What you need to know about harmful algal blooms

What you need to know about harmful algal blooms | www.APHLblog.org

By Julianne Murphy, intern, Environmental Health

Warm weather brings nature walks, picnics and sunny days by the shore, but it can also bring unwanted changes to your favorite beach. As the temperature rises, lake and ocean waters can turn from blue to mossy green as algae proliferates in unsightly and potentially harmful algal blooms.

What are harmful algal blooms?

Algae are plant-like organisms of one or more cells that use sunlight to make food. Together they can form colonies called algal blooms in both marine and freshwater systems. Some of these algal blooms are hazardous to health, but not all algal blooms are harmful.

Harmful algal blooms may release toxins at concentrations unsafe to humans and animals and may drastically reduce oxygen available to aquatic life. In fresh water bodies, cyanobacteria, aka “blue-green algae,” can produce dangerous cyanotoxins; in saltwater or brackish water, acid-generating plankton – dinoflagellates and diatoms – can pose a health threat.

Should I be concerned about algal blooms?

Algal blooms can pose a risk for human and animal health. People and animals can become ill through eating, drinking, breathing or having direct skin contact with harmful algal blooms and their toxins. Illnesses vary based on the exposure, toxins and toxin levels. Public health and environmental laboratories test samples from harmful algal blooms to confirm the presence and level of toxicity. Remember, not all algal blooms are harmful.

How are public health officials responding to the increase in algal bloom events?

As climate change events amplify conditions favorable to algal blooms, public health scientists are studying when and where associated illnesses are occurring and how to mitigate the effects of exposure. Their efforts have led to increased laboratory testing and electronic surveillance measures at the state and federal level.

For example, public health and environmental officials in Alaska have been tracking and testing harmful algal blooms. The Alaska Harmful Algal Bloom Network, a collaboration of the Alaska Department of Health and Social Services (DHSS) and regional monitoring programs, analyzes fish kills, unusual animal behaviors and other related phenomenon to provide early warning of developing coastal marine blooms. DHSS scientists analyze human specimens for illnesses associated with harmful algal blooms, such as paralytic shellfish poisoning (PSP) caused by saxitoxins. PSP is a potentially fatal poisoning with no treatment except supportive care. Samples from symptomatic patients are forwarded to the Centers for Disease Control and Prevention (CDC) for confirmatory testing as needed. Testing of asymptomatic individuals may be included in future studies.

In addition, Alaska Department of Environmental Conservation (DEC) laboratories test marine shellfish meat samples protect public health and safety as well as for regulatory purposes, illness investigations and non-commercial shellfish upon request. This monitoring literally saves lives.

David Verbrugge, chief chemist at the DHSS Division of Public Health, explains the value of Alaska’s testing of harmful algal blooms, “[Laboratory analysis] helps us to understand the nature of PSP exposures: frequency of occurrence, confirmation when lacking meals to test, and the presence or absence of toxins in asymptomatic co-exposed groups. It also allows us to let people know what they are eating before they eat it.”

Is the CDC involved in testing and surveillance for harmful algal blooms?

Yes, only for freshwater. In 2016, CDC created the One Health Harmful Algal Bloom System to provide a voluntary, electronic reporting system for states, federal agencies and their partners. Using the system, which integrates human, animal and environmental health data using a One Health approach, public health departments and their environmental and animal health partners can report bloom events, and human and animal cases of associated illness. Members of the public may report a bloom event or a case of human or animal illness to the One Health system by contacting their local or state health department.

What is the outlook for future testing and surveillance of harmful algal blooms?

As climatic conditions become more favorable to development of harmful algal blooms, state and local health departments will have to ramp up surveillance and testing to protect public health and to preserve local revenue from beaches. These actions will come with a price tag, requiring action at all levels of government. Resources can be leveraged through collaboration to research and expand clinical testing capacity for these persistent health threats.

Learn More:

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Farewell, Providence! APHL Annual Meeting — Days 3 and 4

Farewell, Providence! APHL Annual Meeting — Days 3 and 4 | www.APHLblog.org

After four days of fascinating speakers, networking with peers and partners from around the world, and enjoying public health jokes that only insiders would understand, the 2017 APHL Annual Meeting came to a close. It was the largest meeting yet with over 700 attendees. We are so thankful to the APHL staff, members, partners, exhibitors and speakers who made this meeting a success! See you all in Pasadena, California in 2018!

Below is a round-up of days 3 and 4.

Day 1 round-up

Day 2 round-up

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UberOps CEO talks public health in the cloud

UberOps CEO talks public health in the cloud | www.APHLblog.org

In a very short time, Americans have become increasingly familiar with the cloud. Not the white fluffy ones in the sky, but the cloud where much of our day-to-day computing takes place. Even for people who aren’t familiar with the term, they likely are familiar with the concept of accessing internet-based files from anywhere. Photos taken on your smartphone might be automatically uploaded to a cloud-based storage system where you can view or download those photos on your laptop. Just as this technology has become valuable in our daily lives, it has become valuable in public health.

