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2010 Report: Public Health Preparedness

Section 1: A National Snapshot of Public Health Preparedness Activities - Continued

Laboratories: Identifying and Understanding Emerging Public Health Threats

Laboratories identify disease agents, toxins, and other health threats found in tissue, food, or other substances. Rapid detection and characterization of health threats is essential for implementing appropriate control measures. Identification of the bacterium Salmonella Typhimurium in some peanut butter products in 2008-2009, for example, led to product recalls that stopped the spread of illness due to this bacterium.38 The ability to detect and characterize health threats relies on the availability of laboratory resources (including personnel), accurate and consistent methods, and quick data exchange systems.

CDC manages the Laboratory Response Network (LRN), a group of local, state, federal, and international laboratories with unique testing capabilities for confirming high priority biological and chemical agents. Located strategically across the United States and abroad, LRN member laboratories play a critical role in their state or locality’s overall emergency response plan to detect, characterize, and communicate about confirmed threat agents. Members perform standardized tests yielding reliable results within hours. Approximately 90% of the U.S. population lives within 100 miles of an LRN laboratory, decreasing the time needed to begin the response to a terrorist attack or naturally occurring outbreak.

Highlights of state and locality laboratory activities related to preparedness appear on the following pages. See the summary table on page 26 for national-level data on laboratory activities (Table 3).


The Laboratory Response Network is a group of local, state, federal, and international laboratories with unique testing capabilities for confirming high priority biological and chemical agents. Approximately 90% of the U.S. population lives within 100 miles of a laboratory in the Laboratory Response Network.

Source: CDC


Nationwide Testing for Responding to Biological Threats

The LRN was established in 1999 to create national laboratory capacity for testing biological threat agents and dangerous toxins. Specific examples of biological threats include anthrax, smallpox, plagues, and botulism.39

LRN biological laboratories are designated as national, reference, or sentinel laboratories.

  • National laboratories, including those at CDC, have the most advanced capabilities. These laboratories are responsible for specialized strain characterizations, bioforensics, select agent activity, and handling highly infectious agents.
  • Reference laboratories perform tests to detect and confirm the presence of a threat agent.
  • Sentinel laboratories are primarily hospitalbased and can test samples to determine whether they should be shipped to other laboratories for further testing.

In FY 2008, a total of 151 LRN laboratories in the United States could test for biological agents; 148 of these were reference laboratories and 3 were national laboratories. These laboratories maintain relationships with numerous sentinel laboratories in their jurisdictions that refer suspicious specimens to them for more advanced testing.

CDC funded 54 LRN public health laboratories in FY 2008, one in every state and one in the District of Columbia (with the exception of California, Illinois, and New York, which have two laboratories) as part of the Public Health Emergency Preparedness (PHEP) cooperative agreement. Additional laboratories that participate in the LRN include state and locally funded public health laboratories as well as federal, military, international, university, agricultural, veterinary, food, and environmental testing laboratories.

LRN laboratories could be reached 24/7. Because emergencies can happen day or night, emergency contacts for LRN member laboratories must be accessible 24 hours a day. In FY 2008, CDC successfully contacted 135 out of 151 LRN biological laboratories during a non-business hours telephone drill.

Laboratories improved their abilities to rapidly identify disease-causing bacteria. States must be able to detect and determine the extent and scope of potential outbreaks and minimize their impacts. PHEP-funded states must report on their ability to test for two bacteria and report results within a target timeframe of 4 working days (a CDC performance measure; see page 12). Laboratories in the PulseNet network40 (coordinated by CDC and consisting of public health and food regulatory agency laboratories) use CDC’s pulsed-field gel electrophoresis (PFGE) protocols to rapidly identify specific strains of Escherichia coli O157:H7 and Listeria monocytogenes.

States are improving their abilities to rapidly identify these bacteria. The number of states that submitted at least 90% of Escherichia coli and Listeria monocytogenes test results to CDC within 4 working days increased from 2007 to 2008 (Table 2).

