Public health labs and the Ebola response: ‘This is the type of work they do day in and day out’

By | 2018-01-14T17:36:01+00:00 November 25th, 2014|0 Comments

Months before the first case of Ebola was diagnosed in Texas, the state’s public health laboratory had begun preparing for the disease to reach U.S. shores. And while the virus itself is an uncommon threat in this country, the response of the nation’s public health laboratory system wasn’t uncommon at all — in fact, protecting people’s health from such grave threats is exactly what public health laboratorians are trained to do.

“Having that preparedness background, we’re always ready to get that call at 3 in the morning,” said Grace Kubin, director of the Laboratory Services Section at the Texas Department of State Health Services. “Our staff is already in that mindset, they know they have to be on top of their game all the time. …When you hear about Ebola and hear about the deaths, it makes people pause and rightly so — it’s a deadly disease. But because of their training, the lab staff are able to work through that and get the job done.”

Frenzied news coverage of Ebola in the U.S. may have given the impression that the nation’s public health system was scrambling to respond. The truth, though, is that confronting and containing a disease like Ebola through identification, investigation, science, education and prevention is exactly what the public health system is designed to do. And since the terrorist attacks of 2001, state and local public health departments have received billions in preparedness funding to strengthen the system’s capacity to respond to all types of hazards, including infectious diseases such as Ebola. One of the critical foundations of that system is the public health laboratory. Indeed, it’s not a stretch to say that the public health laboratorians who quickly and accurately identify dangerous diseases and keep in close contact with sentinel labs throughout their communities provide the foundation for the vital disease containment work that follows.

In Texas, the state public health lab that diagnosed the first U.S. Ebola case is part of the Laboratory Response Network (LRN), which became operational in 1999 and is charged with “maintaining an integrated network of state and local public health, federal, military, and international laboratories that can respond to bioterrorism, chemical terrorism and other public health emergencies,” according to the Centers for Disease Control and Prevention. Today, there are more than 150 members within the LRN, representing every U.S. state, Australia, Canada, the United Kingdom, Mexico and South Korea. Texas was among the first dozen of LRN labs to receive the Ebola detection test kit, which was developed at the Department of Defense and which received emergency use authorization from the U.S. Food and Drug Administration in August.

That same month, CDC contacted the Texas state public health lab about Ebola testing, Kubin told me. The lab was a perfect choice — its staff was already highly skilled in handling dangerous infectious and bioterrorism agents. After Kubin received approval from the state health commissioner to move forward with Ebola testing, preparations began. The lab received its first Ebola test kit in August. The test is known as a polymerase chain reaction (PCR) test and it’s a “test that our team is very familiar with running,” Kubin said. To make sure lab staff could accurately use the test, CDC sent them a blind sample panel (or a qualification panel). Staff don’t know what the panel contains and have to effectively deploy the test kit — following its protocols precisely to a tee — to get the correct result. The lab heard from CDC in late August that it had passed the qualification panel on its first attempt.

Kubin and her lab colleagues also began working with epidemiologists within the health department’s Emerging and Acute Infectious Disease Branch to ensure that the proper criteria were in place to determine who would be screened for Ebola. (Kubin noted that the department’s epidemiologists are accustomed to working with local health care providers any time the state experiences a serious outbreak, such as measles or food-borne illness. They’re able to really hone in on the risk factors related to Ebola, which has symptoms similar to many other diseases, and isolate the cases that should be referred for testing, Kubin told me.) Once the epidemiologist gets approval from CDC to test a patient for Ebola, lab staff work with health care providers to make sure blood samples are drawn correctly and the sample is safely packaged and shipped.

On Monday, Sept. 29, at 3 a.m. in the morning, Kubin got notice of a possible Ebola case in Dallas. (That patient was Thomas Eric Duncan, who traveled to Texas from Liberia and who eventually succumbed to the virus.) Later that same day, CDC gave approval for the Texas lab to test Duncan for Ebola, and a specimen was shipped to the lab the next day. The lab received the specimen at 9:07 a.m. on Tuesday, Sept. 30. Results were in just hours later at 1:22 p.m. In addition to testing Duncan, the Texas lab also tested specimens from the two nurses who contracted Ebola while caring for Duncan.