At this year’s APHL Annual Meeting, Eduardo Gonzalez Loumiet, CEO of UberOps, presented on public health in the cloud. We asked Eddie a few questions about the system that he has worked to develop along with APHL informatics and the value that this platform offers public health laboratories and ultimately the American public.

Learn more about AIMS — AIMS Platform: Outpacing Pathogens from the Cloud

In simple terms, what is the AIMS platform? What is the role of UberOps?

AIMS stands for the APHL Informatics Messaging Services Platform. AIMS was developed in 2008 as part of the Public Health Laboratory Interoperability Project (PHLIP) focused on influenza surveillance with the CDC.

AIMS is a secure, cloud based environment that accelerates the implementation of health messaging by providing shared services to aid in the transport, validation, translation and routing of electronic data.

The AIMS Platform has grown to a community of more than 85 trading partners involved in several use cases including ELR, Whole Genome Sequencing, ARLN and NMI. New use cases are being discovered every day.

UberOps is an APHL partner that develops and supports the AIMS Platform. We work on the deep technical aspects of AIMS. Our focus is on continuously securing the environment, trading partner onboarding, and ensuring trading partners have the information and tools to leverage AIMS Platform benefits.

Why should public health labs use a cloud-based system? What are the benefits? 

The benefits of using cloud computing have surpassed perceived risks. AIMS utilizes Amazon Web Services (AWS), the industry leader in Cloud computing. The benefits of cloud computing include:

  1. Security, high availability and reliability
  2. Centralized processing and message routing
  3. Real-time monitoring and audit systems
  4. Reduced message transport complexity
  5. Reduced data translation and transformation complexity
  6. Reduced development and support costs
  7. Flexible capacity infrastructure
  8. FISMA Moderate compliant applications
  9. FedRAMP compliant environment via the cloud provider
  10. Commitment to innovation and the future

Are public health laboratories the only labs using AIMS?

UberOps CEO talks public health in the cloud | www.APHLblog.org

AIMS was built to serve public health laboratories. Over the last 18-24 months the AIMS infrastructure has expanded capability to allow public health agencies and a select group of private laboratories to securely exchange data as well. We have also seen an increase in cross-jurisdictional ELR data exchange between agencies. AIMS has also been used to host other non-profit data, such as STEVE 2.0, which focuses on exchanging birth and death records between states. And AIMS is being used to process data for the first time in the cloud through virtual workstations for the whole genome sequencing project. We are excited for the emerging possibilities!

Is it secure? How do I know my information wont be stolen or misused?

The top priority for APHL and UberOps is a secure and compliant AIMS Platform. Stringent healthcare laws and regulations across jurisdictions are monitored on a regular basis, and revisited on a regular basis. The AIMS Platform is FISMA Moderate compliant, which requires a once per year third-party audit. In addition to the audit, the AIMS infrastructure is required to pass firewall penetration testing.

Each member of the AIMS Platform team attends yearly HIPAA privacy and security training. The AIMS dedicated security team uses advanced, real-time monitoring tools to proactively eliminate potential threats.

What does this mean for the public? Are there clear benefits for people in the community?

AIMS is an extension of everything our public labs represent in the United States. The ability to monitor and detect health threats quickly using a shared technology platform is an invaluable asset for the safety of all citizens. Preventing and/or predicting large expected (like influenza) and unexpected (like Zika) public health events is where the AIMS Platform serves our communities.

What does the future hold for AIMS?

APHL, UberOps and AIMS stakeholders are constantly looking to expand the functionality of the AIMS infrastructure. As the evolution of health data continues, we see new opportunities to assist with integrating data and providing a higher quality experience for trading partners, patients and citizens.

Our recent platform growth between public and private collaboration will continue, and we expect to expand AIMS application services (examples: Dashboards, Portals, LIMS), electronic case reporting and much more!

 

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AIMS Platform: Outpacing Pathogens from the Cloud

AIMS Platform: Outpacing Pathogens from the Cloud | www.APHLblog.org

By Rachel Shepherd, associate specialist, Informatics, APHL

​​In a kindergarten classroom in Des Moines, a small boy begins to shiver uncontrollably. In a nursing home in Phoenix, a pneumonic grandmother fights for her life from a hospital bed. On a crowded metro car in Washington, DC, in the miniscule droplets of saliva from a man’s kind “Hello” to a stranger, it attacks. The flu. It comes every year as the months begin to shift into winter, returning slightly different than before, exploding and thriving, determined to wreak havoc. It descends upon the nation, preys upon us in our most vulnerable moments, and says, “This is my  year.”

In public health, every emerging threat—the flu, E. coli, Legionnaires’ disease, Ebola, Zika—is a race against time. What can scientists learn from these deadly pathogens, and more importantly, how fast? Lives depend on this data, on laboratories’ ability to track patterns, decipher mutations and to share, compare and build upon those findings—crowdsourcing at its finest and most critical.

Only a few years ago, a lab would manually enter its test results and fax them to CDC and other reference centers. Someone would receive the paper transmission and manually re-enter it. The process would take days. In that time, an outbreak could have spread. Lives could have been lost.

