national laboratory to forge a true laboratory system and support from some non-governmental organizations. How can APHL best support development of a nationwide laboratory system that will serve all of Haiti’s people? We look forward to your comments.

Case Study 1 -- The Response

To follow up on our previous post about Mr Fudd and his family's mysterious illness...

Response:

If the specimen was initially tested in a sentinel clinical laboratory where analyses are unable to rule out a possible Bioterrorism agent (in this case, Yersinia pestis) using standard methods they would immediately refer suspicious isolates and specimens to their collaborating LRN reference laboratory.

Case Investigation:

Upon investigation the Fudd family was attending a family and friends reunion in New Mexico. One of the Fudd family traditions is to organize a wascially wabbit hunt the morning of the reunion, and dine on rabbit stew and other assorted rabbit dishes at that evening’s party.

In humans, Yersina pestis is most often acquired from the bite of infected fleas that feed from animal reservoir such as squirrels, rabbits, and prairie dogs. Although rare, there have been several documented reports of Y. pestis infection from the direct contact of contaminated meat products either through ingestion or inhalation.

Celebrating Lab Week -- Case Study 1

Happy National Medical Laboratory Professionals Week!

As a fun activity during the week several programs at APHL will be posting fun case studies related to the work being done in public health laboratories across the country. Today’s case study comes from Infectious Disease, Food Safety, and Emergency Preparedness.

Case Study

Mr. Fudd presents in the emergency room in Chicago with fever, lethargy, severe pharyngitis, tonsillitis and a striking swelling of his neck. The ER Physician ordered Rapid Streptococcus A Dtesting, gram stain, and respiratory cultures.

Two days following the first patient presentation, three additional Fudd family members present to the same emergency room with similar symptoms.

All patient specimens were sent to the laboratory for ordered laboratory testing. The lab results included the following:

Laboratory Tests --
(Photo: Blood Agar Plate Growth at 48 hours)

• Rapid Streptococcus A: Negative
• Gram Stain: Gram Negative Rods
• Culture incubated at 37C for(24 hours): Pin point colonies on Blood agar Plate and Chocolate agar
• Culture incubated at 37C for (48 hours): Grey, white, translucent colonies on Blood agar Plate and Chocolate agar; Clear White Non Lactose Fermenting colonies on MacConkey agar

Biochemicals --
(Photo: Gram Stain of Culture Isolate)

• Catalase: Positive
• Oxidase: Negative
• Urease: Negative
• Indole: Negative

What would your laboratory do next?

Please include your comments/answers below. APHL is excited to hear what your laboratory would do next!  The response and case investigation will be posted this afternoon.  Stay tuned...

 

Heel-Prick Test Conducted By Labs Ideal for Genetic Disorders

A virus that causes about 20% of hearing losses in newborns has received considerable attention of late in mainstream media. A recent study published in the Journal of the American Medical Association (JAMA), finds that this virus—the cytomegalovirus or “CMV”—can be best detected using existing analytical methods, rather than the one evaluated in the study. [insert reference as footnote], For the immediate future, medical practitioners, laboratory scientists and the families they serve will need to rely on other proven technologies, such as testing a baby’s saliva.

Newborn screening is a complex process that can be confusing even to medical experts. Recently a CBS News segment on the JAMA study reported erroneously that newborn hearing tests are conducted at state public health laboratories. This is incorrect. A baby’s hearing is tested at the hospital within 24-48 hours of birth; that test is not performed by state newborn screening laboratories.

State laboratories do, however, shoulder most of the responsibility for newborn screening in the US. They conduct 97% of the testing for the core panel of 29 congenital disorders recommended by the American College of Medical Genetics (ACMG) and the U.S. Secretary of Health and Human Services Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and children (ACHDGDNC). Newborn screening by state laboratories protects over 4,000 children a year from the potentially devastating effects of Phenylketonuria (PKU), Medium Chain Acyl-CoA Dehydrogenase deficiency (MCAD), Maple Syrup Urine Disease (MSUD) and other serious disorders that can lead to death or life-long disability. In addition to the 29 ACMG “Core” conditions, the public health laboratory in some states also screens for some of the 25 “Secondary” conditions.

A new testing method would simplify and expedite testing for CMV if the method could be adapted to use the same instrument platforms as used to detect other newborn screening conditions.

Newborn screening starts with a single heel-prick collected at the birthing facility soon after a baby is born. Blood droplets are collected on a filter paper kit, allowed to dry and then sent to the state public health laboratory for testing using specific analytical tools to detect congenital disorders. Methods used by the newborn screening laboratory include fluorometric and colorimetric immunoassays, electrophoresis, high performance liquid chromotography and tandem mass spectrometry (MS/MS).

