New lab informatics courses introduce basics to non-specialists  

New lab informatics courses introduce basics to non-specialists |

Two online laboratory informatics courses now on the CDC TRAIN site help laboratory staff to understand how their jobs relate to their laboratory’s informatics system. Developed by APHL and the Centers for Disease Control and Prevention (CDC) in collaboration with the APHL Informatics Committee and members of the target audience, the courses follow a TB specimen as it advances through testing and reporting to inform decisions by clinical care providers and public health agencies.

Historically the term “informatics” evoked fear among laboratory staff who avoided the unfamiliar discipline. Responsibility for the function often devolved to one person who became the de facto informatician more by accident than by intent. When the new skill set proved highly marketable, this individual often departed for new opportunities, leaving the laboratory with no one who could distinguish between LOINC and SNOMED codes, much less maintain the Laboratory Information Management System.

But times have changed. With electronic data now integral to work at both private and public sector laboratories, all staff require a basic knowledge of informatics. With an understanding of how the data they touch flows in and out of their facility, staff can improve the quality and speed of laboratory operations and, ultimately, patient treatment and disease control.

The two online courses, Life of a Specimen and Life of a Result, trace the testing and reporting process in plain language, explaining who comes into contact with the specimen at each point, when errors are most likely to occur and how to avoid them, and how a specimen becomes a result and is reported to stakeholders. Both courses offer P.A.C.E.® credits. Visit CDC TRAIN to register.


  • Life of a Specimen introduces staff roles in laboratory informatics, data relationships, data quality and standards, and the generation and flow of information as a specimen progresses through the pre-analytic, analytic and post-analytic phases.
  • Life of a Result examines how data and information move through and outside the laboratory to impact clinical care and public health decision making.  It covers the recipients of laboratory data, data and results storage, and communication of data and results to stakeholders.

The two courses would be a valuable addition to staff onboarding programs at laboratories of all types. Keith Higginbotham, IT systems manager at the Alabama Department of Public Health, laments that such training was not available earlier in his career:

“I wish I’d had access to this training when I was first starting out. It condenses a year’s worth of knowledge into a few hours, giving lab staff from all backgrounds a real head start. Those in leadership can become stronger advocates for their labs by better understanding their informatics needs and capabilities.”

A third course, which takes the student on a deeper journey into Laboratory Information Management Systems (LIMS), is in production and slated for release in 2019.

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Lab Culture Ep. 17: Exploring bioinformatics: From fellow to full time in Virginia

Lab Culture Ep. 17: Exploring bioinformatics: From fellow to full time in Virginia |

Kevin Libuit went from the APHL-CDC Bioinformatics Fellowship to a contractor to working full-time as a bioinformatician at the Virginia state lab (VA Division of Consolidated Laboratory Services (DCLS)). First he talks about when he discovered bioinformatics as a field and how the fellowship propelled his career. Then Kevin takes the mic and interviews Dr. Denise Toney, director of Virginia DCLS, about the value and growing need for bioinformaticians in public health labs.



Kevin G. Libuit, M.S.
Bioinformatics Lead Scientist, Division of Consolidated Laboratory Services (DCLS), Virginia Department of General Services

Denise Toney, PhD
Director, Division of Consolidated Laboratory Services (DCLS), Virginia Department of General Services


APHL-CDC Fellowships

APHL-CDC Bioinformatics Fellowships

Virginia Division of Consolidated Laboratory Services (DCLS)

APHL Off the Bench (new Facebook group!)


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Pandemic preparedness has been a boon for US flu surveillance, but it won’t maintain itself

Pandemic preparedness has been a boon for US flu surveillance, but it won’t maintain itself. |

by Kim Krisberg

At the peak of the 2009 H1N1 flu pandemic, the Wisconsin state public health lab was routinely testing up to 300 specimens every day. On one day, the lab hit a record of nearly 500.

To generate results within 24 hours of receiving a specimen and keep up with its duties outside of flu surveillance, the lab added a second shift of flu testing on the weekdays and worked through the weekends. H1N1 definitely stressed the lab’s capacities, said Peter Shult, PhD, associate director of the Wisconsin State Laboratory of Hygiene, but it also demonstrated the value of years of investing in pandemic preparedness and response. In fact, Shult said that if the lab had received 300 flu specimens in a day only a few years before the H1N1 pandemic, “we’d have been backlogged immediately — it would have taken us weeks to catch up.”