Time matters. But thanks to an APHL-CDC initiative, what used to take days can now take minutes. In 2008, public health labs recognized the need to share their data electronically. APHL worked hand in hand with informatics specialists at state labs and CDC to develop what was then known as the Route not Read (RnR) hub. This seemingly simple, but powerful approach sent public health data through a service that read the outside envelope of the electronic message and delivered it to the intended recipient without opening its contents.

Four years later, the increasing complexity and demands for public health data led to the development of the AIMS platform. Now in a cloud-based environment, AIMS has burgeoned over the years. The new environment accelerates the transmission of data and provides shared services, such as message validation translation, to labs and trading partners. Today, more than 85 organizations and institutions exchange data over AIMS, with more than 25 million messages transported to date.

The vital data exchanged on AIMS includes aggregated influenza test results from public health laboratories to CDC, vaccine-preventable disease reports, biological threat data, immunization data exchange among several public health jurisdictions, electronic laboratory reporting between hospitals and their jurisdictions, and whole genome sequencing through the Advanced Molecular Detection initiative. And AIMS is expanding again to offer electronic case reporting to connect laboratories and health agencies with CDC and with other data recipients nationwide.

Since its launch in 2012, the AIMS platform has equipped public health officials to monitor and respond rapidly to health threats, strengthened labs with shared resources and expedited delivery of time-sensitive health information to consumers. As the platform continues to gain traction, its contributions to the nation’s health infrastructure will be tremendous.

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10 Ways CDC Gets Ready For Emergencies

Dr. Stephen Redd, Director, Office of Public Health Preparedness and Response
Dr. Stephen Redd, Director, Office of Public Health Preparedness and Response

One of the best parts of my job is the opportunity to learn from a wide range of experiences. We have an obligation to not only respond to emergencies today, but to prepare for tomorrow by learning from the past. Our work extends to households affected by disease, communities ravaged by disasters, and U.S. territories battling new and changing threats. In fact, all over the world – we try to get ahead of, and manage, complex responses that touch many lives through ever changing circumstances. In an ideal world the health in every community would be at a level that would make recovery and reliance easier. The reality is that emergencies happen in all kinds of environments and populations.

The Public Health Preparedness and Response National Snapshot is our annual report that gives us an opportunity to showcase the work that we and our state partners do. The report reminds us that no matter how big the emergency, we need to work together to respond to the best of our ability—with the cards we are dealt.

Here are 10 ways CDC’s Office of Public Health Preparedness and Emergency Response worked to keep people safer in 2016 that can inform our work going forward.

1) Four Responses at Once: An Unprecedented Challenge

CDC experts continue to provide 24/7 monitoring, staffing, resources, and coordination in response to natural disasters, terrorist attacks, and infectious disease threats. In early 2016, CDC managed four public health emergencies at the same time through our Emergency Operations Center :

  • Ebola
  • Flint, Michigan, Water Quality
  • Zika Virus
  • Polio Eradication

See us in action:

2) A Complex Threat: Zika Hits the U.S.

CDC scientists and responders were activated in CDC’s Emergency Operations Center, where they combed through research, developed and distributed diagnostic tests, and provided on-the-ground mosquito control and education to protect people at higher risk for the virus, including pregnant women and infants.

3) Right Resources, Right Place, Right Time

CDC’s Strategic National Stockpile is ready to send critical medical supplies quickly to where they are needed most to save lives. The stockpile is the nation’s largest supply of life-saving pharmaceuticals and medical supplies that can be used in a public health emergency if local supplies run out.

Last year, we helped conduct 18 full-scale exercises and provided training for 2,232 federal and state, local, tribal, and territorial emergency responders to ensure that systems for delivering medicines are functioning well before they are needed in an actual emergency. We continue to work with our federal, state, local, and commercial partners to make sure every step of the medical supply chain – from manufacture to delivery – is coordinated.

4) State and Local Readiness

CDC connects with state and local partners to provide support and guidance, helping every community get ready to handle emergencies like floods, hurricanes, wildfires, or disease outbreaks.

This year, we created a new process to evaluate how well state and local jurisdictions can plan and execute a large-scale response requiring the rapid distribution of critical medicines and supplies. Through this program, we conducted assessments of 487 state and local public health departments. The information from these assessments will be used to help improve the ability to get emergency supplies quickly to those who need them most.

5) Cutting-Edge Science to Find and Stop Disease

To protect lifesaving research, CDC experts in biosafety and biosecurity conducted approximately 200 laboratory inspections and thousands of assessments of those who handle dangerous select agents and toxins like anthrax, plague, and ricin to keep these materials safe, secure, and out of the hands of those who might misuse them.

CDC’s Laboratory Response Network (LRN)l also develops and deploys tests to combat our country’s most pressing infectious and non-infectious health issues, from Ebola to Zika virus to opioid overdose. The network connects over 150 labs to respond quickly to high priority public health emergencies.

6) Protecting Our Most Vulnerable

CDC supports efforts all across the country to help those who may not be able to help themselves when a crisis strikes. Some populations, like children, older adults, and others with functional and access needs may need extra help during and after an emergency.

From planning for the 69 million children who may be in school when disaster strikes to the millions of Americans who need to make sure prescriptions are filled, medical equipment is working, and help arrives even if power is out and roads are blocked, it’s up to us to protect our most vulnerable in emergencies.