The introduction of MS/MS revolutionized newborn screening – allowing labs to test for dozens of conditions simultaneously. Currently, not all diseases and conditions can be detected via MS/MS (e.g. biotinidase, galactosemia) but the aim is to detect more disorders using this efficient and effective method to provide more rapid detection of congenital conditions to protect the nation’s children.

National Public Health Week -- APHL Honors Public Health Laboratories

By Mary Shaffran, Senior Director, Public Health Programs, APHL

Along with our partners, the public health laboratories are working to keep communities healthy. Laboratorians work behind the scenes. Public health laboratories serve as the nation’s early warning system for diseases and other health hazards. When health risks emerge or re-emerge, public health laboratories analyze the threat, provide the answers needed to mount an effective response and act to protect the public in collaboration with other decision makers. They protect our health by monitoring continuously for diseases and other health hazards.

Just a few of the things that laboratories are doing every day to make sure that you and your neighbors are healthy: 

- Public health laboratories in every state are the backbone of our nation’s infectious disease surveillance networks. They are analyzing infectious diseases such as influenza to determine if they are changing and reporting this information to public health officials so they can determine effective prevention measures. [More on the Infectious Disease Program]

- More than 11,000 babies are screened daily for potentially life-threatening genetic and congenital disorders.

• Matt and Noelle Bamonte discovered that their seemingly healthy baby boy had PKU, a serious disorder that can cause brain damage if not treated from a very early age. Noelle is certain that without laboratory screening, her little boy would have been vastly different. Now, aside from a strict diet, he lives a normal life! [More of their story]

- Public health laboratorians confirm whether people are infected with sexually transmitted diseases, and confidentially report back the results so that people can be treated and others are not exposed. [More on the Sexually Transmitted Disease Program]

- In order to detect foodborne outbreaks and ultimately keep Americans safe from foodborne disease, public health laboratorians test human specimens and food samples for bacteria such as Salmonella and E. Coli.

• In 2006, the New Mexico public health laboratory pinpointed the exact source of the E. Coli that made its way into spinach and made hundreds of people sick. [More on the E.Coli outbreak]

- Public health laboratorians test environmental, clinical and food samples to determine whether they contain hazardous agents in order to protect Americans from terrorist attacks, and they are able to do this 24/7.

• California scientists are collecting specimens from 2,000 people to test for the presence toxins used in used in industry, agriculture and the home. They’ll use this information to explore such things as the connection between exposure and diseases, and to examine changes in exposure over time and the connection to changing health policies and industry regulations working to reduce exposure. [More on the work in California]

- Public health laboratorians test water samples in flood-ravaged areas to ensure that the water is safe to drink.

• In 2008, severe flooding in Mason City, Iowa caused the closure of the water treatment facility. Residents were advised to boil their water until the system was restored and the water was tested to ensure it was safe to drink. The Hygienic Lab rose to the task and tested the water quickly bringing the treatment operation back online. [More on the floods in Iowa]

We would like to thank our unsung heroes in lab coats for protecting the public’s health – every day.

 

Join APHL and our many partners in celebrating National Public Health Week. For more information, visit http://www.nphw.org/.

 

 

 

 

 

 

 

 

 

Salmonella Outbreak Leads to Heightened Surveillance

As laboratory and epidemiology surveillance systems expand and improve, more foodborne outbreaks are being detected. Additionally, the vehicles responsible have become more diverse. Whereas the classic “church supper” and other point source outbreaks once made headlines, now fresh produce, peanut butter, veggie snacks and even reptiles have been implicated in localized and complex multi-state outbreaks.

New culprits, including ingredients that were overlooked years ago, are now being detected as the source of food contamination. In the past few weeks, public health officials have heightened surveillance for Salmonella in the wake of the recalls of hydrolyzed vegetable protein or HVP. HVP is a flavoring additive that has been widely used in the food industry. It is sometimes referred to on packaging as “natural flavors.” This additive is found in thousands of products ranging from snack foods, ready-to-eat products (hot dogs, for example) soups, sauces and other processed foods. This recall may be the largest to date. (List of recalled foods.) Although no human illness has been associated with the recalls to date, the implicated strain of Salmonella was found at a food flavoring processing plant in Nevada.

APHL continues to support member laboratories on foodborne surveillance networks such as PulseNet. This laboratory-based surveillance system detects clusters of foodborne illnesses by using DNA fingerprinting technology. APHL supports member laboratories in the PulseNet network to improve surveillance though trainings, technical meetings, information dissemination, and grants.