As one might expect, years of preparing for another worldwide flu pandemic has also boosted the lab’s seasonal flu response. During the 2017-2018 flu season — one of the most severe in recent memory with an estimated 80,000 U.S. deaths — Shult said the Wisconsin lab was easily able to keep pace with a surge in testing demands, which while much lower than peak pandemic levels, were still about 30% higher than the average flu season.

“We were busy, but we could comfortably handle the specimen load without expanding testing hours or impacting turnaround times, and we could still carry out all of our other routine testing responsibilities,” said Shult, who also serves as director of the lab’s Communicable Disease Division. “All that speaks to the capacity we’ve developed regarding testing platforms and our staff being able to do this flu testing. …But funding is still needed to maintain this kind of capacity.”

That capacity building goes back more than 20 years when global health officials detected the first human infections of H5N1 avian influenza; a few years later in 2003, the virus re-emerged, spreading from Asia to Europe and Africa. While the virus very rarely spread from person to person, fears that H5N1, which has a mortality rate of about 60%, could evolve to easily transmit between people sparked a new chapter of pandemic preparedness that included billions in federal funding support and a key focus on improving flu surveillance and detection. By the time H1N1 hit in 2009, public health labs had transformed their flu capacities.

Just a few years before the H1N1 pandemic, for example, most public health labs relied on the traditional viral culture to gather data on the flu. Viral cell culture is a reliable way to identify flu strains and monitor which antivirals work best to treat infections, but getting results can take more than a week, which is hardly ideal in any disease outbreak, let alone a flu pandemic. By 2009, however, most labs had built the capacity to use and quickly deploy highly sensitive molecular assays — in particular, a technique known as real-time reverse transcription-polymerase chain reaction (RT-PCR) — that could turnaround flu results in less than a workday.

With a week shaved off testing times, as well as years of cross-training and drilling lab staff in pandemic response, it’s little surprise that investments in pandemic preparedness have also been a boon for seasonal flu surveillance.

“The last flu season was a high-volume one for public health labs, but it was also considered business as usual at this point,” said Stephanie Chester, MS, manager of APHL’s Respiratory Disease Program. “That’s a capacity that labs had been working toward for years, but you do need to maintain that warm base. If funding went down, it could certainly erode that capacity.”

In New Hampshire, the state public health lab tested more than 4,000 flu specimens during the 2009 pandemic. During a more typical year, it tests between 300 and 500 flu specimens from sentinel sites across the state, such as hospital labs and long-term care facilities, according to Carol Loring, MS, supervisor for the Virology and STD Laboratory at the New Hampshire Department of Health and Human Services’ Public Health Laboratories. Compared to clinical flu testing, which typically determines if a patient has influenza A or B, the state lab performs genotyping and subtyping to identify the specific strains circulating in the community, including potential pandemic strains, and to help monitor the effectiveness of each year’s flu vaccine. All that data, Loring said, helps clinicians make better diagnostic and prescribing decisions and helps public health workers more precisely target their prevention resources.

During the 2017-2018 flu season, Loring said the lab didn’t experience a significant increase in testing volumes, but it was prepared to face a surge.

“In my experience, our surge capacities evolve with each event,” she said. “We’re constantly training, drilling and preparing for the next pandemic.”

Loring noted that routine flu surveillance isn’t especially different from pandemic response — “the day-to-day tasks are the same, the only difference often is that there’s less interest from the public,” she said. Still, both capacities are heavily reliant on funding from CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), which is scheduled to begin a new five-year funding cycle in August 2019. A substantial portion of ELC funding, about $40 million a year comes from the Affordable Care Act’s Prevention and Public Health Fund, which the law established as the nation’s first mandatory funding stream dedicated to improving the public health system. If the ACA were repealed and those funds not replaced, it would be a major blow to the country’s flu surveillance system.

Inside the New Hampshire state lab, Loring said at least two instruments that the lab needs to perform nucleic acid extraction, a key step in the RT-PCR process, are slated for retirement by their manufacturers in the next few years. Replacement costs could run up to $100,000 and that’s just for the initial purchase, not the costs of regular maintenance.

