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.)

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Dr. Martin:
Thank you very much, Susan, for sharing that information with us. That was really important information from practical field experiences. Norman, what I would like to do now is as you to talk about one of the more important issues that we’ve heard here and that is issues related to communication. Oftentimes we hear a lot about technology and the importance of implementing technology, but we’ve also heard here today that communication issues are critical for the public and federal laboratories to relate to the hospital laboratories. Can you describe some of your recent experiences and what steps have been taken in Minnesota to address those issues described by Dr. Sharp, including what you’re doing about improving communications between public and private laboratories?

Dr. Norman Crouch:
Yes, thank you, Dr. Martin. I’d be glad to. Let me point out first, however, that each of the 50 state public health laboratories is a Level B facility, either for all the agents or at least for some of the agents. Some of these are actually level C laboratories and as such, it’s very important that each of the state public health laboratories realize that they have a very essential role to play in the laboratory training network.

On my first slide, I want to talk about some of the kinds of materials that we get in the state laboratory to test, as I want to point out that the public health laboratory, its main role, or one of its main roles, is to confirm the existence of a bioterrorism agent in materials that come into the laboratory. The referred isolates are isolates that we receive from clinical laboratories, the Level A laboratories, where they have isolated an organism that they cannot rule out as a contaminant. So it’s sent to our laboratory to determine if it is in fact a bioterrorism agent. We also get environmental samples, and the environmental samples are generally brought the state laboratory by public safety. This can be the fire or police personnel or it can be other federal agencies. We get also powders to test for anthrax spores; certainly the last few weeks this has been a real concern. And I want to point out, again, it’s been mentioned before, that these are potentially very dangerous materials, and they should not be handled in Level A laboratories. It’s required, or it’s certainly recommended, that these only be handled where there are BSL-3 conditions.

Finally, the clinical specimens that we receive in the Level B laboratory or the state laboratory are materials that are sent to us directly for diagnostic testing. And this happens when we have an outbreak, if we have a concern about bioterrorism, or actually there are patients who are becoming ill. This certainly has not happened to a large extent in this current situation, but if a major attack would occur. These are specimens that are not sent to the Level A laboratory, but they’re sent directly to the state laboratory for confirmation and testing for diagnostic purposes.

On this next slide, I want to point out that the state laboratory really plays a pivotal role in the LRN. It, on the one hand, works closely with the Level A laboratories, and, on the other hand, it works directly with the CDC to implement federal recommendations for laboratory practices, and also to implement new methods that are being brought to us from the CDC and their research laboratories. As shown on this slide, the role of the state lab is to first of all confirm suspicious isolates found by the Level A labs in their communities. This is a very important role, of course, for the Level A laboratories. In doing so, the public health laboratory is responsible for accurate and timely reporting of the test results, and they provide this data to the public health officials, and this assures rapid intervention and prevention—for prevention and control. And as Dr. Sharp pointed out, it becomes very important that we not only report to our own—within our own health department but we also need to report back to the Level A laboratories what we have found in our confirmations investigations.

A second part of what the state laboratory does, in addition to testing, is to provide information and guidelines to the Level A laboratories. In Minnesota, we provide the Level A laboratories with community alerts to keep them up to date on what is happening in the community, and particularly what is necessary for them to know regarding laboratory testing. We provide them with technical information, and we provide them with assistance that they may need to have to decide what kind of required actions they might need to take. If a laboratory in the Level A category, the clinical laboratory, has any questions, they should call the state laboratory to get assistance.

Another area of the state laboratory is to effectively facilitate communication. As Dr. Sharp mentioned, communication is really a very key component here. If we’re going to have a network where we interact between public health laboratories, state laboratories and the clinical laboratories out there on the front line, we have to have excellent communications. It has to be between the state laboratory and the clinical laboratories. It also has to be clearly a good communication between the state laboratory and the CDC. The state laboratories have a key role in developing a strong intrastate network between the clinical and public health laboratories. This is what we really are trying to do in Minnesota, is to try to establish an integrated network to make this work well.

These are the key elements that I put on this slide that I think are important in developing this kind of interactive intrastate interaction and laboratory system. In our state, we are trying to address each of these. The first is a statewide database. We’re trying to build this through a comprehensive survey being done with all of our Level A laboratories in the state.

Secondly, we’re trying to develop a communications system that is multifaceted and also very robust, and we’re trying to develop a courier system. This is a continual problem state laboratories, to develop a courier system that is reliable, that transports materials and samples and referral isolates and such from Level A laboratories to the public health laboratory.

And finally, we’re working hard to develop a surge capacity plan. If we’re faced with a situation where we have a major attack, it’s going to be very important to have something in place to be able to deal with this. We can’t do it retrospectively, but we really need to take proactive action. Now, I’d like to discuss each of these separately.

First of all, Minnesota is developing a comprehensive statewide database of all the Level A laboratories in the state, and that includes all of our clinical as well as public health laboratories other than the state laboratory. The first part of this is to develop lab contact information. We need to know who are the key contact persons in each lab, their phone, their e-mail, and their fax numbers and also, if it’s very important (I think Dr. Sharp mentioned this) that the Level A laboratories also need to have this kind of information. They need to have phone numbers of people to contact at the state laboratories so when there are questions or concerns or an emergency, they know where to go. So in Minnesota what we’ve done is we’ve provided a laminated list of key phone numbers and key personnel to all of our Level A laboratories so that they know where to call.