This recall demonstrates the critical importance of the public health laboratory system and the need for maintaining and expanding food safety surveillance networks. By catching contamination more quickly, labs are able to prevent widespread outbreaks of foodborne illnesses; another important way that public health laboratories are keeping you healthy.

Implementation: The Next Step in Health Reform

Last week when President Obama signed the Senate version of the Patient Protection and Affordable Care Act into law, he initiated significant reform of the US health system. The key word here is “initiated,” because the benefits of this far-reaching new law hinge upon its successful implementation.

If governmental public health and its laboratories do not receive adequate funding to underwrite the public health provisions of the Act, then its benefits will be considerably reduced. Specifically, funding from the Prevention and Public Health Fund must be directed to the Centers for Disease Control and Prevention (CDC) for use in support of governmental public health. Anything less will belie the intent and purpose of this landmark legislation.

Key provisions of the health reform law that directly impact public health laboratories include:

• The Prevention and Public Health Fund (Sec. 4002) will fund prevention and wellness activities, including governmental public health, at $500 million beginning in fiscal year 2010 and expanding to $2 billion in 2015. These monies are provided outside of the standard annual appropriations process and in addition to the federal funding already being directed to similar programs. This funding cannot be reduced or redirected, and full disbursement is mandatory within the timeframes specified. APHL is already at work to ensure that a significant portion of fiscal year 2010 funds are directed to governmental public health programs, including those that support laboratories.

• The Public Health Workforce Recruitment and Retention Program (Sec. 5204) provides funding to expand the public health workforce through loan reimbursements and scholarships in exchange for service as a public health professional. This new program is authorized at $195 million in fiscal year 2010.

• Funding for the Epidemiology-Laboratory Capacity (ELC) grant program (Sec.4304) and public health fellowships (Sec. 5314). The ELC program, authorized for the first time, could receive annual funding totaling up to $195 million, with $32 million directed to enhancing laboratory practice and $60 million to improving information systems.

• The Fellowship Training in Public Health adds a section entitled, “Fellowship Training in Applied Public Health Epidemiology, Public Health Laboratory Science, Public Health Informatics, and Expansion of the Epidemic Intelligence Service” to the Public Health Service Act. Under this section, the laboratory fellowship program is authorized at $5 million annually, as is the Public Health Informatics Fellowship program.

World TB Day

By Kelly E. Wroblewski, Manager - HIV, STD, TB, Hepatitis Programs, APHL

Every year approximately 2 million people worldwide die from tuberculosis-related disease. Yet TB prevention and control too often receives scant funding and limited attention from government officials, health professionals and the public.

Observed every March 24 to commemorate the date in 1882 when the bacterium that causes tuberculosis was first discovered, World TB Day affirms the critical role of public health laboratory scientists in controlling and preventing the disease.

Last week the Centers for Disease Control and Prevention released reports indicating that preliminary data shows a 10.6% decrease in reported TB cases in the United States over a one-year period from 2008 to 2009. While many factors, including potential underreporting, could have factored into this decrease, the numbers are still encouraging. Yet public health professionals know we must remain vigilant, for a decline in US funding led to a resurgence of TB cases in the nineties. Moreover, new drug-resistant strains of TB have emerged, making the disease increasingly deadly.

In 2009 APHL members made significant contributions to TB control efforts above and beyond their work in the laboratory. After several years of work by APHL members, the TB self assessment tool, Mycobacteriology: Assessing Your Laboratory, was revised and published in a new electronic format. Additionally, the TB Steering Committee developed and published a document, Core TB Services of Public Health Laboratories, which outlines the role of public health laboratories in TB diagnostics and surveillance.
Now planning is underway for the 6th National Conference on Laboratory Aspects of TB, which will be held in Atlanta, GA, June 21-22, 2010, in conjunction with the National TB Conference.

On this day dedicated to raising awareness of tuberculosis and enhancing prevention and control globally, APHL would like to recognize the members, colleagues and partners who persevere to combat this devastating disease.

CDC Creates New Office of Prevention Through Health Care

By Peter Kyriacopoulos, Director of Public Policy, APHL

The Centers for Disease Control and Prevention (CDC) recently notified Scott Becker, APHL’s Executive Director, about a newly created office: the Office of Prevention Through Health Care (OPTH). This new office will enable CDC to more aggressively and effectively develop and disseminate policies that leverage the health care system to improve health through prevention. According to CDC, OPTH will coordinate health care activities across CDC programs and will lead engagement with external partners on health care issues.

