13Apr / 2020

APHL EVALI response spurred by strong communication

Whether it be a disease outbreak, a natural disaster or a devastating lung condition, regular, responsive communication drives response to public health emergencies. In the summer of 2019, with cases of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) steadily rising, partners at federal, state and local health agencies, health associations, hospitals, poison control centers and other players were in constant contact.

APHL Director of Environmental Health Julianne Nassif recalls, “At the height of the EVALI response, I spent most of my day on conference calls with [the US Centers for Disease Control and Prevention (CDC), US Food and Drug Association, Council of State and Territorial Epidemiologists] and member labs. It was many long hours fortified by a lot of caffeine, but these calls kept us up-to-date and on-task in a rapidly evolving situation.”

EVALI Community Links Members, Partners

APHL facilitated the exchange of time-sensitive information by creating an EVALI community of practice, linking member laboratories, federal agencies and others working on the issue. Building upon relationships developed through various laboratory networks, the group held conference calls to brainstorm ideas and discuss surveillance reports, testing methodology and legal considerations. Experts in testing for e-liquids in vaporized products joined the calls to explain methods unfamiliar to many public health laboratories. The community also served as a nexus for rapid distribution of sampling guidance and analytical methods to scientists working on analysis of EVALI case-related specimens and products. For example, CDC deployed standards for collection of bronchial lavage specimens through the EVALI community. The community continues to hold routine conference calls to exchange notes on recent findings.

APHL also polled member laboratories to solicit their advice on resources and services needed for EVALI response. They returned six recommendations:

Elevation of the EVALI response to an agency-wide level
Addition of experts in environmental and occupational medicine and in epidemiology
Guidance for specimen collection and storage
A template for submitting data to CDC
Extending the time allotted for collection of samples
Building non-targeted testing capability for 1000s of chemicals and providing technical support to assist states with chemical analysis

When APHL forwarded these recommendations to CDC’s Emergency Operations Center, the response was prompt: CDC would provide almost all that APHL had requested.

Existing Relationships Facilitate Response

So why did APHL laboratories and partners communicate so well during the peak of the EVALI outbreak? In short, because they knew each other. By participating in the Laboratory Response Network for Chemical Threats (LRN-C), the National Biomonitoring Network, Opioid Biosurveillance and the APHL Community of Practice for Cannabis Testing, they knew each other personally and trusted one another. Through these same networks, they had also built relationships with hospital staff, poison control specialists, epidemiologists and forensics scientists. In an emergency, these connections proved invaluable.

Learn More

A plenary session about how strong communications enhanced the laboratory response to the EVALI outbreak had been planned for the APHL 2020 Annual Conference, which unfortunately has been canceled due to the COVID-19 pandemic. There are plans underway to turn the session into a webinar, so keep an eye out on the APHL Webinars page for more information.

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13Apr / 2020

APHL, partners garner $550M for data modernization initiative

Like many aspects of public health, the effective, efficient movement of public health data has been chronically underfunded. Faced with this perpetual issue—combined with a sharp increase in data production from new laboratory techniques that have added great volumes of data to an overburdened system—APHL joined with the Council of State and Territorial Epidemiologists, the National Association of Public Health Statistics and Information Services, and the Health Information and Management Systems Society in 2019 to engage in the first serious effort to secure federal funding for improved handling of public health data.

APHL contributed to the production of materials that quickly and easily explained the problem and urged Congress to provide $1 billion over the next ten years, at a rate of $100 million per year. With these materials in hand, APHL met with interested partners on Capitol Hill to press the case for funding. It also organized a Hill briefing for Congressional staff where subject matter experts, such as APHL member Dr. Joanne Bartkus, presented on the challenges with existing data handling processes. Dr. Anne Schuchat, Principal Deputy Director of the US Centers for Disease Control and Prevention (CDC), highlighted these same challenges in virtually every hearing where she testified on public health emergencies.

These educational activities culminated when Congresswoman Rosa DeLauro took up data modernization as one of her key initiatives in the Labor-HHS appropriations bill. Congresswoman DeLauro successfully included the first installment of $100 million for CDC to pursue the data modernization initiative in the Labor-HHS appropriations bill for fiscal year (FY) 2020. This is an unparalleled achievement in the first year of any significant effort, and one made even more remarkable considering that data management is not a particularly trendy or exciting topic.