7) Emergency Leaders: The Future of Incident Response

When every minute counts, we need people who have the knowledge to step in and take immediate action. Learning and using a common framework like the CDC Incident Management System helps responders “speak the same language” during an event and work more seamlessly together.

CDC experts train leaders from around the world—25 countries in 2016—through an innovative, four-month fellowship based at our Atlanta headquarters. Lessons learned from this course were put to work immediately to head off an outbreak of H5N1 influenza in Cameroon.

8) The Power of Preparedness: National Preparedness Month

Throughout September, CDC and more than 3,000 organizations—national, regional, and local governments, as well as private and public organizations— supported emergency preparedness efforts and encouraged Americans to take action.

The theme for National Preparedness Month 2016 was “The Power of Preparedness.” During our 2016 campaign , we recognized the successes of countries and cities who have seen the direct benefits of being prepared, looked at innovative programs to help children and people with disabilities get ready for emergencies, and provided tips for home and family on making emergency kits.

9) Health Security: How is the U.S. Doing?

As part of the Global Health Security Agenda, teams of international experts travel to countries to report on how well public health systems are working to prevent, detect, and respond to outbreaks. In May, a team made a five-day visit to the U.S. to look at how well we’re doing.

In the final report, the assessment team concluded that, “the U.S. has extensive and effective systems to reduce the risks and impacts of major public health emergencies, and actively participates in the global health security system.” They recognized the high level of scientific expertise within CDC and other federal agencies, and the excellent reporting mechanisms managed by the federal government.

10) Helping YOU Make a Difference

Get a flu shot. Wash your hands. Make a kit. Be careful in winter weather. Prepare for your holidays. Be aware of natural disasters or circulating illnesses that may affect you or those you care about. There are many ways to prepare, and in 2016 we provided the latest science and information to empower every one of us to take action.

Every person needs knowledge to prepare their home, family, and community against disease or disaster before an emergency strikes. Whether it’s how to clean mold from a flooded home, how to wash your hands the right way, or how to use your brain in emergencies, our timely tips and advice put the power of preparedness in your hands. From the hidden dangers of hurricanes to the heartbreaking dangers of flu, there are steps we can all take to stay safe every day as we work toward a healthy and protected future.

For more ways we are helping protect America’s health, check out the new National Preparedness Snapshot.

To find out more about the issues and why this work matters, visit our website.

 

If you use this research tool without permission, you’ll hear about it

Sometimes, a seemingly run-of-the-mill retraction notice turns out to be much less straightforward. Such was the case with a recent retraction of a 2016 paper in a journal published by the U.S. Centers for Disease Control and Prevention, apparently over permission to use an evaluation scale designed to test whether patients take their medications as […]

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Antimicrobial resistance: What is it? Why is it a problem? What is being done to stop it?

Antimicrobial resistance: What is it? Why is it a problem? What is being done to stop it? | www.APHLblog.org

By Kelly Wroblewski, director, infectious diseases, APHL

Antimicrobial resistance is arguably the most significant public health threat facing the world today. As resistance builds, the threat of severe illness or death from common infections becomes an increasing possibility for everyone.

What is antimicrobial resistance?

Antimicrobial resistance occurs when microbes, including bacteria, viruses, fungi and parasites, evolve or adapt to survive exposure to drugs or other treatments designed to kill them. Once the microbes have developed resistance, treatments used against them are rendered useless.

While all types of antimicrobial resistance are extremely concerning, antibiotic resistance – when bacteria become resistant to antibiotics – is often seen as posing the most serious health threat. Why is this?

Compared to other microbes, more bacteria are becoming increasingly resistant to treatment, and resistant bacteria can cause more adverse health outcomes in infected people. Antibiotics are also more commonly used than antiviral, antifungal or antiparasitic drugs.

How did antibiotic resistance become such a big problem?

While many complex issues have led to this urgent situation, three factors stand out:

1. The overuse and misuse of antibiotics in healthcare, agriculture and other aspects of day-to-day life is a significant contributor to antibiotic resistance. Simply stated, every time we use antibiotics inappropriately, we’re helping bacteria figure out how to outsmart and outperform them – to resist Inappropriate use includes taking antibiotics to treat viral infections, starting a course of antibiotics and not completing it, using antibiotics in agriculture to improve livestock survival and crop yields, and the liberal use of over-the-counter antibacterial soaps and ointments.

2. Development of new antibiotics and diagnostic tools to detect resistance has suffered due to a lack of investment. As bacteria develop resistance to existing drugs, scientists must work to develop new antibiotics to treat infections. However, for the past 30 years, antibiotic drug development has been stagnant and the prospects are not promising.

Prior to the drug development phase (bringing drugs to market) is drug discovery, the process of identifying candidate medications and active ingredients. This is a challenging and therefore incredibly expensive endeavor with few economic incentives. For companies that make it to the drug development phase, creating drugs that kill bad bacteria without killing good cells (including the host) is extremely difficult.