There is no better way to achieve an immediate improvement in health through prevention than increased surveillance and detection of disease outbreaks. State and local laboratories performing tests of public health significance are on the frontline of this activity and are under extreme pressure to continue their exemplary performance because of the staffing reductions that have resulted from budget cuts caused by the economic downturn. Work on food safety, pandemic influenza, and other infectious diseases is imperiled because of these budget cuts.

An infusion of federal support for state and local public health workforce retention would produce an immediate high-value preventive intervention by preserving the much-needed laboratory professionals who are responsible for surveillance and detection on a daily basis. Improved surveillance and detection coupled with expedient delivery of that information through a robust laboratory informatics network would lead to a reduction in the instances of disease and reductions in the number of individuals seeking health care because of disease. It is hard to imagine a smarter engagement with the health system than by reducing the number of people it is struggling to serve. The positive implications for the payers, public and private, of this care are similarly obvious.

The corollary is also true, the path we are travelling with continued losses of state and local laboratory professionals coupled with the antiquated mechanisms for transmitting laboratory test orders and results can only lead to reduced surveillance and detection and increased incidents of disease that causes public and private payers to expend ever increasing amounts on the delivery of health care to increased numbers of people.

Public Health Preparedness Summit: Huge Success

Last month’s Public Health Preparedness Summit in Atlanta was a huge success. The Summit welcomed over 1,800 attendees and continues to provide a unique forum for multiple disciplines of public health to learn from each other how best to promote a culture of public health preparedness across the nation.

This year's Summit included Town Hall Sessions where organizations such as APHL presented on important topics including "The Wild World of Public Health Laboratories: We do More than Testing for Sexually Transmitted Diseases." This session provided attendees with an overview of public health laboratories, their role in testing for novel influenza A H1N1; detecting Salmonella typhimurium in peanut butter and identifying a nationwide outbreak; screening the nation's newborns for genetic disorders and providing continuity of operations during natural disasters, such as Hurricane Katrina; and working with the Laboratory Response Network (LRN) to test hundreds of white powder threat letters sent to governors and embassies.

In addition to presentations on laboratory-specific activities, APHL's preparedness staff, Anthony Barkey and Sikha Singh, led a session on implementing social networking tools as tomorrow's emergency response engine for local departments of health.

One of the keynote presentations was delivered by Ana-Marie Jones, executive director of Collaborating Agencies Responding to Disaster (CARD). She emphasized the importance of simplifying messages and engaging the public as messengers. Jones encouraged public health leaders to use these tough economic times to eliminate failing programs and look at how to leverage successes of existing programs that succeed in generating measurable change.

Closing keynote speaker, Thomas Frieden, MD, MPH, Director, CDC and Administrator, ATSDR, stated that preparedness is a core function for CDC. Frieden reiterated CDC's commitment to strengthen state and local preparedness to better measure, improve and monitor public health capability; strengthen technical assistance; promote collaboration and train the public health workforce.

This conference will continue be one of the few events that bring together all the major players in the preparedness community, from emergency planners and first responders to policy makers and federal agencies. The summit is quickly becoming an event known for bringing new ideas and technology to the forefront, which is a trend that will only help to strengthen the public health community.

Public Health Funding Through PHEP

By Peter Kyriacopoulos, Director of Public Policy, APHL

Strong governmental public health is capable of responding to the full array of diseases and other health threats that can cause harm to the people of this country. Public Health Emergency Preparedness (PHEP) funding offers one avenue of support, and there will certainly be others similarly targeted. PHEP provides funding to public health departments via CDC to build their capacity and capability to respond effectively to infectious disease outbreaks, natural disasters and other public health emergencies, including those that are willfully introduced.

The correct way to assure an effective and efficient governmental public health response to all threats is through dedicated and continuous federal funding. While there is not yet sustained federal funding for public health laboratories, it remains one of APHL's top policy priorities. Both the House and Senate versions of health reform legislation include provisions creating trusts or investment funds that go far to accomplishing this goal. Until they are enacted, governmental public health will be compelled to seek funding from any and all possible sources.

Newborn Screening: Part 2

By Brad Therrell, Ph.D., Professor Dept. of Pediatrics, UTHSCSA Director, National Newborn Screening and Genetics Resource Center (NNSGRC)

Each year 15,000-16,000 newborns are identified with one of the core 29 conditions tested for using newborn screening. Tests are conducted by analyzing dried blood spots in order to prevent serious medical outcomes from certain congenital conditions.