Photo: A scientist at a state public health laboratory tests a tomato sample during an investigation into a multistate <em>Salmonella</em> outbreak.

A scientist at a state public health laboratory tests a tomato sample during an investigation into a multistate Salmonella outbreak.










Photo source: New Mexico Department of Health


Table 2: Rapid Identification of Disease-Causing Bacteria by PulseNet Laboratories; 2007-2008

Disease-Causing Bacteria Number of states submitting at least 90% of test results to CDC’s PulseNet database within 4 working days
2007* 2008** Percent Decrease
Escherichia coli O157:H7 22 out of 48 (46%) 29 out of 50 (58%) 26%
Listeria monocytogenes 10 out of 30 (33%) 18 out of 32 (56%) 70%

*Data for the 50 states from the PHEP cooperative agreement Budget Period 7 (August 31, 2006 to August 30, 2007)
**Data for the 50 states from the PHEP cooperative agreement Budget Period 8 (August 31, 2007 to August 9, 2008)
Source: CDC, OPHPR (DSLR)

Most laboratories passed proficiency tests for detecting biological agents. CDC conducts proficiency testing to evaluate LRN reference and national biological laboratories’ abilities to receive, test, and report one or more suspected biological agents. If a laboratory is unable to successfully test for an agent within a specified period of time and report results, it will not pass the proficiency test. In FY 2008, LRN biological reference and national laboratories passed 261 out of 277 tests (94%) to identify biological agents in unknown samples.

Nationwide Testing for Responding to Chemical Threats

In 2003, the LRN started testing clinical specimens to measure human exposure to toxic chemicals. LRN laboratories that can test for chemical agents are designated as Level 1, 2, or 3.

  • Level 1 laboratories have the most advanced capabilities. These are surgecapacity laboratories that can test for an expanded number of agents, including nerve agents, mustard agents, and toxic industrial chemicals. They also maintain the capabilities of Level 2 laboratories.
  • Level 2 laboratories test for a limited panel of toxic chemical agents. They also maintain the capabilities of Level 3 laboratories.
  • Level 3 laboratories work with hospitals and other first responders to maintain competency in clinical specimen collection, storage, and shipment.

In 2009, a total of 56 LRN laboratories in the United States could handle and/or test for chemical agents; 10 of these were Level 1 laboratories, 37 were Level 2 laboratories, and 9 were Level 3 laboratories.

A majority of LRN chemical laboratories demonstrated proficiency in core methods to rapidly detect and measure chemical agents. Level 1 and Level 2 chemical laboratories undergo proficiency testing to determine if they can use six core methods to rapidly detect and measure chemical agents that can cause severe health effects. These methods can help determine the scope of an incident, identify those requiring long-term treatment, assist with non-emergency medical guidance, and help law enforcement officials determine the origin of the agent. Laboratories are tested annually to evaluate ongoing proficiency in the six methods.

In 2009, 34 out of 47 Level 1 and/or Level 2 LRN chemical laboratories were able to demonstrate proficiency in all six core methods (an additional seven laboratories demonstrated capabilities in four or five core methods). It should be noted that the states and localities with Level 1 and/or Level 2 laboratories that are not proficient in all six core methods may have completed extensive work in the two steps that precede proficiency testing: training and validation in the core methods.

Budget and Workforce Cuts, Virus Uncertainties Strain State Response to 2009 H1N1 Influenza Pandemic

Budget and Workforce Cuts, Virus Uncertainties Strain State Response to 2009 H1N1 Influenza Pandemic
Health officials anticipated and prepared for an influenza pandemic. The identification of a novel H1N1 influenza virus in April 2009, however, still stressed the response capabilities of the public health system. Although every state had laboratories with pandemic response plans in place, many were operating with a reduced workforce. Additional challenges to a rapid response included obtaining approved testing equipment and supplies, and training staff on the new testing protocols. Despite these difficulties, every state and the District of Columbia had at least one public health laboratory that could test for the 2009 H1N1 influenza virus by early June.

