Three years ago this April, Mexico health officials reported the first cases of H1N1 influenza to the World Health Organization, and in the United States, public health officials announced that seven people in Texas and California have been diagnosed with H1N1. Shortly after, health officials across the globe were on alert for a flu virus feared to have pandemic potential. Behind the scenes, public health laboratories and their highly skilled workers were furiously working to stay one step ahead of the virus and provide the critical information health officials needed to control its spread and put precautionary measures in place.
The H1N1 outbreak is just one example of the vital role public health labs play in keeping people healthy, preventing disease and detecting new and emerging threats. Below, Public Health Newswire talks with Scott Becker, MS, executive director of the Association of Public Health Laboratories (APHL), about the vital services labs provide, the challenges they face and why he became an outspoken advocate for the oft-invisible world of public health labs.
Q: Most people, even some public health practitioners, are unfamiliar with the work of public health laboratories. Can you put in context the wealth of services that such labs provide and how their work is directly linked to protecting people’s health?
Public health laboratories often operate in the background, so it is not surprising that a person would be unfamiliar with their work. They often interact with specimens more often than with people; that’s the nature of what they do. But every specimen tells a story.
Public health laboratories test for agents of infectious disease; detect food-borne illness; assess biothreats; test water, soil and air for toxins; screen 97 percent of all newborn babies for severe disorders; participate in PulseNet, a nationwide database that allows laboratories to rapidly detect food-borne clusters; and serve as the state’s reference lab — that is, when a clinical laboratory has a hard time determining what a bug is, they often engage the public health laboratory’s expertise to determine a diagnosis. In every example I just mentioned, a lab’s work is linked to protecting people’s health.
Q: Three years ago this month, the World Health Organization declared the 2009 H1N1 flu outbreak a public health emergency of international concern. Take us back to the early days of that outbreak. How did our nation’s public health labs respond?
The early days were admittedly chaotic. The scope of the outbreak was unclear. Based on the information from Mexico and what was occurring in Texas, it was quite chaotic. It was beneficial that we had been working with the Influenza Division at the Centers for Disease Control and Prevention for five years — we already had a plan. Most importantly, we had a five-target assay designed for seasonal flu surveillance with a focus on detecting novel viruses that was already cleared by the U.S. Food and Drug Administration.
CDC was able to quickly modify the assay (an investigative procedure) and deploy it to public health laboratories for use so we could determine the scope of the outbreak in each community. The fact that FDA provided emergency use authorization (initially it was only for the public health laboratories, but it was later expanded) was a life-saver. Not only was this a good example of FDA’s modernization of regulatory science, it was also good common sense.
I feel strongly that the public health laboratories responded quite well. They were able to communicate effectively with in-state epidemiology partners, the clinical lab community and with CDC. APHL coordinated 50-state conference calls on a routine basis as well as participated in numerous national coordinated response efforts. We even operated two emergency operations centers during the event, one at our main offices and one on-site during our annual meeting in Anchorage, Alaska. It felt like we were working 20 hours a day and the sun pretty much never set on this response (because, in Alaska, it didn’t!).
Q: Are public health labs better prepared for such an event today?
Yes — because we take very seriously the concept of after-actions.
APHL brought together experts from the field and looked at all of the areas in which public health laboratories touched the pandemic. In 2010, we published “Lessons from a Virus,” which collects all of the knowledge gained from that experience so others can benefit from it in the future.
We are also sponsoring the Right Size Influenza Virologic Surveillance Project to answer the question of how much flu surveillance is necessary. Implementation of right-size surveillance guidelines will assist CDC and public health laboratories to maximize resources, and redirect and build new capacity as needed for optimal surveillance. It will be extremely useful for future pandemic planning and response.
Q: What makes sustaining public health laboratory capacity particularly challenging? Work force issues? Keeping up with technological advances?
We, along with everyone else in public health, face workforce challenges. Public health laboratories hire scientists from many different fields. Our unique challenge is that there is no one source for new lab scientists. We don’t have a one-stop-shop, so to speak. It is an ongoing challenge.
Another challenge is maintaining a source of financial support. We all know that states are suffering from the economic downturn. Deep budget cuts have affected laboratories’ resilience and led to reduced testing capacity, termination of certain types of tests, and in some cases, impaired support to outbreak investigation, surveillance and emergency response. In order to address this, APHL and CDC have launched the Laboratory Efficiencies Initiative (LEI). The LEI will help public health laboratories fully implement and maintain efficient management practices despite the challenges they are all facing. President Obama’s 2013 budget included $20 million for LEI via the Affordable Care Act’s Prevention and Public Health Fund.
