When you have the flu, it isn’t just about you

By Melissa Warren, Senior Specialist, Influenza, APHL

Fever, body aches, cough… you suspect the flu. You drag yourself out of bed to visit your healthcare provider where they use a swab to take a small sample from your throat or nose for a point-of-care diagnostic test. It’s positive; you’ve got the flu. After stopping at the pharmacy to pick up the antiviral medication that was prescribed, you head home to hunker down under the covers and queue up Netflix.

Unfortunately for the sample your healthcare provider collected, there is no time to rest. The point-of-care diagnostic test was just the beginning; that test gives your healthcare provider the information they need to provide treatment. But the public health system needs more information on how your case fits into the national – and, in many ways, the global – flu picture. At the end of the week, your healthcare provider’s laboratory staff sends all relevant samples to the public health laboratory. This is where your sample’s journey in the public health system begins.

Samples like yours inform the WHO, WHAT, WHEN and WHERE of influenza activity:

  • WHO is being most affected? Young children or the elderly? Are positive patients hospitalized or outpatient? Were they vaccinated or not?
  • WHAT type/subtype of flu is making people sick and how prevalent is that type/subtype? Furthermore, what is the specific strain and does it match well with the current vaccine?
  • WHEN did the season start, when does it peak and when will it end?
  • WHERE are people getting sick? What is happening in each state and/or region?

TWhen you have the flu, it isn’t just about you | www.APHLblog.orghis is a look at the journey your sample will take and how it will help the public health system respond to this flu season and prepare for the next. Get ready, little sample! It’s a long ride…

(Click the infographic to view larger size.)

Arrival at the public health laboratory

Your sample arrives at the public health laboratory’s centralized check-in where the package is opened, paperwork is reviewed and a laboratory identity is created (your personal identity no longer accompanies the sample). Because public health labs receive hundreds of samples every day for not only respiratory illnesses such as flu, but also diarrheal illnesses, sexually transmitted infections, newborn genetic screening and many others, this process is critical to ensure each sample is accurately documented and delivered to the appropriate laboratory for testing. In fact, during the course of one flu season, a state public health laboratory can receive approximately 4,000 samples for influenza testing alone!

Once that process is completed, your sample is delivered to the virology lab for testing.

Testing Begins

Your sample has been kept cold and properly stored to maintain the integrity of the virus, which is important for the laboratory testing. This lab uses a molecular method called PCR to rapidly amplify and detect a region of viral RNA. In fact, the PCR test performed at public health labs is specially designed to not only confirm and subtype flu, but also to detect new and emerging flu viruses. This is an important function of public health labs as our nation’s first line of detection for novel flu viruses.

Results received and reporting begins

The test results for your sample indicate you are sick with influenza B. Because your case is typical for flu season, state epidemiologists do not initiate further investigation. However, the data from your sample does get included in their weekly summary report informing physicians and the public of influenza activity in your state. Furthermore, this information is recorded electronically in the laboratory information management system (LIMS) and a lab report is faxed back to your healthcare provider’s office. (This information typically would not impact your treatment.) Data is also transmitted to the Centers for Disease Control and Prevention (CDC) for national flu surveillance using the Public Health Laboratory Interoperability Project (PHLIP). Standardized PHLIP messaging simplifies the secured electronic transfer between public health laboratories. Once at CDC the data contributes to FluView, their weekly flu surveillance report.

Further characterization of specimen

Your sample was selected to be included in your state public health lab’s biweekly shipment to their designated national Reference Center – one of three National Influenza Surveillance Reference Centers, state public health laboratories that act as an extension of CDC’s Influenza Division – where it will be isolated and further characterized.

