On September 7, 2001, I broke my leg. On September 11, 2001 a senior scientist ran down to the lower floor of our lab with the most shocked look on her face I have ever seen. Much like my leg, that was the initial feeling (or lack thereof):numbness. We had prepared for something like 9/11 and the anthrax attacks that followed — but we could never really imagine something like that until it happened.

In 1997, we began working with law enforcement to put in place protocols should a biological attack occur. By 2001, we had a level of understanding with the Federal Bureau of Investigation(FBI) and I, as head of the Missouri state lab, had met with the FBI weapons of mass destruction coordinators to create protocols for how to process suspected biological agents. Because of these relationships, it was much easier to coordinate with local law enforcement and draw resources from our state health department to ensure first responders knew how to process potential biological agents.

Consequently, we had the authority to exercise more control over what was submitted to the laboratory and what we had to test. This saved us from being completely overrun with samples like some other states. This groundwork proved to be invaluable.

As head of the Missouri state laboratory, I knew my job was to keep things running as close to normal as possible. This meant efficiently testing all the powders and other oddball things that came in, but also ensuring that we were meeting our routine obligations such as the newborn screening, since babies were still being born. In short, we had to handle the influx of samples while not cutting vital services to Missourians.

Immediately after 9/11 we enacted our emergency response plan which included specific measures for microbiological attacks. We extended work hours and set up rotations to handle the massive amount of samples. Instead of working 8:00-5:00, we worked 6:00-8:00 and had people on call 24 hours a day. But I made sure we rotated people through so as not to burn them out. Given the shock of the events, we had to be careful not to over-stress people more than they were already.

In total, we ran around 500 samples over the course of about five weeks — with most coming during the first three weeks. We also processed a hundred or so additional samples forth Centers for Disease Control and Prevention(CDC) because a pallet wound up in Kansas City that was originally in New Jersey. In total, we had done a pretty good job preparing for some sort of tragedy — we knew there would be a massive influx of work. However, what we didn’t account for nearly enough waste need to help the public work through these tremendous tragedies.

Lab’s Lab

In a sense our lab staff was lucky. With security heightened, our building was determined to be a possible target so we were given guards. Our security detail was pulled from the state fire marshal’s office and with him came his Labrador retriever. Quite simply, the dog helped our workers. If the marshal and his dog were there to greet them in the morning, they knew all was well. The dog would greet every person with a wag of its tail. The dog was calming and reassuring — it was something normal during a time that was anything but. We rechristened the dog “the Lab’s lab.”

I knew that we had to try and provide the same level of comfort to the public.

As the head of the lab, I took it upon myself to be the front end of the response and shield my staff from the media so they could perform the real and potentially life-saving tasks. Since the media knew where the suspect anthrax samples were coming, I worked with the health department administration and became the spokesman because I knew what to say, what not to say and that I could give the right amount of information succinctly— so I spoke with media across the state for about a month — almost nonstop. It was crucial to place myself at the center of the information because there were so many rumors circulating and it was difficult to coordinate within all levels of the health department.

That said, I don’t know if there was much we could do to completely ease the public’s concerns. Nevertheless it’s vital to work with the public and disseminate clear, concise and consistent messages. I think this is overlooked as a critical element in response to any tragedy.

As we tried to calm the public, samples came in less frequently, eventually returning to the norm of two to three environmental samples per month.

Lessons Learned

Aside from the learning curve involved with informing the public, the biggest challenge we had was that no one was really battle-tested when it came to operating the incident command center concept. This concept is “a set of personnel, policies, procedures, facilities and equipment, integrated into a common organizational structure designed to improve emergency response operations of all types and complexities” according to the United States Center for Excellence in Disaster Management and Humanitarian Assistance.

Once samples stopped coming in, we immediately worked to get people trained in incident command. With the funding from the Public Health Emergency Preparedness (PHEP) agreements, Missouri and other states were able to stand up their emergency response operations, specifically utilizing incident command principles. This represented a major shift in how labs prepared for potential attacks.

By the time H1N1 rolled around, there was a dramatically improved ability to quickly stand up emergency response centers — a capability we didn’t have in 2001. This really represents the big change in the last decade. While we incorporated some of these response strategies in 2001, we were slower to get there and it wasn’t under one unifying umbrella. Now with all the training and certifications, it can be stood up much quicker.

Quite simply, with incident command, we can better respond on a broader front as a health department and lab to the public and are better equipped to organize the response to the event itself.

We Need to Keep Going

The current budget situation and economic climate has started to erode the response capability and capacity in public health laboratories and agencies. I’m not trying to overstate this but the PHEP agreements have been diluted by funding more activities with the same amount, or less money. States have laid people off, reduced services and lost people who have the response expertise and experience.

We have worked hard to build incident command and expanded the number of labs with information management systems. However, my real fear is that now that we can take lab data and zip it from state-to-state and get it to providers and public health agencies, there won’t be anyone in the labs to do the tests and in the health agencies who know how to act on the information. I am truly concerned that what we have built up to respond to these events (which worked for H1N1) is eroding significantly.

If you said to me that tomorrow we’ll have another event, I’d think that you’ll see states scramble to be able to respond. We are probably victims of our own success because the H1N1 response went so well that the laboratory role is taken for granted and undervalued by policymakers and our public health colleagues.

My concern is not abstract. When you think about what is happening in Japan with their nuclear plants, it reminds me of the situation in Chernobyl in the late 1980s. Back then, the United States had many sites throughout the country monitoring air. Yet now we are looking to just state capabilities on the west coast to monitor air quality and possibly standing up 10 more labs to monitor air quality across the country. If there is a release, we need to know more than just what is dropping on the west coast. What about the central part of the country? The east coast? With this recent event in Japan and our experience 10 years ago, we know a biological event requires a country-wide response, yet we haven’t maintained that capability and there doesn’t seem to be the interest or will to restore it.

By Eric C. Blank, DrPH, Senior Director, Public Health Systems, Association of Public Health Laboratories

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