Webcast Transcript
CDC Responds: Coping with Bioterrorism—The Role of the Laboratorian
(November 9, 2001)
(View the webcast on the University of North Carolina School of Public Health site.)
Segment 7 of 9
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Ms. Rayam:
Welcome back to “CDC Responds: Coping with Bioterrorism—The Role of the Laboratorian.”
In the first half of today’s videoconference, we heard about the
impact on the U.S. of recent bioterrorist events associated with
anthrax. We also heard about the Laboratory Response Network that
has been established to assure availability of appropriate testing
across the country, and we talked about the role of Level A laboratories
and how clinical laboratories in this country form the basis for
the Laboratory Response Network. Now we’d like to talk about some
real-life field experience, and we’ve invited Dr. Robert Martin,
director of the Division of Laboratory Systems at CDC; Dr. Susan
Sharp, director of the Clinical Microbiology Laboratory, Mt. Sinai
Medical Center and Miami Heart Institute; and Dr. Norman Crouch,
director of the Minnesota Public Health Laboratory, to talk about
their experiences with these events. When it comes to events like
these recent bioterrorism activities, we can understand how important
it is for clinical laboratories to interact and talk to their counterparts
in public health laboratories, to get information about how to deal
with new public health issues that are dependent on laboratory information.
Dr. Martin, welcome. I’d like to begin by asking you to explain
how the clinical laboratory and the public health laboratory normally
interact.
Dr. Robert Martin:
Thank you, Lisa. That’s a good question, and the answer
is somewhat dependent on the policies and practices that have been
established in each state. Let me give you an example. Our division
provides consultation services to public health laboratories across
the country, and I was recently working with the Department of Health
laboratory in New York City. It was gratifying to see that the public
health and clinical community in New York had established an advisory
council made up of the directors of hospital microbiology laboratories
around the city. In times of crisis, having venues like that for
discussion become even more important. Around the country, there
are some important efforts underway to help us address improvement
of collaborations and communications between clinical and public
health laboratories.
I’d like to call on Dr. Susan Sharp first to talk about the experiences
of a large clinical laboratory during these recent events, and then
ask Dr. Norman Crouch to talk about how the public health laboratory
is addressing these issues in Minnesota. Dr. Sharp, can you tell
us about your laboratory’s experiences during these events?
Dr. Susan Sharp:
Certainly, and thank you, Dr. Martin. Over the next few
minutes I’d like to try to give you an idea how the Level A laboratories
have viewed and dealt with the current anthrax crisis. And I’d like
to start by reviewing how the Level A laboratory in south Florida
handled the first inhalational anthrax case.
It was Tuesday, October 2, early in the morning. The onsite immediate
response laboratory of this Medical Center reports that they had
a spinal fluid that contained white blood cells and gram-positive
rods. The specimen was then sent to the main laboratory. About 10:00
that morning, the offsite main microbiology laboratory speaks to
the ER personnel to report that they had a Gram stain that was consistent
with Bacillus species which was nonmotile by wet prep of
the spinal fluid. About 11:00 that morning, an India ink preparation
was made from the spinal fluid, and it was determined at that point
the organism was negative for capsule formation. About 3:00 in the
afternoon, the isolate was already growing on a blood agar plate
and was shown to be nonhemolytic. The laboratory then mailed the
organism by overnight courier to the Jacksonville laboratory in
northern Florida.
On Wednesday, October 3, at 8:00 in the morning, the main microbiology
laboratory noted that central spores had formed in the organisms
that were growing on the culture plates. By 11:00 in the morning,
the Florida Department of Health had received the organism.
By the next day, Thursday, October 4, in the morning, the Florida
Department of Health reports to the CDC and the FBI that the definitive
tests confirm that the isolate was a Bacillus
anthracis. In the afternoon of October 4, the submitting laboratory
in south Florida finds out the identification of the organism from
a television news report.
So what worked in this scenario? The Level A laboratory response
was excellent in this case. The organism was identified as a possible
Bacillus species from the Gram stain the same day the spinal
fluid was submitted. The organism was shown to be nonmotile and
nonhemolytic, and at this point capsule-negative; again, the same
day the spinal fluid was submitted. The organism was forwarded to
a Level B laboratory the same day that the specimen was submitted.
And by the next day, the organism was found to form central spores.
Now, what didn’t work in this case? As you can see by this graphic,
the submitting laboratory was located just north of Miami in Fort
Lauderdale. They sent the organism by overnight courier to the Jacksonville
laboratory in north Florida, which was approximately 300 miles away.