Every two weeks during flu season, all state and some local public health laboratories participate in national surveillance by sending up to eight influenza specimens to one of three National Influenza Surveillance Reference Centers. These eight specimens consist of up to two samples of the four seasonal strains of flu: influenza A(H3N2), influenza A(H1N1)pdm09, influenza B/Yamagata lineage and influenza B/Victoria lineage positive specimens. When combined with all of the other public health lab submissions, this relatively small number of samples allows CDC to watch closely for drift. (Drift happens when small genetic changes accumulate over time as a virus replicates and result in viruses that are antigenically different. When this happens, the body’s immune system may not recognize those viruses and may have trouble fighting them off). And with all of that information, CDC can be 95% confident that, should a drift variant emerge at 3% prevalence or higher across the country, at least one of those drift variants will be detected over a month surveillance period. Knowing about drift sooner would hopefully lead to a quicker response than before this submission guidance was in place. At the reference centers and CDC, these specimens undergo further antigenic and genetic characterization which generates data that helps select strains to be used in the development of future seasonal vaccines.

Finally your sample gets to rest

After a whirlwind of tests, your sample finally gets to rest in a chilly -80°C freezer. Public health laboratories keep samples like yours should additional testing be needed and to aid in the development and validation of new laboratory tests or methods.

Your little sample contributes in a big way

While the sample sits frozen, the data remains actively in play. Public health officials will look at the data from your sample along with thousands of other data points to determine what influenza strains are circulating in the United States, detect novel viruses and monitor whether the virus begins to drift away from the strains in the vaccine. On an even bigger scale, vaccine strain selection is a global process so your sample may ultimately inform vaccine strain selection for the entire world.

Next time you are sick and your healthcare provider takes a little sample from your nose, remember that you are not only getting the diagnosis necessary for your own treatment but you’re contributing to national and global influenza response.

Read more about influenza response:

When you have the flu, it isn’t just about you | www.APHLblog.org

 

APHL Staffer Shares her Career Path with the Next Generation of Public Health Students

By: Bertina Su, MPH, senior specialist, Laboratory Systems and Standards, APHL

Last fall I was invited back to my alma mater to talk about life after University of Maryland’s (UMD) Master of Public Health (MPH) program. A former classmate was coordinating an informational session for undergraduate students to help them get a sense of where the MPH grads went in their careers; she asked me to participate and I happily accepted both because she is a friend but also because I could have used an event like this when I was finishing my undergrad degree.

APHL Staffer Shares her Career Path with the Next Generation of Public Health Students | www.aphlblog.org

My journey into public health was not something that I planned. I earned a bachelor’s degree from Washington and Lee in chemistry, but as graduation loomed, I still had no idea what I wanted to do with my life after receiving my diploma. Reality was sinking in. My fellow chemistry classmates went into research or continued to medical school, and while those options seemed to be the logical next steps, they were not the right fit for me.

I took a year off after graduation to volunteer at Bread for the City, a non-profit in Washington, DC, that provides food, clothing, medical care, legal and social services residents in need; it was there that I became exposed to the world of public health. I worked in the medical clinic doing mostly administrative work helping with health insurance enrollment and coordinating health education programs. I began to understand what public health was, and that I could use my science education in this field to help people. I spoke with many of the staff about how they found their way into public health, and they all had MPH degrees. It became clear that if I wanted to move my career in this direction, I needed to find an MPH program that worked for me. Before I knew it, I was back in school learning about biostatistics, program evaluation and epidemiology. After completing UMD’s two-year MPH program, I interviewed for a program manager position at APHL, and I have been here ever since.

Fast forward a few years… There I am setting up my information table at UMD’s School of Public Health featuring APHL’s Annual Report, Lab Matters and my own business cards. I even wore my APHL STAPH staff t-shirt. I had the opportunity to speak with several students who asked questions mostly about my MPH experience and responsibilities at APHL. Some were not familiar with either public health laboratories or association work, so it was rewarding to expand their knowledge. I talked about my quality improvement and survey work, but their ears really perked up when I told them that I get to travel and work with people all over the country.

I’d love to see undergraduate public health programs hold more events like this one to give the next round of graduates the opportunity to hear from alumni about their journey into the public health workforce and about other career paths they had not considered. While my path into public health may have been unconventional, I am thankful that I took it. The work has been rewarding, and I hope that my participation will encourage another public health student to pursue an equally fulfilling position.