Many states are considering evidence that points to the value of adding more conditions to the recommended core screening panel. The Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends additional tests; the most recent is Severe Combined Immunodeficiency Disease (SCID), better known as 'Bubble Boy Disease'. Krabbe Disease, now screened for only in New York, is also being considered as a possible addition. Former Buffalo Bills quarterback Jim Kelly (Hunter's Hope Foundation) is actively seeking expanded newborn screening including the addition of Krabbe Disease which took the life of his son Hunter before newborn screening was available.

There have been inaccurate reports regarding the use of a baby’s DNA obtained from newborn screening. As mentioned previously, the newborn screening specimens are stored as dried blood spots, not as DNA. If DNA extraction is necessary and possible, there is usually a dissent process in place and there are educational materials about newborn screening distributed by every newborn screening program. In fact, the Secretary of Health and Human Services' ACHDNC is already hard at work considering national guidance on the issue of storage and use of dried blood spots.

It is important that everyone has the facts about newborn screening available to them. Regardless of the inaccuracies that exist out there, parents deserve to have factual information on the entire process.


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

Newborn Screening: Part 1

Newborn screening is the process of testing a newborn baby for genetic and congenital disorders that can cause illness, disability and death. Virtually every state now screens for a core panel of 29 rare genetic and congenital disorders, which include sickle cell anemia, PKU (phenylketonuria) and MCAD (medium chain acyl CoA dehydrogenase deficiency). The test is a small heel-prick to draw blood that is then sent to a laboratory (97% of which are state public health laboratories) for testing. This test allows thousands of babies to be diagnosed with devastating diseases in the earliest stages of their lives, and allows doctors to begin managing these diseases while they still can.

State public health labs are part of a newborn screening system that includes public health staff, birthing center staff, primary care physicians, metabolic specialists, educators and families. Careful coordination among all parties ensures that the infant receives prompt and appropriate treatment, follow-up care and continued evaluation.

There are countless stories from parents who are grateful that their children are alive and healthy thanks to newborn screening.

Parenting Magazine recently published an article telling the story of one family whose baby’s life was saved by early intervention newborn screening.

And in Wisconsin, a family had a scare when a test came back positive for a fatty acid oxidation disorder, a potentially deadly condition.

APHL will be doing a series of posts to LabLog on newborn screening. Please feel free to leave comments and questions.

Safety First

By Sikha Singh, specialist, Laboratory Response Network

Last month I had the privilege of observing the Emory University Southeast Regional Center of Excellence for Emerging Infections and Biodefense (SERCEB) BSL3 Science and Safety course, with the purpose of gaining a better understanding of how this program addresses the needs of biosafety professionals and laboratorians.

Instructor Sean Kaufman and his team offer an innovative teaching environment, utilizing a combination of lectures and interactive discussions coupled with a focus on and acknowledgement of behavioral aspects that may impact biosafety environments.

A mock scenario: You are suited up in a high-containment laboratory, working under the hood with a select agent. Fire alarms sound. React. The room shakes. React. The power goes out. React. The route to safety is obstructed. React. Your colleague has fallen to the floor. React again. Repeat.

This insertion of “noise” into a once familiar environment followed by candid feedback on how to consciously respond in panic situations serves as a compelling mechanism of provoking behavioral responses. Drills, performed in conditions both routine and threatening, reinforce to participants the importance of safeguarding the integrity of their secure environment as well as the agents with which they work.

I was extremely impressed by this course, which succeeds in making difficult and cumbersome material interactive by engaging participants. Training activities such as this course are vital tools to prepare laboratorians to safely work with and contain dangerous pathogens.

Yet Another Multi-state Salmonella Outbreak Proves Need for PulseNet

The latest large-scale foodborne disease outbreak—involving Salmonella-tainted Italian salami products—has sickened at least 225 people in 44 states and Washington, DC. More than 50 are suffering illness severe enough to require hospitalization.

Coming on the heels of several high-profile, multi-state outbreaks involving everything from spinach to peanut butter, the latest incident raises questions about the safety of the food supply.

A quick review of the current outbreak reveals several trends.

1) The outbreak involves a collection of food items: about two dozen different ready-to-eat salami products. (Recall that a 2008-2009 Salmonella outbreak was linked to more than 400 different peanut-butter-containing foods).

2) The volume of products recalled is immense: more than 1.25 million pounds of meat.

3) The suspected source of the bacterium is an imported food item: the black pepper used to flavor the salami products.