“ELC funding is critical to enable us to purchase instruments,” she said. “If I don’t have the financial resources to maintain our instrumentation or update it, we’ll be that much less prepared for a pandemic.”

Also on Loring’s lab wish list: its own courier system for getting flu specimens into the lab. Right now, the lab depends on its clinical partners across the state to send in specimens for surveillance. Some send in their samples via US mail, others use courier services and some drive their samples over and drop them off. The hodgepodge of delivery methods makes it hard to predict when specimens will show up, and many don’t arrive within the recommended three days of being collected.

“A better specimen transport system would definitely help improve our efforts,” Loring said.

In Wisconsin, the state’s public health lab is also one of the country’s three National Influenza Reference Centers (NIRCs), which serve as extensions of the CDC Influenza Division’s Virology, Surveillance and Diagnosis Branch and allow the federal agency to focus on more advanced testing and global flu monitoring. As a state lab, the Wisconsin State Laboratory of Hygiene subtypes every flu specimen it receives, testing samples for flu as well as 18 other respiratory pathogens. As a NIRC, the flu specimens it receives from around the country have already been subtyped ; the center’s job is to conduct genetic sequencing and grow the specimen up with the traditional viral culture. The sequencing, in particular, is key to detecting signs of evolving genetic change and antiviral resistance.

Data generated by public health laboratory testing helps form the basis of CDC’s FluView, the agency’s weekly flu surveillance report. Data and specimens coming out of the three NIRCs — also located in New York and California — go onto CDC for additional study, inclusion in FluView and are fundamental to planning each year’s flu vaccine composition.

Shult, the Wisconsin lab’s associate director, said it’s critical to maintain the ability to quickly detect both novel and seasonal flu viruses across the public health system if responders hope to stay one step ahead of a potential outbreak.

“In 2009, H1N1 went across the country and the globe in a matter of weeks,” he said. “That’s how quickly a novel virus can emerge and spread globally.”

In 2009, at the peak of the pandemic’s first wave, the Wisconsin lab was routinely testing up to 300 specimens a day; in a more typical flu season, it receives a couple-hundred of specimens in a week. In the early days of the pandemic, the lab was the only one in the state that could perform real-time RT-PCR on H1N1 samples. Now, Shult said nearly 50 labs in the state use real-time RT-PCR in their flu testing.

“It was game-changing in terms of how we were able to respond,” said Shult of the shift to RT-PCR. “The results were reliable and the turnaround time was remarkably quicker. …If we had received 400 specimens in a day (like we did in the H1N1 pandemic) and we were still depending on viral culture, we’d have been immediately behind.”

To further illustrate how far flu surveillance has come, Shult noted that only about 15 years ago — before the influxes of federal pandemic and preparedness funds — a flu season as severe as the 2017-2018 one would have significantly strained the lab’s capacities. Instead, Shult said the Wisconsin lab was “able to take on a season like the past one more or less in stride.”

Like his colleague in New Hampshire, Shult is concerned about sufficient federal funding to both preserve the country’s investment in flu surveillance and response and ready the system for the future.

“We’ve had a lot of funding to build this capability and capacity, and slightly less funding to maintain it,” he said. “We have staff to pay and train, we have equipment that ages out and needs maintenance … there are considerable ongoing costs.”

Shult’s laboratory wish list? Enough funding to keep getting better and faster at chasing the flu.

“My wish is having enough dollars to maintain what we’ve built and keep on top of new technologies that will help us respond even quicker,” he said. “Right now, if we were to face a severe pandemic, we’d be stressed but we’d still be in the game. But if funding were severely cut? Then we’d be in trouble.”


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New Lab Matters: Time to welcome the next generation of public health laboratory scientists

New Lab Matters: Time to welcome the next generation of public health laboratory scientists |

The Bureau of Labor Statistics estimates that 12,000 new laboratory professionals are needed each year to meet consumer demand. At the same time, while automation has eliminated some less-skilled laboratory jobs, the growing sophistication of public health laboratory analyses has generated demand for scientists with highly specialized training. As our feature article shows, laboratories are recruiting new talent for the “hidden profession” by taking a hard look into what they really want, and how they want to work.