I encourage you to contact your alma mater to share your knowledge, experience and lessons-learned with public health students. You just might inspire someone to pursue a career in a public health lab.

Keeping Tabs on Deadly Diseases

Microscopic view of Ebola virusCDC is responsible for protecting the public from a host of health threats, including some pretty scary pathogens, like Ebola virus or anthrax for example. One way we do this is through our Select Agents Program which is responsible for governing and regulating the use of certain pathogens by research facilities and labs around the world. In the beginning of December I had the remarkable opportunity to accompany the inspection team who helps regulate the Select Agents Program on one of their routine lab inspections. I was invited to an inspection of a laboratory in the Southeast region of the U.S. that handles rare and dangerous pathogens to get a glimpse of how the Inspection team operates, what they look for, and what they do to protect us.

Laboratory inspections are an important aspect of the Select Agents Program since they ensure that labs and research facilities are complying with guidelines and regulations specific to biological research. In order to improve our understanding of human health and disease, some laboratories handle rare and potentially dangerous biologic agents and toxins, which are known to cause severe infection, illness, and sometimes death in humans. Laboratories that possess and use these types of biologic agents and toxins for manufacturing purposes, research use, or diagnostics must be registered through this program. When they register with the program, they agree to follow all requirements in the regulation (42 CFR Part 73 – Possession, Use and Transfer of Select Agents and Toxins) including, safety, incident response, security, and having appropriate training in place. CDC’s job is to ensure that all precautions are being taken at laboratories so that the public remain unexposed and unharmed by these potential health threats.

Suiting Up

Man inspecting door sealThe inspection that I joined actually began one week prior to the inspection date when I met with the Inspection Team to prepare a folder with all of the Southeast facility’s biosafety plans, incidence response plans, and security plans. The following week, I flew to the site to meet with the inspection team. I was set to be with the team for the first and most active day of their inspection.

The inspection started with introductions and a briefing among the group. Then there was a visitor’s training to instruct all personnel of potential hazards as well as actions to take in the event of an emergency. To avoid workplace injuries and hazards, personnel must meet all occupational health qualifications. In this laboratory, personnel must perform an exercise test to confirm adequate fitness to wear a respirator. There are two types of respirators at this facility, one that is simply a facemask and another that is a full-body suit. The team thought that I would opt for the full body respirator because it did not require that I shave my beard. However, I gladly accepted the challenge to dawn the facemask respirator (and shave my beard!) to earn my place as member of the team.

Suited up in gowns, gloves, shoe covers, masks and other inspector accessories, we were ready to begin our inspection. Our goal was to go through all of their laboratory space to check that the facility was adhering to appropriate biosafety measures. We checked biological safety cabinets and animal cages, catalogued inventory, and performed other tasks associated with laboratory compliance. Lab personnel graciously halted their work during our visit

The devoted team sought to conduct as much of the laboratory-based inspection as possible the first day. We were successful. After seven hours of tireless work and a brief stint for lunch, we had canvassed the entire facility. The personnel at the Southeast facility were pleasant, welcoming, and grateful for the visit, remarking that they looked forward to an external perspective. Having thoroughly inspected the lab, we finally retired for the day.

A Days Work is Never Done

Man and woman wearing protective gear and holding note books in a laboratory Though I remained for only the first day, the team continued diligently throughout the week. They reviewed all of the Southeast facility’s documents, checked its security, and evaluated its waste, storage, and laboratory maintenance procedures. The team is then responsible for generating a report that lists observations that deviate from regulatory requirements. After much collaboration between the Select Agents Program and the Southeast facility, the Southeast facility is expected to implement changes to receive standard renewal.

I was incredibly impressed with the Select Agents Program’s laboratory inspection. I know that because of them, we can rest assured that high containment facilities operate at the toughest standards. Thanks to this program, the biosafety measures in place consistently enhance the safety and security that the CDC promises to uphold to the American people.