In short, the food chain has become increasing convoluted and global in nature. Foods travel farther distances to reach consumers, and one product may contain ingredients sourced from several distinct producers (who may be based in the US or abroad, potentially in countries with more lax food safety regulations than the US). All of these factors increase the risk for contamination.

While APHL has no formal role in preventing food contamination, the association has played a pivotal role in detecting it so fewer people suffer illness. Laboratory-based surveillance—using the APHL/CDC PulseNet system—enables outbreaks to be identified much more swiftly than would otherwise be the case (including the ongoing salami-related outbreak), and undoubtedly detects small outbreaks that would otherwise go unnoticed. In the absence of more stringent food-safety regulations, PulseNet offers some assurance that tainted food products will be brought to the attention of state and federal authorities. In fact, the PulseNet system has proven so effective that there has been great interest in expanding it internationally.

APHL has also provided substantive input into the Guidelines for Foodborne Disease Outbreak Response recently released by the Council to Improve Foodborne Outbreak Response. These guidelines are important because they provide a model and benchmarks for the kind of multi-disciplinary and multi-agency collaboration essential to contain an outbreak. The recent Salmonella outbreak, for example, involves ingredients regulated by two different federal agencies: the USDA, which regulates meat, and the FDA, which regulates pepper.

APHL Working to Ensure Power for Laboratory Services in Haiti

When the electrical grid comes back on-line in Haiti, the country’s laboratory system will be able to ramp up services quickly thanks to measures put in place before the magnitude 7.0 temblor January 12.

Even before the devastating earthquake, electrical power in Haiti was unreliable, with routine outages and serious voltage and frequency variations that compromised laboratory testing. Outages can lead to the loss of valuable testing reagents that must be stored at controlled temperatures, while “dirty power” is damaging to a wide range of laboratory equipment, including instruments used for diagnostic testing to support antiretroviral treatment for HIV-infected patients.

With funding from CDC’s Global AIDS Program and funding and technical assistance from the US Agency for International Development, APHL invested in site-specific technologies to improve the quality of the power received from the electric grid and provide continuous power during grid power outages. The core technologies include uninterruptible power supplies, generator back-up power with automatic transfer switches and no-contact inverter battery systems.

In addition, APHL has provided on-site maintenance and supervisory support visits with two-person teams comprised of one laboratory technologist and one service technician that travel to 16 supported sites throughout the country. Thankfully, Haiti’s national public health laboratory, the Laboratoire National de Santé Publique in Port-au-Prince, remains standing in the aftermath of the earthquake.

Although the massive relief effort has consumed all the country’s resources—with surviving laboratory staff understandably focusing on their homes and families—APHL is hopeful that conditions will improve enough to enable public health testing to resume in the not too distant future. At that point, the electrical support infrastructure will be a valuable help.

TFAH Report Highlights Gaps in Laboratory Preparedness

Several priority APHL messages are highlighted anew in a recent Trust for America’s Health (TFAH) report, Ready or Not? 2009. Among other things, this assessment of U.S. readiness for public health emergencies finds:

• 11 states and the District of Columbia lack sufficient public health laboratory staff to work five 12-hour days for six to eight weeks during an emergency such as the novel H1N1 pandemic.
• 6 states do not have a disease surveillance system compatible with CDC’s National Electronic Disease Surveillance System (NEDSS).
• 14 states lack courier systems to assure timely, 24/7 pick-up and delivery of specimens to Laboratory Response Network (LRN) labs.
• 24 states cut public health funding between FY2008 and FY2009.

The TFAH report estimates a $20 billion/year shortfall in funding for public health and notes that federal funding for public health emergency preparedness fell 27% between FY2005 and FY2009. Both TFAH and APHL stress the critical need for adequate, sustained long-term public health funding.

APHL has long considered the shrinking public health laboratory workforce and the scarcity of real-time electronic laboratory messaging systems to be serious preparedness gaps and has launched major initiatives to address these, including its National Center for Public Health Laboratory Leadership, a number of fellowship programs for scientists-in-training and the Public Health Laboratory Interoperability Project, which has developed and piloted the IT architecture and tools to enable real-time data exchange between public health labs and CDC for several priority pathogens.

“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.

APHL Aids Agencies, NGOS to Set Up Critical Lab Testing Services in Haiti

Dave Doherty, senior technical consultant for APHL in Haiti, manages a four-person field team that is presently assessing the post-earthquake status of public laboratories for Dr. Jacques Boncy, Director of Laboratoire National de Santé Publique (LNSP), and in support of PEPFAR activities under the direction of Dr. Steve Harris, CDC/GAP Haiti Chief of Party.

