While it appeared that the 9/11 and anthrax tragedies were unforeseen and caught the country totally unprepared, public health departments and laboratories had been planning for disaster for years.
For public health laboratories, the coordinated national response framework began with the formation of the Laboratory Response Network (LRN)by the Centers for Disease Control and Prevention(CDC), the Federal Bureau of Investigation (FBI)and the Association of Public Health Laboratories(APHL). This national resource became operational in August 1999 and continues as a collaborative effort among the founding partners. That early framework has been strengthened by the infusion of federal preparedness funding in the decade since the events of 2001, but support is eroding and new challenges face the network.
When the planes hit the World Trade Center towers, the LRN steering committee was meeting at CDC. The first crisis driven action of the LRN was the preparation and distribution of a message reminding member laboratories to consider the risk of secondary attacks and to be on the alert for unusual packages and samples. The LRN planning provided the contact information needed to quickly send critical information to every state and major city public health laboratory.
The initial planning, development, distribution and use of common laboratory assays, training of personnel and consistent use of those procedures prevented total chaos when anthrax spores were dispersed through the mail in 2001.Laboratories would have cultured those ‘white powders’ and other environmental specimens and used unfamiliar testing protocols to identify the organisms that grew. Misidentification would have happened and the credibility of the state laboratories would have been challenged.
The people in Virginia who contracted anthrax survived. Part of the reason for the positive outcome was the responsive infrastructure developed through the LRN.
One patient went to an emergency room and was discharged after having a blood sample drawn for culture. When the blood culture developed growth, the hospital sent the lab the positive bottle. Within40 minutes of receiving the specimen, the LRN polymerase chain reaction was reactive for Bacillus anthracis. The patient returned to the hospital and was successfully treated with the appropriate antibiotics. The LRN provided the assay, the equipment, the reagents and the training. Having that laboratory infrastructure available prevented deaths, and having consistent, reliable laboratory testing available in every state and major city helped calm the hysteria after it was determined that anthrax was being sent in letters through the postal system.
The Division of Consolidated Laboratory Services(DCLS) avoided inundation with low or no priority samples because relationships had been built. District Health Departments, local police departments, fire departments and hazardous materials teams coordinated sample collection and triage to assure that only credible samples reached the laboratory. The system didn’t always work, but the laboratory wasn’t completely overrun with samples. Still, the laboratory ran out of space to secure samples before and after analysis. People worked 16-hour days to keep up with the workload; white powders and other samples were tested for anthrax and timely reports were issued to the submitters. And the laboratory system learned from the experience.
A Decade of Progress
Still the relationships weren’t perfect. When anthrax hit, hazmat teams and many local responders had not identified DCLS as their laboratory. They do today and they know how to access and use DCLS. While the early response was good, the interactions today between the local first response communities and the lab have improved dramatically. First responders train with laboratory personnel. Procedures now instruct first responders to split the sample and send a portion to DCLS before exhausting the sample with field assays. Priority and high profile samples are split and a portion is sent to DCLS for a definitive analysis.
In 2001, DCLS was in an old building that didn’t have secure evidence storage for samples before testing. Locks were put on the conference room to secure the ‘evidence.’ Shelves were added. Someone stood at the building entrance to log samples and assure chain-of-custody and integrity of packaging was intact. Without a Laboratory Information Management System (LIMS)everything was logged, analyzed and reported on paper. Samples were placed in red bags and moved to the pre-analytical evidence room. The lab did not have an evidence storage facility for samples that had already been tested. An unused firing range in the basement was retrofitted for post-analytical evidence storage.
Retrospectively, the attacks proved to be a great training exercise. The ability to respond has been improved by the Public Health and Emergency Preparedness cooperative agreement. That surge of funding helped restore the failing public health infrastructure and provided staff, new equipment and a far more robust training mechanism.
The preparation/capability/infrastructure is eroding — state and local salaries have not kept up with the times; we lose good people to positions in other laboratories or to other careers. Routine equipment maintenance agreements are essential to assure timely service and preventive maintenance on critical equipment, yet those agreements are expensive. A maintenance agreement on a $150,000 piece of equipment can cost $20,000 or more per year.
Unfortunately, aging of the existing laboratory infrastructure isn’t the country’s only vulnerability. Currently, the country has very limited capability and capacity to test environmental samples for chemical weapons materials, and few laboratories have the equipment and expertise to test human samples for radiation. If someone in the United States was exposed to Polonium, similar to the event that occurred in England, our total country-wide laboratory capacity would be overwhelmed in hours. Radiation testing equipment is expensive and trained personnel are in very short supply. Ramping up laboratory capability and capacity after an attack would be incredibly difficult if not impossible.
My view of laboratories and their relationship to public health might be different than others because of the way the Virginia laboratory is structured. We are not just a state public health lab charged with providing support for the Virginia Department of Health. DCLS also provides laboratory consultation and support for the Department of Environmental Quality, the Department of Agriculture and Consumer Services, the Department of Labor and Industry and many other local, state and federal Agencies.
The laboratory is a Division in the Department of General Services, an agency that does not use DCLS testing. Consequently, the laboratory had to build strong relationships with various government agencies, law enforcement groups and others to ensure the pipeline of samples and other responsibilities flows efficiently.
We moved into our new building in May of 2003.A training lab was a priority in design. We knew that access to laboratory training was essential to having a robust laboratory system in Virginia. Science changes and the laboratory must adapt. Laboratory space was designed for maximum flexibility to accommodate change without renovation. The events of 2001 provided many insights into how that flexibility might be needed. LIMS now support critical laboratory functions. We are better staffed. We have much more capacity and more equipment.
If a similar attack occurred today, the laboratory would be far more capable of providing timely and accurate laboratory support.
Jim Pearson, Dr. PH, BCLD,Virginia Department of General ServicesDeputy Director for Laboratories,Consolidated Laboratory ServicesDuring 9/11 and Anthrax