3. It is difficult to systemically detect, track and respond to new resistant pathogens and outbreaks without a comprehensive global surveillance system. To slow the spread of resistance, we have to know where to find it and have a plan to stop its spread. Though the United States has acted to counter resistant forms of diseases like TB and gonorrhea, it hasn’t taken a public health approach to diseases commonly found in health care settings like the superbug CRE. Failure to detect and stop the spread of these infections at the community level contributes to increased numbers of resistant infections, poor patient outcomes and increased healthcare costs. What’s more, aggressive detection and response efforts are needed to prevent local outbreaks from becoming pandemics.

What’s being done to slow or stop antimicrobial resistance?

The past few years have brought much needed progress. Finally, the US public health and health care systems have a comprehensive plan to combat this problem and resources to make it happen.

In 2014, the White House released the National Strategy on Combating Antibiotic-Resistant Bacteria and President Obama signed an Executive Order directing key federal agencies to take action to combat the rise of antibiotic resistant bacteria. In December 2015, Congress passed a budget providing $375 million to implement this strategy with $161 million going to CDC.

Since then, significant steps have been taken to move the dial in the right direction.

  • CDC has distributed approximately $67 million to local and state governments to improve their ability to detect and respond to existing and emerging resistance as well as implement strategies to improve antibiotic stewardship.
  • CDC has established the Antimicrobial Resistance Laboratory Network (ARLN) which will provide infrastructure and capacity for seven regional public health laboratories across the country to better identify and characterize some of the most significant antimicrobial resistance threats. In addition, the ARLN will provide resources to all state and several large local public health jurisdictions to improve their CRE surveillance capacity.
  • CDC, FDA and NIH have launched a comprehensive campaign aimed at improving antimicrobial stewardship in healthcare and reducing the frequency of antibiotic use in agriculture.
  • NIH and the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR) launched the Antimicrobial Resistance Diagnostic Challenge, a $20 million prize competition that to stimulate innovation in the development of new, faster diagnostic tools.
  • CDC and FDA have collaborated to establish the Antimicrobial Resistance Isolate Bank, a repository of resistant pathogens that will be made available to companies developing new antibiotics and diagnostics.

These are significant and valuable steps forward. As these and future efforts get underway, collaboration across sectors will be critical to success. APHL is committed to supporting members and working closely with partners in the battle against antimicrobial resistance.

Read more:

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Inside the public health lab Zika response: ‘It’s the great unknown as to how much longer this will go on’

Inside the public health lab Zika response | www.APHLblog.org

By Kim Krisberg

Public health laboratory scientists are well used to the preparations and demands that come with emerging disease threats. But Zika virus is different.

“With SARS, West Nile virus, H1N1 flu, mumps outbreaks — those came and were gone in a few months,” said Michael Pentella, PhD, director of the state public health laboratory at the Massachusetts Department of Public Health. “We’ve been ramping up and dealing with Zika for a long period of time now and there’s no end in sight.”

While the Aedes aegypti mosquito — the species by which Zika is most commonly spread — is not found in Massachusetts, the state’s public health lab began preparing for the disease in late 2015. At first, the pace of testing was fairly slow, Pentella said, with the lab receiving less than 20 specimens a week as of January. The weekly volume quickly ramped up to about 150 a week in February, then slowed around the time that officials began warning at-risk populations to avoid travel to high-transmission regions. As of early September, volume was back up, with about 130 specimens arriving at the Massachusetts state lab every week. Most of those specimens are coming from Massachusetts residents, but the lab is also providing testing for a handful of other states where Zika testing is not yet fully operational.

At the moment, Pentella said Zika testing is “by no means overwhelming” the lab’s capacity, though he said it is adding significantly to staff workload. He is worried, however, that if another health threat arises on top of Zika, it could quickly push the lab to capacity. For example, the same personnel who conduct Zika testing also perform influenza testing. So if the upcoming flu season is particularly bad or a new flu strain emerges as Zika demands continue inching upward, “I’m very worried about our ability to handle both at the same time,” Pentella said.

Public health systems, including labs, continually prepare and practice for the possibility of outbreaks and disasters, and staff are ready for the additional duties that come with understanding, monitoring and containing a dangerous pathogen. Still, effective and sustained response requires sufficient funding. And in the case of Zika — a complicated disease with multiple modes of transmission and the potential for devastating birth defects — that funding has hardly been forthcoming. As of Sept. 20, with more than 20,000 Zika cases confirmed in U.S. states and territories, including 43 locally acquired cases in U.S. states, Congress had yet to authorize emergency funding for Zika response.

The White House first submitted its request for $1.9 billion in emergency Zika funds back in February based on recommendations from the scientific and public health community. But instead of acting quickly on those recommendations, Congress deadlocked on the issue. To make matters worse, that inaction comes on top of years of declining public health preparedness funding at the federal level as well as declining state and local public health budgets. Inside a public health lab, that funding inaction can have an acute effect. The equipment and its maintenance are expensive, the training is complex and the skill set is competitive. Yet, public health labs are indispensable to combating a disease like Zika. They provide the data that shape and drive effective interventions and provide testing services for all residents, regardless of their ability to pay.