Here are just a few of this issue’s highlights:

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Lab Culture: Introducing PKU Life Podcast with Kevin Alexander

Introducing: PKU Life Podcast with Kevin Alexander |

Fifty-five years ago, newborn screening was born. At the time, though, that little heel prick was performed to screen for only one condition: phenylketonuria (PKU). Without early intervention, babies born with PKU faced severe cognitive, behavioral and other neurological disorders. The advent of PKU newborn screening allowed health care providers and families to make critical changes to a baby’s diet to prevent those consequences.

TIntroducing: PKU Life Podcast with Kevin Alexander | www.APHLblog.orgoday, December 3, is PKU Awareness Day. It’s hard to say where newborn screening would be without that first PKU test. And 55 years later, it’s hard to say where newborn screening would be without the families and individuals living with PKU who have shared their stories to convey the value of this simple test. One of those individuals is Kevin Alexander.

Kevin has been a leader in the PKU community simply by sharing his story and his experiences living with PKU. He has spoken at conferences and events around the world, created a video documentary about his life, served as a leader and friend to others living with PKU, and now he shares his voice in a new podcast.

For this PKU Awareness Day, we are sharing Kevin’s podcast, PKU Life Podcast with Kevin Alexander. We are so appreciative of Kevin’s willingness to both share with and listen to those in the newborn screening community. Kevin, thank you for your leadership, friendship and generosity!

Listen here or subscribe wherever you listen to podcasts:


PKU Life Podcast with Kevin Alexander – Facebook

PKU Life Podcast with Kevin Alexander – Instagram

PKU Life Podcast with Kevin Alexander – Twitter

APHL’s Newborn Screening Program

APHL blog posts about PKU

PKU Awareness Day

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5 most unexpected and unique partnerships forged through the Zika response

Top 5 most unexpected and unique partnerships forged through the Zika response |

By Kelly Wroblewski, director, infectious disease, APHL

While the US public health system has been through a number of infectious disease responses in the last decade, the Zika response was unique in both its duration and complexity. For more than 20 months (January 22, 2016 – September 29, 2017), CDC’s Emergency Operations Center was activated to respond to the US’s largest Zika virus outbreak. State and local public health departments began their responses as early as November 2015 and continue to respond today. Through the uncertainty, public health built relationships with new partners and found opportunities for unique collaborations with old partners.

APHL explores the journey in detail in our new book, A Complex Virus, A Coordinated Response: Public Health Laboratories Battle Zika. For APHL and public health laboratories, five unique and unexpected partnerships forged during the Zika response proved critical to progress on this journey. Learn about them below:

1. Vector Control

Vector control is, of course, a time-honored, if underappreciated, public health partner; after all, CDC was established in the 1940s in response to malaria. The Zika response reinvigorated those relationships as public health laboratories and vector control programs worked together on the best methods and approaches for vector surveillance (i.e., testing vectors to see if the pathogen is present) and insecticide resistance testing (testing insects to determine which sprays will be most effective). Once local transmission occurred in Florida and Texas, vector control relied on public health laboratory test results to focus mosquito control efforts on the areas where transmission was most likely to occur.

2. Maternal and Child Health and OB/GYNs

While public health laboratories may connect with maternal and child health departments for other types of testing like newborn screening, it is unusual for these groups of public health professionals to work together in response to an emerging infectious disease. Many OB/GYNs treating patients concerned about their risk of Zika infection and exposure were used to working with clinical and commercial laboratories for prenatal testing, but had never ordered a test at a public health lab. Public health labs across the country worked with their maternal and child health counterparts to ensure they had the most up-to -date information on accessing testing, knew how to correctly complete test request forms and could interpret test results to pass along to appropriate healthcare providers.

3. Commercial Laboratories

At public health laboratories, Zika testing represented a massive increase in workload. Beyond demand from patients worried about their exposure, there were multiple new tests to validate, different tests required for different patient populations and often a single specimen from which multiple laboratories needed to conduct multiple tests. In April 2016, commercial laboratories began performing Zika testing, thus distributing some of the specimen volume, taking some of the load off public health labs and offering OB/GYNs access to testing from laboratories with whom they had established relationships.

