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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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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