While public health staff across the nation met these challenges by working long hours for several months, the response placed increased and unsustainable strain on a system already weakened by workforce shortages. Preparing adequately for future public health responses requires predictable and adequate longterm funding to improve infrastructure, staffing, and training in public health laboratories. In his May 2009 testimony to Congress, Daniel Sosin, MD, MPH, Acting Director of CDC’s Office of Public Health Preparedness and Response, noted that "with stronger laboratory capacity in states, we could accelerate the detection and study of new viruses such as the 2009 H1N1 virus, helping us to better understand and respond to emerging health threats."

Source: Association of Public Health Laboratories, On the Brink: H1N1 Drains Labs Hit by Cuts (2009)


Some LRN laboratories also demonstrated proficiency in additional methods. Proficiency in additional methods – required for Level 1 laboratories and optional for Level 2 laboratories – demonstrates a more advanced level of preparedness capability. CDC’s LRN program for assessing proficiency in detecting and measuring chemical agents continues to evolve through the ongoing incorporation of additional methods. Because the list of additional methods continues to increase, state and local laboratories are not expected to be proficient in all additional methods. (As of September 2009, there were six additional methods.)

In 2009, 26 out of 47 Level 1 and/or Level 2 LRN chemical laboratories demonstrated proficiency in at least one additional method to rapidly detect chemical agents. CDC continues to work with public health laboratories to assist them in expanding their chemical laboratory capacity to prepare for and respond to chemical terrorism incidents or other emergencies involving chemicals. CDC also partners with the Association of Public Health Laboratories to ensure support for public health laboratories involved in responding to chemical-exposure events from all sources, including those related to terrorism.

Maintaining Core Laboratory Functions During An Emergency

Improvements are needed in continuity of operations plans, which ensure that core functions of state public health laboratories are not disrupted during emergencies. In FY 2008, 23 of the 51 state public health laboratories and the District of Columbia had continuity of operations plans, 15 had state plans that included laboratory operations, and 13 were developing plans. More work is needed to ensure that laboratories can withstand emergencies.

National Snapshot of Laboratory Activities

A summary table of national-level data on laboratory activities in 2008 and 2009 appears on the following page (Table 3). Note that these items represent available data for preparedness activities and do not fully represent all state and locality laboratory efforts. For individual state and locality information in the area of laboratory activities, see Section 2 starting on page 42. See appendix 1 for an explanation of data points.

States Facing Challenges in Maintaining Laboratorian Workforce


Laboratorians provide critical expertise to effectively identify and respond to public health emergencies. Their responsibilities during a public health event include testing to identify known agents and providing timely laboratory information to response agencies.

According to a 2008 national survey, public health laboratories across the country are experiencing significant difficulties maintaining the highly skilled workforce of laboratorians necessary to ensure an effective response. State public health laboratory directors reported that the factors most severely impacting their workforce were hiring (41%) and retention (28%). For those reporting hiring as a primary concern, 36% identified lack of funding and 31% cited hiring freezes as impacting their ability to hire staff.

Sources: Association of Public Health Laboratories (APHL), Summary on Standards Needed for Preparedness Education for Epidemiologists, Public Health Laboratorians, Public Health Nurses, and Environmental Health Specialists/Sanitarians (2007). APHL, State Public Health Laboratories: Sustaining Preparedness in an Unstable Environment (2008).