4. The Zika Coalition (So. Many. Partners.)

This group, led by the March of Dimes, was comprised of more than 70 member organizations committed to the health and wellbeing of US children and families. It was established in response to Congress’ delay in approving the Obama Administration’s emergency request for funding to respond to the Zika crisis in the US. The request was made in in February of 2016 and was not approved by Congress until that September. The Zika Coalition visited congressional offices, wrote letters and testified before the Senate Appropriations Committee advocating for and applying pressure to ensure public health got the funding necessary to respond.

5. CDC, FDA and CMS – Tri-agency Taskforce for Emergency Diagnostics

Although partnerships with the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) are neither unique nor unexpected during an infectious disease emergency response, the Zika response did change their nature with the establishment of the Tri-agency Taskforce for Emergency Diagnostics. Throughout the 20 month response, as we learned more about how the Zika virus behaved, APHL worked with these agencies to ensure that laboratories had access to the best possible tests through the emergency use authorization (EUA) process (FDA’s role), guidance on how to use those tests (CDC’s role) and assurance that the tests were being implemented in compliance with quality testing standards (CMS’s role). This taskforce remains intact for future responses.

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Influenza prevention and response requires a One Health approach

Influenza prevention and response requires a One Health approach |

By Jill Sutton, respiratory diseases intern, APHL

Did you know there’s no known influenza A subtype that’s only found in humans? That makes influenza a perfect example of why a One Health approach is critical to disease prevention and response.

One Health is about breaking down the silos between human, animal and environmental health and adapting a synergistic approach for planning and responding to threats. When it comes to influenza, this multi-disciplinary approach can make us better prepared to evaluate, predict and respond to infections in both humans and animals.

Toward the end of last year’s flu season, I decided I wanted to delve deeper into One Health. I registered for my first One Health Academy talk, which covered the 1918 influenza pandemic and ended with a discussion around the adjacent possibilities in 2018. As I learned more about influenza, I realized the flu wasn’t just a disease infecting humans each winter, but rather a year-round burden causing severe disease in animals too. Eight months later, here I am as the respiratory diseases intern at APHL, and I haven’t missed a single One Health talk yet. If there’s one thing I’ve learned thus far in my career in public health, it’s that we can’t control the future, but we can control how we respond to try and shape the future.

What are some implications of influenza for human & animals?

Influenza prevention and response requires a One Health approach | www.APHLblog.orgZoonotic diseases, such as avian influenza, can infect and cause severe disease in both animals and humans. According to the CDC, 60% of known infectious diseases in humans are of animal origin and 75% of new and emerging infectious diseases are spread from animals. Not only does the flu infect humans, influenza also infects a number of other animals (both domesticated and wild) and can cause severe disease.

The primary threat, of course, is the spread of new influenza strains. Influenza pandemics occur when a novel influenza virus emerges in an animal host, changes to the point where it is able to infect humans, and then changes further so it can continue to spread from one person to another.

Once the virus can be transmitted from human to human, a pandemic becomes possible. Global population movement directly influences the spread of influenza pandemics. Looking back to the 1918 influenza pandemic, troop movement during World War I was a major factor in the spread of the virus between continents. Today, international trade and travel has connected every region of the world. Transportation of humans, animal and goods increases the risk of exposure to pathogens. Did you know the influenza virus can remain infectious on surfaces for up to 48 hours? And when airborne, viral particles from a cough or sneeze can remain suspended in the air for up to 30 minutes. That is, if someone who is infected with the flu sneezes while on an elevator or in the bathroom of an airplane and 10 minutes later you enter that elevator or bathroom, you could become infected from those particles.

Aside from humans moving around the globe, animal travel is capable of spreading influenza too. Each year, birds such as ducks, swans and geese migrate between continents. If the any of those birds are infected with avian influenza, the virus can be carried and transmitted. If agricultural operations, domesticated animals or other potential hosts come in contact with infected birds or their feces, new influenza infections can be sustained.

Because we live in a shared environment where global travel is fast, global trade is easy and plenty of opportunities for inter-species transmission of influenza viruses exist, it’s important that experts work collaboratively. Within the veterinary community, areas of knowledge exist that can complement existing areas of knowledge in human health, and vice versa. One Health allows for an easier exchange of information and support between those professional communities.