Though the Senate never produced a Labor-HHS bill for FY 2020, but indicated that it would not accept the House amount of $100 million for data modernization, APHL persevered, continuing to work closely with Senate staff to advance the funding of the data modernization initiative. Ultimately, Congresswoman DeLauro was able to include $50 million in the final version of the bill. The COVID-19 response allowed for an additional $500 million to be directed to data modernization, and it appears that the balance of the $1 billion ($450 million) could be included in the next emergency supplemental funding bill.

APHL continues to pursue additional annual federal funding for the data management initiative, beginning with fiscal year 2021, and production of the required CDC report to Congress detailing how these federal funds will be expended in 2020 and the spend plan for the subsequent nine years.

While APHL looks forward to more nimble response to public health emergencies, such as COVID-19, due to improved public health data management, the association remains energized by the benefits to result from the $550 million already allocated to the data modernization initiative.

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18Nov / 2019

APHL’s newborn screening program goes global

APHL's Jelili Ojodu receives the the Gerard Loeber Award for Contributions to Newborn Screening Expansion in Developing Countries

While much remains to be done to achieve this goal, as more countries consider the impact of non-communicable diseases on their populations, interest in newborn screening is growing. In the last year alone, APHL has received requests for technical assistance to develop or expand newborn screening programs from Brazil, Canada, Ghana, Jordan, India, Mexico, Nepal, Nigeria and Tanzania.

Such interest has led APHL to expand partnerships with nonprofits and governmental agencies to develop newborn screening guidance and resources. For example, APHL has collaborated with the Global Issues Working Group of the Sickle Cell Disease Coalition to develop a Global Resource Library with information on sickle cell disease activities worldwide and a public service announcement. In addition, the association worked with other sickle cell disease advocates to create tools to assess a nation’s needs and readiness to develop a sickle cell disease program. APHL is also currently collaborating with the US Centers for Disease Control and Prevention (CDC), the CDC Foundation, the Pediatric Endocrine Society and Vanderbilt University Medical Center to finalize a document detailing the capabilities required to launch a newborn screening program.

On the ground, APHL continues to extend its reach within Africa, South America, Europe and Southeast Asia. It supports development of implementation plans and strategies, offers related training and shares recent developments in US newborn screening. For example, APHL recently participated in the first Pan-African Workshop on Newborn Screening in Rabat, Morocco, where delegates reported on the status of newborn screening in their countries, and APHL discussed developing a newborn screening case registry to coordinate patient follow up, and infrastructure required for electronic data exchange of newborn screening results.

The association has also been collaborating with partners in India as that country gears up to implement universal newborn screening—a daunting undertaking in a country where 1.5 million babies are born each month. APHL recently teamed up with PerkinElmer to support newborn screening and genetics training for a fellow from Jaipur, whom APHL staff later visited to assess readiness for newborn screening new disorder implementation and technical assistance in that state. Currently, APHL is developing case studies about the benefits of newborn screening to educate physicians in Jaipur, and, with the International Neonatology Association (ISNS), is coordinating with local NBS leaders to explore opportunities to initiate an ISNS chapter in India.

Despite the challenges of strengthening newborn screening programs in countries where the service is now virtually unknown, Ojodu and his team foresee tremendous benefits to public health as well as national income and stability. Says Ojodu: “When we reduce or eliminate the symptoms of newborn screening disorders, kids are healthier, healthcare costs go down and mothers can take on income-generating work. This raises family income and, when multiplied by millions of families, also raises national income. We get a cascade of benefits from a single investment in public health.”

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18Nov / 2019

APHL’s newborn screening program goes global

Outside of the US and other resource-rich nations, few countries have the capital, infrastructure and human resources required to sustain a newborn screening program. Despite these barriers, APHL staff and members have worked diligently to increase access to newborn screening worldwide. In recognition of these efforts, APHL Newborn Screening and Genetics Director Jelili Ojodu received the Gerard Loeber Award for Contributions to Newborn Screening Expansion in Developing Countries at the tenth in September. The award recognizes years of work by Ojodu and his team at APHL to make newborn screening the norm—not the exception—for babies around the world.