Another major challenge is keeping up with technology. Right now, there are new technologies available or coming soon to market that show great promise for public health laboratories. However, new technology may also present new challenges.
For example, there are exciting advances in bioinformatics, but many are beyond the capabilities of a public health laboratory. Another example is the growing use of culture-independent diagnostics; while there are many clinical benefits to this technology, it would mean that there wouldn’t be samples to send to public health laboratories for characterization and typing, which presents a number of challenges in outbreak detection.
Q: Public health labs are central to the nation’s prevention efforts. For example, such labs screen for a variety of health disorders for nearly all babies born in the United States and provide doctors with the information they need to prevent serious health complications and even death. Can you provide more examples of how investing in public health lab capacity is saving significant health care dollars?
In public health, early detection is prevention. Early detection prevents needless illnesses and deaths and it saves money in terms of medical costs and hospitalizations. If we can detect an outbreak of any kind early, we can quickly put interventions in place to stop it.
CDC estimates that 48 million people are sickened and 3,000 people die from food-borne illnesses each year. To rapidly detect food-borne outbreaks, public health laboratories participate in the national molecular subtyping network called PulseNet. PulseNet allows scientists across the country to compare the DNA fingerprints of bacteria from sick people to determine if they might have become sick by eating the same product. It is invaluable to detection and ultimately prevention.
Here are a couple more examples:
— Newborn screening saves lives. That is detection-as-prevention at its best. Every baby born in the United States is screened for a panel of extremely dangerous disorders that are life-threatening or can cause irreversible debilitation. However, the disorders are all treatable in some form — some can be cured, some require a special diet, but all can be treated if detected early. Public health laboratories conduct 97 percent of those tests.
— The Laboratory Response Network is an integrated network of public and private laboratories. It is equipped to respond to acts of biological or chemical terrorism, emerging infectious disease, natural disasters and other public health threats. Needless to say, having the network in place prevents a very expensive response and potential clean up.
There are countless more examples of public health laboratories keeping Americans safe, thus reducing health care costs — from detecting dangerous contaminants in the environment so they can be removed to monitoring emerging infectious diseases. As I mentioned, in public health, detection is a key part of prevention.
Q: How is the Association of Public Health Laboratories working to shore up lab capacity in developing countries? And how is this work connected to protecting the health of residents here in the United States?
Global health is built into APHL’s DNA. People who work in public health immediately see the value in contributing across the globe because it contributes back to the health of Americans.
APHL’s global health team works in 21 nations with funding from the President’s Emergency Plan for AIDS Relief. In order to help build a laboratory system that meets their needs, we focus on training, leadership development, and recruitment and retention of a competent workforce in each country.
We also participate in the World Health Organization’s Laboratory Twinning Initiative, a project that pairs “expert” laboratories with those in developing nations to improve laboratory practice. There are currently three APHL member laboratories matched with national laboratories in developing countries, and projects are in the planning stage for Mexico and Paraguay.
Another shining example for us is the International Institute for Public Health Laboratory Management held with the George Washington University, a program designed to build a team of senior laboratory professionals who can lead the development of public health laboratory systems in resource-poor countries. The institute has been held for five years and has had 140 graduates. Laboratory leadership is laboratory leadership no matter which country or system you are working in.
And our annual meeting this year will focus on the “One World One Health” theme — the idea that everyone is only one plane ride away from the next big outbreak.
We’re not in this to provide an American model to labs around the world. We’re in this to provide resource-poor countries with a laboratory system that meets their needs. Our members always come back from an assignment energized; we always leave events with smiles on our faces.
Q: On a personal note, what makes you such a passionate advocate for public health laboratories?
That’s easy — what public health laboratories do impacts every single American. Though not formally trained in public health, I have found a home here thanks to the guidance of my many public health heroes. It is my job to do whatever I can to help and support the public health heroes in lab coats. The work that they do impacts me and my family, and you and your family, everyday, everywhere.
To learn more about the work of public health labs, visit www.aphl.org.
Photo of public health lab technician by Jim Gathany, courtesy CDC Public Health Image Library