In addition to the risk of transmission, influenza pandemics can have serious economic impacts. Societies around the world depend on the health of humans, animals and the environment for food, income and health security. Influenza is a major threat to animal agriculture as it can be fatal to chickens, turkeys and pigs. When a new influenza strain emerges, the livelihood for global communities, especially those who are largely dependent on agriculture cultivation, is put at risk. For example, live poultry markets have been identified as significant risk factors for transmission of avian influenza. Because many people who sell poultry at live bird markets are dependent on their operation for income, they are less likely to implement measures of prevention especially if it means closure of the market even temporarily and are at higher risk for exposure to avian influenza. Their poultry can continue to transmit the virus and, if they themselves become infected, they might also transmit the virus to other customers, their families or community members. In these cases, it’s important to include and understand all stakeholders such as farmers, consumers, market operators, supply chain transporters, and human and animal health professionals by taking a One Health approach to implement long term management for control and prevention of avian influenza.

What gaps exist?

The health of our ever-changing world depends on breaking down the walls between animal, human and environmental sectors. To effectively detect, respond to and prevent outbreaks of pandemic potential, epidemiological and laboratory data needs to be shared across sectors.

Integrated human, animal and environmental health/management systems promotes communication and collaboration among human-animal-eco sectors, thus optimizing success. Multi-sector coordination helps address joint issues and opens discussion on what to anticipate, what gaps exists, how to reduce duplication of efforts and enhances risk reduction. We need harmonized human and animal surveillance and research efforts that compliment and build upon one another. This is important because it can help human and animal health professionals identify the determinants that affect disease transmission such as pathogenicity, infectivity, antigenicity and resistance. By capitalizing on existing systems and infrastructure and by investing in capacity building, we can enhance our understanding of circulating viruses within animals, and better predict when and where a spillover could occur. Increasing laboratory and data sharing capacity at both the human and animal levels so that they’re equally capable to diagnose both human and animal influenza can help prevent knowledge gaps and identify where intervention is needed to prevent exposure. Furthermore, this can increase surge capacity so that more laboratories are able to provide the necessary help for when an outbreak occurs.

As we move forward, we must use a One Health approach to prevent multi-disciplinary threats like influenza pandemics. By collaborating between professionals with a range of experience and expertise, we can better address the unanswered questions around the risks for pandemic influenza at human-animal-environmental interface.


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A Little Girl and a Deadly Virus

A Little Girl and a Deadly Virus |

By Linette Granen, director, Marketing & Membership, APHL

This story begins as many others. A young lady met a young man, got married and had a baby, whom they adored. They were children of immigrants — her family was from Germany and his from Italy. They began their lives together in the early part of the 20th century in New Orleans, Louisiana. He worked for the New Orleans Park Service — he always had a green thumb and immensely enjoyed working outdoors — while she settled down as a housewife, raising a variety of animals on their small property. One room of their shotgun-house was devoted to a small flock of canaries, and outside they had a plethora of chickens, geese, rabbits and guinea pigs. They shared their double shotgun-house with her brother, a chief in the New Orleans Fire Department. In 1916 they had a baby girl.

A Little Girl and a Deadly Virus | www.APHLblog.orgYes, they were happy — until October 1918, when their only child, nearly three years old, got very sick. She had influenza, although at the time they didn’t know what was wrong. This disease spread quickly through New Orleans, and it became suddenly clear that it was spiraling out of control. On October 7, just one week before the young girl’s untimely death, the New Orleans Board of Health made this then-unknown illness a mandatory reportable disease in order to understand the impact on their population and to track the epidemic’s progress. Two days later, at the recommendation of health officials, the mayor closed all schools, churches, theaters, movie houses and anywhere else people might congregate. Quickly, additional actions were taken to prevent crowding and gathering in the hopes of slowing or stopping the epidemic.