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13Nov / 2019

In Puerto Rico, a new molecular bacteriology lab allows better control of foodborne outbreaks

Public health laboratory scientist performing tests

Sometimes a new facility is more than just four walls and a roof. In Puerto Rico, it was the springboard to improving foodborne outbreak response on the whole island.

In May 2019, Puerto Rico inaugurated a new molecular bacteriology laboratory at the Puerto Rico Department of Health’s laboratory (PRDOH) in San Juan. The original laboratory had been out of commission since Hurricane Maria devastated the island in 2017, and was rebuilt with APHL contracting support for repair and redesign. Today, the new laboratory boasts additional space for laboratory instruments, supplies and staff, as well as a reliable roof.

With the molecular bacteriology laboratory up and running, the PRDOH could take on a top goal: implementing whole genome sequencing (WGS) for foodborne outbreak response. WGS provides faster detection of pathogens than alternative methods, leading to rapid implementation of prevention and control measures and speedier investigation of foodborne outbreaks. Like other members of PulseNet, the US network for detection of foodborne outbreaks, the PRDOH needed to add WGS as another detection tool. Now, with a bit of assistance, it could.

APHL helped the PRDOH by procuring Illumina’s MiSeq Sequencing Platform and supporting installation and hands-on training for laboratory staff. The association also facilitated staff travel to CDC headquarters in Atlanta for a deeper dive into WGS methodology and procured BioNumerics software to upgrade the laboratory’s database so it could support WGS data. These efforts were all financed with crisis response funding from the US Centers for Disease Control and Prevention (CDC).

To date, the molecular bacteriology laboratory has made excellent progress toward implementing WGS methods for foodborne pathogens. The laboratory is now working toward validation of these methods; once validation is completed it will apply for certification under the Clinical Laboratory Improvement Amendments Program, which oversees standards and certification for human testing in the US. The laboratory also plans to introduce a new tool—matrix-assisted laser desorption/ionization – time of flight (MALDI-TOF) mass spectrometry—as a complement to WGS in the effort to detect foodborne outbreaks.

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13Nov / 2019

In Puerto Rico, a new molecular bacteriology lab allows better control of foodborne outbreaks

Sometimes a new facility is more than just four walls and a roof. In Puerto Rico, it was the springboard to improving foodborne outbreak response on the whole island.

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21Aug / 2019

Lab Culture Extra: Progress in Sierra Leone

APHL has a long history of involvement in Sierra Leone where we’ve provided technical assistance to strengthen the nation’s laboratory system for over a decade. Following the 2014-2015 Ebola outbreak, we were invited back to build laboratory response capability for Ebola and other highly infectious diseases.

We found there was a lot to be done: a strategic plan for the laboratory system, renovation of the central lab, training and mentoring of lab staff, reducing turnaround time for Ebola testing, and much more.

With the engagement completed earlier this year, APHL Executive Director Scott Becker and Manager of Global Health Sherrie Staley share insights from APHL’s on-the-ground experience, which include the value of a healthy ram.

Listen here or wherever you get your podcasts.

Links:

Photo album — Progress in Sierra Leone

APHL joins partners in Sierra Leone to strengthen lab capacity in Ebola’s wake

High profile APHL team explores MOHS public health laboratory priority needs

APHL in Sierra Leone: Building a resilient lab system

Sierra Leone and Guinea: Building a resilient lab system

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19Aug / 2019

APHL workshop advances integration of HIV, HCV and syphilis testing

Attendees of the testing algorithms pre-HIV Diagnostic Conference workshop listen to a presentation.

Integrating HIV, hepatitis C virus (HCV) and syphilis testing is a laboratory best practice that improves detection of common co-infections and expedites treatment, but integrating these tests is not always easy. Each health department is unique, so they must take a customized approach to implementation based on their distinct set of requirements. To succeed, a health department and its public health laboratory must share common goals and be willing to work together to forge a mutually acceptable agreement.

Until recently, laboratories aiming for test integration had no venue to discuss the practical issues involved. This changed in 2019 when APHL sponsored a one-day workshop prior to the HIV Diagnostics Conference to review HIV, HCV and syphilis testing algorithms; discuss diagnostic testing challenges for each of the three pathogens; and compare recommended methods and protocols to those in use at attendees’ laboratories.