And even though the U.S. is well into mosquito season, public health officials like Pentella say federal emergency funding is still needed — urgently.

“We need to take the broader perspective and look longer term so we’re not constantly on this yo-yo of ramping up and ramping down because funding goes away,” he said. “[Federal Zika funding] is becoming more urgent every day. I see the possibility of us falling behind and it will limit our capacity to respond. It really is tying our hands when we need to have all hands on deck.”

Zika lab response: ‘We’re in a very tenuous place’

Today, thankfully, there is nationwide coverage for the three tests used to screen for Zika virus, with public health labs bearing the majority of the testing burden but some commercial and clinical labs receiving authorization from the Centers for Disease Control and Prevention (CDC) to test as well. What’s unique about Zika, however, is that it requires both molecular and serological diagnostics.

Inside the public health lab Zika response | www.APHLblog.orgOn the molecular side, nearly every public health lab in the country has been confirmed to screen for Zika via polymerase chain reaction (PCR) testing, which CDC recommends for symptomatic patients tested less than 14 days after the initial onset of symptoms as well as for asymptomatic pregnant women who may have been exposed to the mosquito-borne virus. A positive PCR requires no follow-up. If the result is negative, however, the next step is serological testing using the IgM Antibody Capture Enzyme-Linked Immunosorbent Assay (MAC-ELISA), which detects the antibodies the body uses to fend off Zika infection.

In addition to confirming a negative PCR result, the serological test is recommended for asymptomatic pregnant women tested 14 or more days after potential virus exposure as well as for symptomatic patients beyond the 14-day window from initial onset. The challenge is that the MAC-ELISA is incredibly complicated, the throughput takes days longer than PCR, and, in general, serological testing isn’t a typical component of a lab’s surge response.

Plus, many public health labs have either cut back or stopped ELISA testing altogether because of previous funding cuts, said Chris Mangal, director of public health preparedness and response at APHL. Those funding cuts meant many labs have had to spend valuable time and resources bringing their serological capacity back to the frontline. As of late summer, 43 public health labs could test for Zika using the MAC-ELISA.

“When Congress opts to not provide resources for these emerging threats, it has a big effect,” Mangal said. “Yes, they’re prepared by virtue of their membership in the [CDC Laboratory Response Network (LRN)], but you still have to keep replacing the gas in the gas tank, if you will. That one tank of gas won’t get you across the country.”

The MAC-ELISA may be the best way to identify Zika in asymptomatic patients, but it’s also incredibly nonspecific, said Kelly Wroblewski, director of infectious diseases at APHL. In other words, the ELISA can also pick up antibodies to dengue and West Nile virus, which are in the same genus of viruses as Zika, and that means a positive ELISA for Zika has to be confirmed with yet another highly complex test — the plaque reduction neutralization test (PRNT) — that only a small number of public health labs and CDC have the capacity to perform.

Fortunately, Wroblewski said, most labs are currently able to handle the volume of specimens coming their way, with the exception of Florida, which is being bombarded with testing demands in the wake of local mosquito transmission.

As of September 20, the Florida Department of Health reported nearly 700 travel-related Zika cases and 89 non-travel-related cases, 87 of which involved pregnant women. It also reported that the department had conducted Zika testing for more than 7,815 people so far, noting that it only has the capacity to test 4,930 people for active Zika (PCR) and 8,364 for Zika antibodies (ELISA). Florida is home to both mosquito species that carry Zika and mosquito season in the Sunshine State is pretty much year-round.

“I think we’re in a very tenuous place,” Wroblewski said. “This isn’t going to be something that goes away after mosquito season is over. The public health system has done an amazing job responding without congressional support…but once the immediate danger is over, we’re very likely going to be in the same position rolling into next mosquito season.”

Labs in action: High-risk to Big Apple

Texas is considered a high-risk state for Zika, as it shares a border with Mexico and is home to both mosquito species that transmit the virus. As of September 20, Texas had 195 reported cases of Zika, all travel-related or transmitted via sexual contact.

At the state public health lab in the capital of Austin, Grace Kubin, PhD, director of the Laboratory Services Section at the Texas Department of State Health Services, said the volume of Zika-related specimens arriving at the Austin lab every day has doubled since February — as of early September, the volume was about 50 a day. However, that number would be a good bit larger if Texas wasn’t able to spread its Zika testing demands across its network of state and local public health labs. Kubin said almost all LRN public health labs in Texas can perform the more rapid PCR test, while Austin- and Dallas-based public health labs can perform serological testing, with labs in Houston and San Antonio working to bring serological capacity online as well.

“I’m happy to report that of the specimens coming in, we seem to be keeping up,” Kubin said. “We don’t have a backlog for either PCR or serology. We’ve gotten to a comfortable place right now, where we’re able to test whatever comes our way.”

Bringing testing capacity online had its challenges, Kubin reported. While the PCR process was fairly typical, the serological response, i.e. MAC-ELISA, was much more difficult. The MAC-ELISA, which received emergency use authorization in February, came with very specific biosafety guidelines that apply to serious or potentially lethal agents and complying with those guidelines is no easy task, Kubin said. Another challenge for labs is simply the time it takes to run a MAC-ELISA. For example, for the PCR test, the Austin lab can process a plate of 38 specimens in just a few hours. Serology also runs on a plate, but it holds just eight specimens and takes three days to process. To speed things up, the Austin lab set up a new system that allows it to process multiple serology plates each day.