Although many of the facilities are severely damaged, many laboratory technicians and supervisors are at the hospital sites and doing what they can under these difficult circumstances. The response of the Haitian laboratory staff is commendable and an illustration of the heroic response of the people of Haiti who have lost family and homes.

The AIDS Relief organization in Haiti identified five Vitros chemistry analyzers and the PEPFAR Supply Chain Management System will provide reagents, so these needed instruments can be used at emergency trauma centers. Doherty’s team will transport the equipment and reagents, and coordinate staff needs and training for technicians. Dr. Boncy has directed APHL to put the instruments into operation at the major hospitals in the Southwest and South where most of the trauma patients are received.

Laboratory Workforce News: The Good, The Bad, The Ugly

By Nancy Maddox, MPH

The Good
U.S. News & World Report recently named “lab technician” one of America’s best careers for 2010.

Lab technician was one of 11 healthcare careers recommended for “traumatized job seekers and anxious students.” The magazine notes that “job growth is expected to be faster than average, with the number of clinical lab workers rising about 16 percent” and additional openings available to replace retiring workers.

The Bad
ASCP reports in its January 1 ePolicy News update that the University of Nevada, Las Vegas, is mulling the closure of its 20-year-old clinical science program—despite the program’s status as the only of its kind in the state, and despite graduates 100% success rate securing positions within three months. ASCP indicated that it planned to approach program administrators to “shed light on the laboratory workforce shortage.”

The Ugly
Unfortunately, the U.S. News & World Report article mentions lab technician opportunities in private diagnostic laboratories and physicians’ offices and fails to mention opportunities in public health.

Ditto for the entry on clinical laboratory technologists and technicians in the current edition of the Occupational Outlook Handbook put out by the U.S. Bureau of Labor Statistics.

The Scoop: Michael Taylor, FDA’s First Deputy Commissioner For Foods

By Nancy Maddox, MPH

The new Food and Drug Administration (FDA) post, deputy commissioner for foods (DCF), was created to help fulfill President Obama’s pledge to strengthen food safety in the wake of a number of multi-state outbreaks that have made Americans wary of the food-industrial complex.

According to an FDA press release, the deputy commissioner will:

• Help the agency plan and implement a “prevention-based strategy for food safety.”
• Implement new food safety legislation being crafted in Congress that will almost certainly expand FDA oversight authority.
• Ensure accurate nutritional information on food labels.

The first person to hold this post, Michael Taylor, has received mixed reviews from the blogosphere owing his industrial ties. Taylor has been in and out of government service, mixing work at the FDA and U.S. Department of Agriculture (USDA) with a “public policy” (a.k.a. lobbying) position at Monsanto, a position at a law firm representing Monsanto, a stint at a think tank (Resources for the Future) and a research and teaching position at the George Washington University (GWU) School of Public Health and Health Services.

The Washington Post reports that Taylor was responsible for unpopular federal safety regulations impacting producers of seafood, juices, meat and poultry. But during his FDA tenure, the agency approved Monsanto’s bovine growth hormone, declared that milk producers have no requirement to disclose BGH use, and issued a policy stating that genetically-engineered plant varieties (such as those produced by Monsanto) require no special agency oversight.

Most recently, as a senior FDA advisor, Taylor tried to ban the sale of warm-water oysters harvested between April and October, unless treated to kill Vibrio vulnificus. Faced with opposition from Sen. Mary Landrieu (D-LA) and others, the agency has agreed to postpone a ban and study the issue further.

Noted nutritionist Marion Nestle, a professor at New York University, considers Taylor a good choice. She points out that as head of the USDA Food Safety and Inspection Service, he required science-based hazard analysis and critical control point (HACCP) systems in every meat and poultry plant—a move that took “real courage.”

Nestle also applauds “Stronger Partnerships for Safer Food: An Agenda for Strengthening State and Local Roles in the Nation’s Food Safety System,” a report Taylor co-authored while at GWU in collaboration with the Association of Food and Drug Officials, the Association of State and Territorial Health Officials and the National Association of County and City Health Officials.

The report endorses many APHL food safety priorities, including implementation of guidelines produced by the Council to Improve Foodborne Outbreak Response (CIFOR), of which APHL is a member.

Among other things, the report calls for more uniform laboratory methods for food safety testing, increased funding for FoodNet, greater multi-disciplinary collaboration in food safety investigations and greater federal investment—specifically in the form of a food safety block grant and federal matching grant program—to build the capacity of state and local food safety programs and “foster improvement and innovation beyond base capacity building.”

APHL wishes the new commissioner the best of luck and looks forward to working with him to advance many of these goals.