Modeled upon similar APHL workshops for influenza, the workshop brought together representatives from 20 states, the three CDC divisions that funded the workshop and professionals from related areas of public health. Participants exchanged information on common issues such as educating providers and submitters about HIV and syphilis algorithms, appropriate use of nucleic acid testing (NAT) for confirmation of HIV infection, access to ribonucleic acid (RNA) testing for confirmation of HIV and HCV infection, and selection of the optimal syphilis algorithm. Participants like Mary Louise Walmsley, MT(ASCP)—a public health microbiologist in the Alaska State Virology Laboratory’s Department of Immunology—were enthusiastic about the workshop: “Because of the workshop, new and pertinent information regarding HCV and syphilis will be incorporated into the programs at our facility. This was a fantastic workshop, and I hope APHL hosts another one.”

Pending available funding, APHL hopes to continue to sponsor this workshop at future conferences, with a possible return to the HIV Diagnostics Conference, which is held every two to three years. However, given this interval between conferences, APHL is also exploring options at conferences of partner organizations whose work relates to HIV, HCV and STD testing.

In related efforts, APHL has urged the US Department of Health and Human Services (HHS) to develop an STD Federal Action Plan that aligns with other HHS initiatives to combat overlapping epidemics. Additionally, APHL is supporting the Ending the HIV Epidemic plan and efforts to eliminate HCV.

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19Aug / 2019

APHL workshop advances integration of HIV, HCV and syphilis testing

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15Aug / 2019

Self-directed regional networks: Connecting neighbors strengthens labs

(Photo: The Pacific Rim Consortium met in person for the first time at the Hawaii Public Health Laboratory in March, 2019.)

How can a public health laboratory with limited resources sustain and expand its capabilities? One strategy is to leverage the resources and expertise of its neighbors.

With support from the US Centers for Disease Control and Prevention (CDC), APHL is assisting with development of self-directed regional laboratory networks (SDRN) to facilitate collaboration and resource management among neighboring public health and environmental laboratories. SDRNs operate independently, establishing their own governance and strategic priorities based on their unique needs. Soon these networks will be linked through a Coordination Council, which will bring together representatives from each of the SDRNs for joint planning and resource development.

A growing community of networks

Today, 48 states and one territory, Guam, are members of an SDRN. The original SDRN was founded over forty years ago when laboratory directors in New England came together in the mid-1970s to share common concerns around newborn screening legislation then pending in multiple states. This group evolved to become the New England Public Health Laboratory Directors Group (NEPHLD), and then became NEEPHLD when it expanded its constituency to include laboratories responsible for environmental testing.

However, the regional model did not pick up momentum until a review by APHL and CDC demonstrated its value in the early 2000s. This provided the impetus to form the Northern Plains Consortium in 2006, the Southeast Consortium in 2015, the Mid-Atlantic Consortium in 2017, and the Midwest, Pacific Rim, Four Corners and Central Plains networks in 2018 and 2019.

Members “have our back”

SDRN member laboratories report many benefits from participation. Members share technical expertise, technologies and capacity, and they forge relationships with colleagues at other laboratories, making it easier to collaborate when emergencies arise or a testing system goes down. Emily Travanty, PhD, scientific director of the Laboratory Services Division at the Colorado Department of Public Health and Environment reports: “Our fellow consortium members have our back when we need them. For example, the Utah Public Health Laboratory did TB testing for us when our laboratory was in the midst of renovations. Because of them, we were able to still meet our test turn-around times and keep our customers happy.”

Members also collaborate on fundraising, informatics systems, training and leadership development, as well as recruitment and retention. According to Denise Toney, PhD, director of the Virginia Division of Consolidated Laboratory Services:

“The Mid-Atlantic Consortium provides a venue to share ideas, resources and expertise across our region so we don’t have to reinvent the wheel. One project we worked on collectively was a compensation study, funded by CDC and APHL. Our members are using this data to educate their own state leaders about the salary levels needed to recruit and retain top-notch scientific staff in our region.”

SDRNs show strong prospects for the future, with planning in progress within and across networks. With sustainability a perennial challenge for state and local laboratories, that’s good news for public health.

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