As was mandated, case reports of influenza began to flood the New Orleans Board of Health. On October 12 and 13 alone, there were 4,875 cases reported in the city. At that point, the US Surgeon General instructed the health department to secure additional hospital space for ill military personnel from nearby military installations. Within days, 17 wards of the city’s Charity Hospital were totally dedicated to influenza care. The newly appointed medical advisor, Dr. Gustave Corput, began working with the Red Cross to convert another facility, the Sophie Gumbel building on the Touro-Shakespeare almshouse property, into a 300-bed emergency hospital. At that time, the health department did not employ nurses, so the Red Cross began recruiting nurses and physicians for the emergency facility — some volunteering time and some working part-time. Through funding from the Red Cross and the Public Health Service, the facility was opened and maintained, along with smaller facilities at the Southern Yacht Club on Lake Pontchartrain and a Knights of Columbus hall across the river.

The little girl died on October 15, 1918.

By the end of October, two weeks after the little girl’s death, Tulane University scientists developed and produced a vaccine for local use against a bacteria called Bacillus influenzae (now known as Haemophilus influenzae). Despite being untested, deploying this type of vaccine was worth any risks because of the large number of cases in a city desperate for relief. Laboratories at local hospitals began manufacturing the Tulane vaccine and more than 4,000 city government employees and factory workers were immunized. Medical and nursing students were deployed all over the state: third-year nursing students staffed the emergency hospitals and fourth-year Tulane medical students were appointed as assistant US Public Health Service surgeons. Later that month, it appeared that the tide was beginning to turn, perhaps due to the actions taken by the health department and the Tulane vaccine.

By the spring, the devastating epidemic in New Orleans was finally declared over. Between October 1918 and April 1919, the city experienced over 54,000 cases of influenza and almost 3,500 deaths. The case-fatality rate was 6.5%; only Pittsburgh and Philadelphia had higher death rates.

This story is very personal to me. Not only am I a career public health scientist from New Orleans, that little girl who died on October 15, 1918 was my aunt, Gladys Mary Cucinello. Her parents – my grandparents – later had four sons, one of whom was my father who recently passed away at the age of 95. Born in 1922, he was not alive for the epidemic and never met his sister, but he remembered the heartache my grandmother expressed whenever she talked about that time. The only picture of my Aunt Gladys lives in a place of honor in my house. Such a tiny girl was no match for such a deadly virus.


*Much of the historical information about New Orleans during the 1918 influenza pandemic came from the Influenza Encyclopedia.

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Improving newborn sickle cell screening in Africa: ‘We can affect change there just like we did in the US’

Improving newborn sickle cell screening in Africa: ‘We can affect change there just like we did in the US’ |

by Kim Krisberg

In the US, nearly all children born with sickle cell disease survive into adulthood. Across the globe in sub-Saharan Africa, more than half of babies born with the genetic condition don’t survive until their fifth birthdays.

A major reason for the stark disparity is the region’s lack of newborn screening capacity, which allows for early detection and medical intervention. Here in the US, state public health laboratories automatically test babies for a number of genetic and metabolic disorders, including sickle cell disease, as part of their universal newborn screening programs. In sub-Saharan Africa, however, diagnostic and treatment capacity is severely limited, despite the region being home to more than 75% of the disease’s global burden.

Researchers estimate that about 240,000 babies are born with sickle cell disease in sub-Saharan Africa every year, with studies estimating that at least half of such children die before age five (though research finds the under-five mortality rate related to sickle cell disease in the region could be as high as 90%). Globally, the number of people with sickle cell disease is expected to grow by 30% by 2050. Early detection and diagnosis is critical to pushing that child mortality rate down, but to date, no country in sub-Saharan Africa has been able to establish universal newborn screening for any disease, including sickle cell disease.

Sickle cell disease is an inherited red blood cell disorder in which abnormally shaped red blood cells block the adequate flow of blood and oxygen throughout the body. The disease causes a number of adverse and debilitating effects, including anemia, chronic pain, delayed growth, vision problems and more frequent infections. The disease is manageable with access to relatively easy, low-cost interventions, such as folic acid supplementation, vaccines and antibiotics, pain treatment, dietary changes and high fluid intake.

“This is the same disease we screen for here in the US and we know that if we’re able to detect it early enough and provide the right treatment — prophylaxis penicillin and folic acid — it increases their chances of having a normal life enormously,” says Jelili Ojodu, MPH, director of newborn screening and genetics at APHL. “Sickle cell disease doesn’t have to be a death sentence, as it is now in these countries.”