Clinical Learning in a Virtual World

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

Take it with you! APHL’s Department of Continuing Education and Training has released an outstanding new online course in CD format entitled Red Blood Cell Morphology. The course can be used as a review for hematology technicians, clinical lab scientists, technologists and pathologists. To those new to the field, this course is an invaluable training tool in identification of normal and abnormal red blood cell morphology. In addition to course content, scenarios were developed to provide real-life simulations in a hematology lab setting. These 10 different scenarios include both case studies and bench work situations. Patient history and lab results are presented and the viewer can examine virtual blood smears for each activity. Several practice questions are provided for each scenario, challenging the learner’s comprehension. APHL CD format allows for training at the convenience of the laboratorian. This basic course offers 2 contact hours through the ASCLS P.A.C.E.® Continuing Education Program.

In addition to our On-Demand line up of programs, APHL strives to provide and encourage high quality Continuing Education and Training Programs using a variety of different presentation formats, including seminars, hands-on laboratory workshops, teleconferences and webconferences. Check out the link to APHL’s Featured Training and all our program offerings!

Why Don’t They Get It?

After having published a Lab Matters article about CDC’s “remarkable feat” in rolling out novel Influenza A H1N1 rapid test kits within three weeks of the first confirmed US cases last year, I was flummoxed to read in The Washington Post that the United States relies “on an outdated, slow method for diagnosing cases of H1N1” and “our diagnostic technologies are difficult, expensive and time-consuming.”

Who would make such a claim?

No less than former senators Bob Graham (D-FL) and Jim Talent (R-MO), co-chairs of the Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism. The pair go on to say, “The really bad news is that we are far more prepared to respond to a flu outbreak than to any other biological event. . . . For most new diseases, the response time would be more like six to nine years.”

Hello?

To get an expert take on the matter, I sent the editorial to one of the most knowledgeable people I know when it comes to H1N1 and other infectious pathogens: Pete Shult, head of the communicable disease division at the Wisconsin State Laboratory of Hygiene. After reading the piece, Pete used phrases such as “totally ridiculous,” “inflammatory” and “flat-out wrong.” Tough language coming from a lab denizen.

Being a thoughtful scientist, Pete was careful to acknowledge problems with vaccine production and to say, “I don’t think anybody would say the response was perfect.”

However, he rightly pointed out that new laboratory-based diagnostic technologies are not likely to be dramatically faster than those now in use and that past public health laboratory responses to emerging pathogens—such as West Nile virus and SARS—were on the order of weeks; not years. The response to monkeypox and the spinach-based E. coli outbreak in Wisconsin, Shult said, was mounted in “days to a couple of weeks.”

Moreover, Shult noted that the H1N1 pandemic has jump-started high-quality molecular testing in hospital labs, even smaller clinical labs in Wisconsin that—I quote—“I never would have guessed in a million years would be throwing themselves into molecular diagnostics.” All of this experience and technology dissemination put the nation on relatively firm footing for future infectious disease outbreaks or, heaven forbid, a bioterror attack.

So, my question to the public health laboratory community is this: What can we do to better publicize our success stories? Yes, public health programs generally—and public health laboratories in particular—are under-staffed, under-funded and in desperate need of better electronic messaging systems. But how can Graham and Talent be so far off the mark?

The Michigan Laboratory System Advisory Group Experience

By Patty Clark, M.P.H., Michigan Department of Community Health Bureau of Laboratories

The first meeting of the Michigan Laboratory System Advisory Group (LSAG) met in November, 2009. The LSAG was formed as a direct result of the Michigan Laboratory System Improvement Program (LSIP) held last March. The intent of the LSAG is to provide a forum where Lab System partners can meet, discuss issues affecting system partners, and participate in workgroups by interest and need to solve common problems. During the LSAG meeting, a brainstorming session created a list of areas where system partners felt there was need for improvement. The items on this list were prioritized by voting as high, medium, or low priority. At this point, system partners were asked for input as to how they would like to see the group move forward. Some partners voiced a concern that we had not captured all data from the original LSIP meeting in our priority voting and all were confused as to how to proceed. The intent to get buy-in from partners by involving them in the decision making process resulted in confusion and the inability to move the group forward. We ended the meeting assuring partners we would revisit the LSIP documentation, review the brainstorming and priority lists, and get back to them with a comprehensive list from both the LSIP and the LSAG. My suggestion for others planning such a meeting is to provide more direction and ask for opinions from the group rather than expecting the group to make decisions, at least in the initial meetings.

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.