Unbeknownst to this laboratory, there was yet another Level B laboratory
that was located in Miami, almost 25 miles to their south, so not
a very far distance away. They could have had the specimen to a
Level B laboratory one day sooner. This would have allowed for the
identification of the organism 24 hours sooner. So a recommendation
might be to have more visibility of our Level B and our Level C
laboratories. Also what didn’t work in this case is that the public
health officials did not report back to the submitting laboratory
the identification of the organism in a timely manner. The public
was informed of the confirmed anthrax case before the submitting
laboratory was informed. This caused somewhat of a loss of credibility
of the laboratory management staff with the technical people in
the laboratory. And the laboratory felt they were very needlessly
kept out of the loop by the public health officials. So another
recommendation would be to have more effective and timely reporting
back to the submitting laboratories.
A big concern at the Level A laboratories was with communications.
Level A laboratories were being inundated with telephone calls requesting
information. These calls would come from doctors, healthcare providers,
our medical center administrators as well as our security departments,
and a wealth of phone calls were also coming in to Level A laboratories
from the public. No information was forthcoming rapidly from the
public health sector to the Level A laboratories. Some information
may have been provided to infection control practitioners in our
institutions, but again, the laboratory felt they were left out
of the loop.
It was very difficult for Level A laboratories to initiate contact
with the public health sector. It was very difficult to actually
speak to a key person within the framework of the Laboratory Response
Network. Oftentimes no one answered the phone, and this was especially
a problem after hours and on weekends during this crisis. If you
did get through, oftentimes you got a voice mail, the voice mail
oftentimes was full, and you could not leave a message. If you were
able to get through and actually leave a message, very few of these
phone messages were actually returned in a timely manner.
And then, of course, there was the issue of the nasal swabs, which
we all had to deal with. We had no early guidance on whether Level
A laboratories should provide anthrax cultures from nasal swabs.
Again, as mentioned earlier, we know that the sensitivity and specificity
of this assay were unknown. We didn’t know whether people that were
possible exposures or the “worried well” should or should not be
cultured, but we did have doctors insisting that these cultures
be performed, and yet we had no ammunition from the public health
departments to try to deter this practice.
There was also sometimes contradictory information received from
the public health sector. The Department of Health would state,
for example, that nasal swabs should not be done, and then we would
hear from the local public health epidemiology department that if
a doctor orders a nasal swab, it should be performed at the Level
A laboratory. So another recommendation would be to expedite the
verbal communications coming from the Level A laboratories, and
perhaps designating personnel from the Level B, C, and D laboratories
for this purpose would be beneficial. In addition, more effective
information flow to all Level A laboratories is also necessary.
Another concern of the Level A laboratories is with education. We
need to ensure proper education of all Level A laboratory staff.
We need to procure funds for the education of the Level A laboratories,
which is crucial for the functioning of the Laboratory Response
Network. We need to promote the recognition of bioterrorism agents
in the Level A laboratories, perhaps by using avirulent strains
or perhaps strains that would mimic bioterrorism organisms in some
kind of a proficiency testing survey. So another recommendation
is to move forward with bioterrorism training for all Level A laboratory
personnel throughout the country.
Another Level A laboratory concern is with our participation with
the Level B laboratories. There have been reports that testing of
suspicious isolates may be taking too long at some Level B laboratories.
Some Level B laboratories, as we heard earlier, can become overburdened
by the amount of material that they’re receiving, which is an overwhelming
amount. Credibility could become an issue with the delay in the
testing of samples, and, lastly, but certainly not least, the public’s
health could be possibly compromised by prolonged turnaround times
of these test results. In our Level A laboratories, there is a wealth
of bioterrorism expertise that already exists. There are very qualified
and technically skilled individuals working within the confines
of the Level A laboratories, and the infrastructure also exists
to support working with the agents of bioterrorism in some of these
Level A facilities. The identification of individuals in the Level
A laboratories that are capable of training additional Level A laboratory
staff as well as assisting the public health system with the threats
of bioterrorism would be beneficial to the entire laboratory response
network. The laboratory response network is now several years old,
and its structure is currently in a state of flux and constantly
renewing itself. The laboratory response network may need to be
re-examined and perhaps retooled in light of the present circumstances.
So our final recommendation would be for more community laboratories
to be designated as B or perhaps a new level of designation of AB.
These would be community laboratories that would have the training
and the expertise to assist the Level B laboratories when the need
would arise in functioning in a bioterrorism crisis.
So, in summary, there are three recommendations: first and foremost
is communication from the top down to the Level A laboratories,
we must have communications. We also need to have effective ways
for the Level A laboratory to communicate back to the public health
sector. Secondly is education. We need to have education for all
personnel working in the Level A laboratories, and I’m happy to
report that the National Laboratory Training Network has plans to
more aggressively pursue this training in the future. And last would
be the participation of selected Level A laboratories with the public
health system to assist with the burden of bioterrorism during a
crisis situation. Thank you.
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