A second part of this is personnel experience in the statewide database. We want to know what is the level of staff training in these laboratories in the state and what kind of technical expertise is available. As Dr. Sharp mentioned, there’s a lot of technical expertise in these clinical laboratories. It’s important for the state laboratory to know what these are and where they are. Laboratory capability and capacity is another important item. What is the technical capability of the various clinical laboratories? And what are the lab’s capacities to increase this activity in case we would have a situation where there is a need for expanding our surge capacity, and, finally, our communication capability, and that’s the kingpin that we’ve talked about here. We need to find out what our clinical labs—what is their capability to communicate with the state lab? Do they have access to the Internet? Do they have e-mail? Do they have fax capabilities? And it’s not always the case, and we need to know that and add that into our database.

Secondly, we’re developing in Minnesota an effective communications system between all of the clinical laboratories and the state laboratory. First of all, we are trying to develop very broad-based e-mail and broadcast fax capability. We want to be able to reach all of the Level A laboratories, and in doing so not just getting the information out there and wondering if it actually got to these laboratories, but having a way of knowing whether this communication has really reached all of the laboratories that we’re trying to reach.

A second part of this is the Health Alert Network. Now, the Health Alert Network is not part of the LRN, this is separate, but we are using this in Minnesota, because we do have a robust Health Alert Network, and we’re trying to use this as also a way to communicate with our clinical laboratories. The Health Alert Network was originally set up to provide electronic communication infrastructure between the state health departments and all of the local public health agencies. But we have found that we can add on to this group, the public health and the clinical laboratories in the state, which will then provide us with an ability to provide them with clear, short laboratory alert messages and concise information and recommendations, and it really will facilitate our ability to communicate, Another part of this, and linked to the Health Alert Network, is the use of a secure Web site so that we can put on this Web site, password-protected essential information that we might need to get out to the laboratories.

And finally, active surveillance. I want to just give you an example of active surveillance that we’ve put in place using this kind of communication network in Minnesota. With the situation that is occurring, we are now in a situation where we have active surveillance for gram-positive rods in Minnesota. And we are sending out a message every morning to all of these clinical laboratories to ask them to report back immediately, to find out if they have isolated any gram-positive rods that might be contaminants or they might in fact be isolates of Bacillus anthracis. We are doing this in a way that we can get a quick request out there and a quick reply back. We hope it’s meaningful, and we hope it also will become habit forming. I say habit forming not in jest, but I think that’s what we’re faced with. We need to develop communication systems that are routine and every day; there’s an expectation of communication.
Next is the reliable courier system. In Minnesota, we’re trying to establish a reliable courier system between the Level A laboratories and the state. And this is essential for the network, but there are problems with the current system, and this is probably the case in most states. One of the problems is the scheduled transport. When we try to rely on scheduled transport where a clinic may have a pick up early in the morning, and if we miss that we might have to wait another day before we can get the material we need, it may cause delay if the pick up is missed, so we need to have some kind of on call backup in place.

Another problem is remote out-of-state services. In the rural areas it’s very problematic to getting access minimums and such to the state laboratory. This can cause significant delays and specimen compromise if there are extended delays.

Finally, multiple couriers per sample. In some of the situations, particularly remote areas, couriers pass off a sample from one to the other, and samples can get lost and also samples can be delayed in getting to the state laboratory. What is needed is a well-defined courier system that will ensure delivery at any time. Finally, we’re putting into place a surge plan so that the state laboratory can quickly expand its capacity to handle an extremely large volume of testing.

The development of this plan hinges on what I’ve just talked about: a statewide database, having a statewide database, having an effective communication system, and also having a reliable courier system. We’re interested in looking at facilities. The state lab might not have enough space to conduct all the necessary testing. We need to prearrange this. Confirmatory testing might be delayed. We need to have prearranged ability to utilize appropriate additional laboratories, either Level A or extending some of the Level A to Level B capabilities. Personnel recruitment, we need to have in place the ability to recruit additional staff. We might have space but might not have the staff to do all the testing.

Emergency training—If we’re going to recruit additional staff from other places, we need to be able to train them quickly. We’re preparing a CD-ROM for this purpose and also developing a rapid training format.

And, finally, reagent distribution. If there would be a surge, would need to be able to contact the CDC to acquire additional reagents that might be necessary for dealing with the surge. Finally, from the state laboratory perspective, at least the one I’m talking from, the LRN is becoming a very powerful network, but there still remain some challenges. One of these challenges is the communication capabilities. What we have found in Minnesota, that the clinical laboratories vary greatly in their communication ability. Some differ markedly. And so we have to try to link all of the laboratories in a way that we can really completely build this robust communications system.

Another problem with is with out-of-state laboratories. Many clinical laboratories submit specimens that go out of state to these large commercial laboratories, which do an excellent job, and these are actually Level A laboratories, but we have a problem with a loss of the rule-in isolates. If they find what they consider to be a contaminant, it’s not sent to the state laboratory for further analysis. And so we need to correct that by developing a relationship with these large commercial laboratories. And finally, sustained collaboration. In order to have a laboratory network where we have an integrated system of the public health laboratories and the clinical laboratories, we have to work on a system that we can sustain. And I think one way to do that is to develop the laboratory, the national laboratory system where we have a system where we have an integration of the clinical laboratories in the state with the public health laboratories so that we can meet the needs of an attack that might be perpetrated upon our country. Thank you.

Dr. Martin:
Well, thank you very much, Norm.

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