While I was talking to Kubin about the lab’s role in containing Ebola, it was clear that while Ebola is certainly an unusual threat to face in Texas, the lab’s response is hardly out of the ordinary. Her message was clear: This is what we do — this is what we train for. Like all labs in the LRN, the Texas public health lab has “Biosafety Level 3” capacity, which means it has the training, infrastructure and resources to test for infectious agents that can cause serious and lethal diseases. As an LRN member, the Texas lab also works with hospital and commercial labs (also known as sentinel labs) to provide training on testing as well as how to safely package and ship specimens. (Not surprisingly, when I spoke with Kubin in early November, the lab’s upcoming packaging and shipping training was completely full.)

Kubin credited much of her lab’s emergency capacity, in part, to federal public health preparedness funds. Unfortunately, as of fiscal year 2013, funding for CDC preparedness and response activities was down by $1 billion since funding began in 2002 in response to the Sept. 11 terrorist attacks.

“That funding has allowed us to be ready to handle Ebola,” Kubin said. “That was our foundation, that was our infrastructure. The funding we receive today pays for people who do the work and supports the facility we’re working in. These are highly specialized lab facilities and a huge amount goes into making the people and the environment safe. There will always be ongoing and recurring costs.”

To the west in Arizona, Victor Waddell, laboratory director of the Arizona Public Health Laboratory at the Arizona Department of Health Services, noted that “yes, labs are expensive…but in this instance, we can show the value that people are getting for their money.”

Waddell is referring to his lab’s capacity to test for Ebola. A member of the LRN, the Arizona lab received the Ebola test kit in early October and passed the validation panel on its first attempt. Like their public health lab colleagues in Texas, responding to the Ebola threat is part and parcel of what the Arizona lab does on a routine basis. Arizona public health lab staff regularly take part in drills and activities that exercise the lab’s response and surge capacity; staff also work with sentinel labs throughout the state to provide biosafety, packaging and shipping training. (When I spoke with Waddell in late October, he said the lab had been fielding many calls a day, mostly from sentinel labs with questions about developing a response plan and safely packaging and shipping specimens for testing.) As part of their Ebola response, Waddell said the lab began posting extra guidance for sentinel labs, emphasizing the need to ramp up biosafety supplies and personal protective equipment. The Arizona lab’s capacity and training mean that it’s able to test for Ebola and procure a result within six hours of receiving a specimen.

“Being in the lab, we think a lot differently about these things because we’ve been brought up to know how to handle these types of infectious diseases,” Waddell told me. “You can ask people in the lab if it scares them and they’d say, ‘no, we handle (these types of agents) all the time.’ …From a lab perspective, we’re here to help people, we’re here to make sure the (public health) system can respond effectively. It’s really key for the lab response to be a part of this and to be able to get samples tested quickly so public health officials can make appropriate decisions.”

In fact, the work of the nation’s public health labs in response to Ebola is not much different than how they would respond to other emerging threats, said Chris Mangal, director of public health preparedness and response at the Association of Public Health Laboratories (APHL).

“This is a core function of public health laboratories, so this is a typical part of their routine,” Mangal told me. “This is the type of work they do day in and day out.”

As of Nov. 17, 39 U.S. public health laboratories have the ability to test for Ebola using the Department of Defense-developed test kit, which is distributed through the LRN system. According to Mangal, the LRN is the perfect mechanism for such distribution — it holds its member labs to a high standard of quality and safety and has a standardized communications network that allows laboratorians to rapidly communicate and share results with CDC. For example, it was the same network used to test for H1N1 as well as Middle East respiratory syndrome (MERS). The LRN facilitates constant dialogue and information sharing, noted Peter Kyriacopoulos, senior director of public policy at APHL.

But all of this capacity doesn’t come for free, Kyriacopoulos said. Sustainable funding is needed to support public health lab technology, procure equipment, maintain that equipment and make sure staff knows how to safely and effectively use it. Ongoing proficiency as well as surge capacity is key, Kyriacopoulos said, adding that in light of the strain that results from funding cuts, “we’re fortunate that we have not had more than one crisis develop at a time.”

“So much of our response starts with the public health lab,” he said.

According to the latest report from the World Health Organization, there have been 15,351 reported Ebola cases in eight countries with nearly 5,500 reported deaths. Liberia, Guinea and Sierra Leone continue to experience the worst of the global outbreak.

To learn more about the role of public health laboratories in protecting the nation from emerging diseases and threats, visit the Association of Public Health Laboratories.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

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Kim Krisberg
Kim Krisberg is a freelance public health reporter living in Austin, Texas, and has been writing about public health for more than 15 years. Follow me on Twitter — @kkrisberg — or send me story ideas at

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