Laboratories: General
Maintaining core laboratory functions during an emergency

Status of laboratory continuity of operations plan (COOP) for 50 states and DC:

  • 23 out of 51 had a state public health laboratory COOP
  • 15 out of 51 had a state COOP that included laboratory operations
  • 13 out of 51 had a COOP that was under development

APHL; 8/31/2007-8/30/2008

Ensuring availability of Laboratory Response Network(LRN) laboratory results for decision making

53 out of 54 states and localities had a standardized electronic data system capable of messaging laboratory results between LRN laboratories and also to CDC

CDC, OSELS; as of 9/30/2008

Laboratories: Biological Capabilities
Participation in LRN for biological agents

148 out of 151 LRN laboratories were reference laboratories that could test for biological agents

The remaining 3 LRN laboratories were national laboratories that could test for biological agents

CDC, OID (NCEZID); as of 9/30/2008

Assessing if laboratory emergency contacts could be reached 24/7

135 out of 151 LRN laboratories were successfully contacted during a non-business hours telephone drill

CDC, OID (NCEZID); 8/2008

Evaluating LRN laboratory capabilities

261 out of 277 proficiency tests were passed by LRN reference and/or national laboratories

CDC, OID (NCEZID); 1/2008-9/2008

Rapid identification of diseasecausing bacteria by PulseNet laboratories

Rapidly identified E. coli O157:H7 using advanced DNA tests (PFGE):

  • 50 out of 50 states performed tests on E.coli 0157:H7 samples
  • 29 out of 50 of the states that performed tests submitted at least 90% of test results to the PulseNet database within 4 working days

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

Rapidly identified L. monocytogenes using advanced DNA tests (PFGE):

  • 32 out of 50 states performed tests on L.monocytogenes samples
  • 18 out of 32 of the states that performed tests submitted at least 90% of test results to the PulseNet database within 4 working days

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

Assessing laboratory competency and reporting through exercises

49 out of 51 public health laboratories in 50 states and DC conducted exercises to assess the competency of sentinel laboratories to rule out bioterrorism agents

APHL; 8/31/2007-8/30/2008

Ability of CDC-funded LRN laboratories* to contact the CDC Emergency Operations Center within 2 hours during LRN notification drill:

  • 35 out of 54 laboratories passed
  • 15 out of 54 laboratories did not participate
  • 4 out of 54 laboratories did not pass

*There is one CDC-funded LRN laboratory in DC and in each state, with the exception of CA, IL and NY, which have two.

CDC, OID (NCEZID); 3/2008

Laboratories: Chemical Capabilities
Participation in LRN for chemical agents (LRN-C)

56 LRN-C laboratories in states and localities could respond if the public was exposed to chemical agents:

  • 10 out of 56 are Level 1 laboratories (most advanced testing capabilities)
  • 37 out of 56 are Level 2 laboratories (testing capabilities for limited panel of agents)
  • 9 out of 56 are Level 3 laboratories (specimen collection, storage, and shipment)

CDC, ONDIEH (NCEH); as of 9/14/2009

Evaluating LRN-C laboratory capabilities through proficiency testing

34 out of 47 Level 1 and/or Level 2 LRN-C laboratories successfully demonstrated all six core methods to rapidly detect chemical agents

26 out of 47 Level 1 and/or Level 2 LRN-C laboratories successfully demonstrated at least one additional method to rapidly detect chemical agents

CDC, ONDIEH (NCEH); as of 9/14/2009

Assessing LRN-C laboratory capabilities through exercises

LRN-C laboratories ability to collect, package, and ship samples properly during LRN exercise:

  • 49 out of 56 laboratories passed
  • 3 out of 56 laboratories did not participate
  • 4 out of 56 laboratories did not pass

CDC, ONDIEH (NCEH); as of 11/9/09

25 out of 31 Level 1 and/or Level 2 LRN-C laboratories successfully demonstrated the ability to detect 2 chemical agents in unknown samples during the LRN Emergency Response Pop Proficiency Test (PopPT) Exercise*

*Not all Level 1 and Level 2 laboratories are eligible to participate in this exercise.

CDC, ONDIEH (NCEH); as of 8/31/2008

Level 1 LRN-C laboratories took an average of 98.3 hours to process and report on 500 samples during the LRN Surge Capacity Exercise (range was 71 to 126 hours)

CDC, ONDIEH (NCEH); 1/9/2009



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