“We have a little bit of extra room that maybe other labs don’t have,” Kubin said, noting that the Austin-based lab is one of the largest public health labs in the country. “Being such a large lab with a lot of testing divided out as far as molecular techniques being done in different areas…it allows us the ability to ask for additional help.”

Of course, once a local mosquito-transmitted Zika case is detected in Texas, testing demands will likely surge — a turn of events the Austin lab is preparing for at the same time it responds to daily Zika needs. Kubin said the Iowa state public health lab has already offered its assistance to Texas in case Zika demands begin to overwhelm the Lone Star state.

“Zika will continue to be the next new thing,” she said.

Inside the public health lab Zika response | www.APHLblog.orgThe Aedes aegypti mosquito doesn’t travel as far north as New York City, but its relative and potential Zika vector, the Aedes albopictus, does. According to the New York City Department of Health and Mental Hygiene as of Sept. 9, the city was home to 568 Zika cases, all travel-associated. Scott Hughes, PhD, associate director of environmental sciences at the New York City Public Health Laboratory, said the lab is receiving Zika-related specimens from about 50 patients every day. As of early September, the lab had performed testing for about 7,500 patients and received about 12,000 specimens. It began serological testing about two months ago.

In addition to human testing, the New York City lab is testing mosquitoes too, screening about 200 pools of trapped mosquitoes every week. Like other lab officials, Hughes said he is also concerned about the lab hitting capacity if another outbreak happens in the midst of Zika response.

“We really went from zero to 60 in a very short time,” Hughes said. An agency graphic shows that Zika testing requests for pregnant women went from zero in late March to nearly 2,500 in mid-July. “It’s the great unknown as to how much longer this will go on or whether this will become part of the everyday menu of tests we perform.”

Another Zika challenge both Hughes and Kubin mentioned was working with local obstetric/gynecology providers to receive specimens for testing, as such practices don’t typically work with public health labs. In New York City, the health department established a call center where providers can get more information; in Texas, public health officials partnered with professional pediatric and medical associations to disseminate information, among other measures. Out in California, Neil Silverman, MD, said educating medical providers is a “critical component” of Zika response.

A high-risk pregnancy specialist, Silverman is an obstetrician at the Center for Fetal Medicine & Women’s Ultrasound in Los Angeles and since February, has been serving as a perinatal consultant on Zika for the California Department of Public Health. In his consulting role, he helped craft messaging for obstetricians that not only educated on the nature and epidemiology of Zika, but on who should be tested and how to go about accessing testing. To paint a clearer picture of the process, Silverman pointed to his own experience.

Since the end of January, his practice has seen more than 200 pregnant women for Zika-related travel risks. At first, patient specimens were collected at the practice, then couriered to a nearby hospital lab, which then facilitated shipment to the county public health lab and on to CDC. Fortunately, the Los Angeles County public health lab now has Zika testing capability, but provider specimens are still couriered through a hospital lab. In particular, Silverman said, providers needed to know that any specimens sent to public health labs have to be accompanied with the proper epidemiologic paperwork; without it, testing can’t proceed.

“I get questions about Zika every single day,” he said about his practice. “The anxiety level is high and I think it’s only a matter of time before we start seeing some local cases.” As of September 16, California had no locally acquired Zika cases.

Silverman noted that as commercial labs have come online, it’s lessened the burden on California’s public health labs. But he also said that public health labs still offer one big advantage: they serve as a buffer against testing people who don’t need to be tested, making it easier for those truly at risk to access timely screening. Also, public health labs provide Zika testing for all those who need it, regardless of income or payer status, Silverman said, noting that one of the commercial labs his practice works with charges $165 upfront for Zika PCR testing.

“Our public health department and public health labs really are the boots on the ground,” he said. “They’re the sentinels when outbreaks occur, and it really is unfortunate that people don’t think of everything they do until there’s no money to fund them.”

Emergency funds still critically necessary  

Unfortunately, dealing with severe funding cuts and budget shortfalls while still maintaining core public health functions has become a mainstay of public health practice. However, in the face of a threat like Zika and its potential consequences for newborns and families, one would think emergency funding would be a slam-dunk.

Inside the public health lab Zika response | www.APHLblog.orgBut despite the concerted efforts of public health advocates, Congress has yet to authorize any emergency funding. In the face of such inaction, the White House redirected about $600 million away from Ebola response to fight Zika, and CDC was forced to redirect more than $44 million in Public Health Emergency Preparedness (PHEP) funds away from state and local health departments and toward national Zika response, though some of those funds returned to at-risk states and localities via CDC’s Epidemiology and Laboratory Capacity (ELC) program. The U.S. Department of Health and Human Services (HHS) redirected hundreds of millions of funds to domestic response as well, including $222 million that went to CDC.