This summer, the Sickle Cell Disease Coalition — APHL is a member of its steering committee — released a new public service announcement directing viewers to a library of global resources on sickle cell disease screening sites and treatment centers in African regions. Also unveiled was an eight-minute documentary from the American Society of Hematology on sickle cell disease newborn screening efforts now underway in Ghana and how families impacted by sickle cell disease can access appropriate care.

For more than a decade, APHL has been working with providers and health officials in sub-Saharan Africa to institute newborn screening for sickle cell disease, providing technical assistance and guidance on testing methodologies, facilitating relationships with laboratory vendors and in some cases, providing hands-on training in validating lab instruments. The goal, Ojodu said, is to help countries take the first steps in the slow scale-up toward universal newborn screening and foster small pilot projects that expand the evidence base and justification for further investment. For example, in Ghana, where sickle cell disease is endemic, APHL partnered with the Centers for Disease Control and Prevention and the Sickle Cell Foundation of Ghana to offer technical assistance on a variety of related screening activities, such as needs assessments, genetic counseling and educating providers and parents. The initiative, launched in 2011, began with a survey of community needs, which revealed a gap in the availability of genetic counselors who specialize in sickle cell disease.

In turn, APHL led a 2013 workshop on developing a sickle cell disease counselor training and certification program in Ghana, where participants helped tailor a culturally competent training program specific to the needs of Ghana’s communities. Then in 2015, APHL put together a curriculum and trained the first 15 counselors using the new Genetic Education and Counseling for Sickle Cell Conditions in Ghana. A second training workshop took place in Ghana in the summer of 2016.

In all, Ojodu said, APHL has worked with providers in about a half-dozen African nations to improve sickle cell disease outcomes and newborn screening, including Mali, Kenya, Nigeria, Liberia, Uganda and Tanzania. The work, he said, has shown that newborn sickle cell disease screening and counseling in sub-Saharan Africa is possible — the real sticking point is securing the funding and support to shift from small pilots at hospitals and universities to population-wide screening. (He added that most sickle cell disease screening in sub-Saharan Africa is happening in hospital labs, which he said might be the preferred setting for such newborn screening in the region, as public health agencies there must focus their limited resources on considerable communicable disease threats.)

In Ghana, Ojodu noted, providers use the same technology to screen for sickle cell disease as labs do in the US, which underscores the adaptability of current sickle cell disease screening techniques to a variety of settings.

“If we can do it here, they can do it there,” Ojodu said. “Of course, it will take time and coordinated efforts. It’s really a slow build-up of justifying that No. 1, this saves lives, and No. 2, it can be done.”

Venée Tubman, MD, MMSc, a member of the African Newborn Screening and Early Intervention Consortium, which came out of the American Society of Hematology’s Sickle Cell Disease Working Group on Global Issues, noted that a number of attempts have been made to start newborn screening programs in sub-Saharan African, but also reported that no country has yet succeeded in adopting a universal screening effort. She noted that based on progress in sickle cell disease survival rates in the US — where about 96% of babies with sickle cell disease now survive into adulthood — it’s reasonable to believe that similar improvements can be achieved for children in sub-Saharan Africa with the expansion of early detection and treatment. For instance, in the US, CDC reports that with the introduction of pneumococcal disease vaccination, sickle cell disease related deaths among black children younger than four dropped by 42% between 1999 and 2002.

“That fact that we were able to implement some basic measures and increase survivability pretty dramatically leads me to believe that, yes, most of these deaths are preventable,” said Tubman, an assistant professor in pediatrics at Baylor College of Medicine.

She added that the existence of the consortium and the Sickle Cell Disease Coalition speaks to the progress being made to boost early detection and intervention in sub-Saharan Africa.

“Even beginning to strategize and organize around this problem — the infrastructure limitations and the myth and perceptions around sickle cell — is a sign of progress,” Tubman said. “We have a long way to go, but at least we’re on the road.”

Ojodu noted that with the elimination of CDC funding for global newborn screening development, APHL is looking for new funding partners to continue its work abroad.

“This is possible,” he said, referring to improving sickle cell disease survivability rates in sub-Saharan Africa. “We can affect change there just like we did in the US.”


*Header photo is a screenshot from the Sickle Cell Disease Coalition’s “Global Sickle Cell Disease Public Service Announcement.”

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