But those are only stop-gap measures. In an August letter to key members of Congress, HHS Secretary Sylvia Burwell wrote that “CDC is on pace to virtually exhaust all of its domestic response funding by the end of the fiscal year.” Without additional funds, Burwell stated that CDC will have “severely limited” capacity to support mosquito control and surveillance and improve diagnostic Zika testing.

“Labs, like the rest of public health, are barely funded and because of that, they’re able to do a terrific job on a finite set of activities,” said Peter Kyriacopoulos, senior director of public policy at APHL. “For instance, they can do standard flu testing, but when there’s a pandemic flu outbreak they need additional resources because they’re working additional hours, using additional materials, using their machines more often, which leads to more maintenance…and all of that burden comes on top of their daily work. When you layer on top of that something like Ebola or Zika, that’s when the system begins to fray.”

In turn, federal emergency funding is still desperately needed, said Kyriacopoulos, who noted that APHL has had more meetings with congressional offices on Zika than it has on all other outbreaks combined. In particular, Kyriacopoulos worries that the inaction on Zika funding and resulting reprogramming of funds away from other public health priorities could set a dangerous precedent.

“Right now, we’re just kicking the can down the road,” he said. “This is not the way to effectively handle a public health crisis.”

Learn more about Zika:

Fighting antimicrobial resistance requires clinical and public health response

Fighting antimicrobial resistance requires clinical and public health response | www.APHLblog.org

By Kelly Wroblewski, director, Infectious Disease Programs, APHL

They may be invisible to the naked eye and their names may be hard to pronounce, but antimicrobial resistant bacteria – bacteria that don’t respond to common antibiotics – pose a serious threat to the public’s health that is impossible to ignore. Until recently, antimicrobial resistance was seen as a problem to be addressed at the patient or healthcare facility level where the impact on the lives of people was immediately visible. Testing, responding to and controlling antimicrobial resistant pathogens was not often seen as something that fell under the purview of public health. But that’s finally changing.

I began my career as a clinical microbiologist. My first job was the lead micro technologist in a small hospital laboratory in a rural area at a time when hospital acquired MRSA – or “nosocomial MRSA” –rates had doubled. I still think about a specific case, an eight-month old baby girl who was a patient in the ER. I drew her blood myself, brought it to the lab and immediately inoculated it into blood culture bottles. A few days later, I was the person to isolate and identify MRSA in her sample. Several weeks after she had been transferred to a hospital with more advanced pediatric care, I saw her obituary in the paper.

MRSA control was a significant focus for the hospital where I worked. Because we were a small hospital, it was easy to keep track of patients who presented with MRSA, something I began doing shortly after starting my job. The patient population was mostly elderly and we often admitted, discharged and readmitted patients from the community’s three long-term care facilities and one rehabilitation center. It quickly became clear that the frequent transfer of patients between facilities was contributing to MRSA rates in the entire county. (Patient transfers between health care facilities is a well-known source of antimicrobial resistance spread.)

The hospital was able to work with the other facilities to implement infection control strategies to control (but not eliminate) the problem. This was possible because our small community allowed for open communication between healthcare facilities and meant that all testing was occurring in a single microbiology laboratory. Coordination of this sort of response and control effort would be much more difficult in a more populous area without external monitoring and assistance. This is where public health can and should play a vital role.

Fighting antimicrobial resistance requires clinical and public health response | www.APHLblog.orgWhen I transitioned into a career in public health and joined the staff at APHL, I was surprised to learn that public health laboratories play a very limited role in antimicrobial susceptibility testing for what (to me) was and is clearly a public health problem. That is finally going to change.

In the coming year, public health laboratories will play a critical role in the Obama administration’s National Action Plan to Combat Antimicrobial Resistance. One of the initial roles for public health labs was announced by CDC last week: the launch of the Antimicrobial Resistance Laboratory Network (ARLN). Seven public health laboratories have been chosen to provide testing in support of a national surveillance system that will monitor and respond to drug resistance throughout the country. This fall the chosen laboratories will receive training and begin implementing highly specialized tests that will allow them to respond to outbreaks, characterize and track different mechanisms of resistance, and to detect new kinds of resistance in the pathogens that most concern public health officials. All 50 state labs, DC and several large local labs will also be implementing testing to confirm and characterize carbapenem-resistant Enterobacteriaceae (CRE), which has been described as one of the most urgent threats to public health.

APHL looks forward to assisting CDC in the roll-out, training and coordination of this laboratory network in the coming months. My colleagues and I are eager to see the impact of the ARLN on antimicrobial resistance surveillance and response activities

While no one will ever know if the ARLN or other new public health measures would have prevented that baby girl from contracting and succumbing to MRSA, I am optimistic that the network represents a significant step forward.

Read more on antibiotic resistance:

Top photo: This 2014 image depicts a Centers for Disease Control (CDC) microbiologist holding up two Petri dish culture plates growing bacteria in the presence of discs containing various antibiotics. The isolate on the left plate is susceptible to the antibiotics on the discs and is therefore unable to grow adjacent to the discs. The plate on the right was inoculated with a carbapenem-resistant Enterobacteriaceae (CRE) bacterium that proved to be resistant to all of the antibiotics tested and is therefore able to grow near the discs.