Steps to Improve the Network
The Stevens case revealed both strengths and weaknesses in the laboratory network, according to Susan Sharp, director of the Clinical Microbiology Laboratory at Mt. Sinai Medical Center and Miami Heart Institute. She told a panel of lab experts during an Internet videoconference sponsored by the CDC that the hospital laboratory performed well, producing preliminary test results consistent with a diagnosis of anthrax within a few hours of the patient’s admission. Given the rarity of anthrax, this was quite remarkable.

However, like most Level A laboratories, it was not equipped to run the tests for a definitive diagnosis, so the hospital sent the specimen by overnight courier to a lab 300 miles away. The hospital personnel did not know there was a Level B laboratory just 25 miles away that could have run the confirmatory tests and thus produced the definitive result 24 hours faster. This weakness reveals one of the ways the laboratory network is being improved. Awareness of the resources available and their location is an important factor in expediting the processing of specimens, required for more rapid diagnosis.

(Important Note: It is very unlikely that an earlier diagnosis would have made a difference in Stevens’ case. By the time he arrived at the emergency room, it was already too late. While he was given massive doses of antibiotics, the anthrax had already spread through his system, where it had released deadly toxins.)

Federally-funded courses to make lab personnel aware of just these resources has been and will continue to be offered to further improve the ability to rapidly respond to public health emergencies such as this one. Other steps that are being taken are described below.

Training
As part of setting up the network, special training is being provided to Level A laboratories to familiarize them with potential threats and to train personnel in how the response network works. As the Stevens example showed, personnel in Level A laboratories need to know which Level B lab is closest to them and who their contacts should be. Lab personnel also need to be familiar with certain details, such as the correct packing and shipping protocols for these samples.

The CDC is providing technical information to Level A labs, for example posting the correct protocols for testing on its website and that of the American Society for Microbiology, where Level A labs can find quickly the correct approaches to tests. Most important, the CDC is urging local laboratories to develop an action plan should they be confronted with a suspected terrorist attack.

The CDC’s work on upgrading this network began before the terrorist attacks of September 11th 2001. “The National Laboratory Training Network has provided 95 different courses to approximately 5,000 participants since January of 1999,” said Sharp. Laboratories are being sent educational videos and CD-ROMs, and personnel can find additional educational information on the websites of the CDC and American Society for Microbiology.

Upgrades and Added Resources
Level B labs are being upgraded with new technologies, and the approximately 100 Level B and C labs are being linked through a secure website. Stockpiles of antibiotics are being expanded, and the CDC is increasing the amount of available reagents and special kits, which are needed to perform many types of medical tests.

Pilot Projects
A key to the functioning of the network will be the actions of state governments, and the CDC has funded pilot projects in four states to improve their ability to respond. At the recent conference on preparedness sponsored by the CDC, Norman Crouch, director of the Minnesota Public Health Laboratory, discussed key aspects of the pilot project in his state.

“First of all,” he said, “Minnesota is developing a comprehensive statewide database of all the Level A laboratories in the state.” This database will include information on key contacts in each Level A lab, and these people will be provided with the phone numbers of key personnel in the state lab so they will know whom to call in an emergency. This database will also include the level of staff training and the technical expertise of personnel as well as the technical and communication capabilities for each laboratory.

“Secondly, we’re developing in Minnesota an effective communications system between all of the clinical laboratories and the state laboratory,” Crouch said. By developing a broadcast e-mail and fax capability, the state lab will be able to reach all the Level A labs with important information. For example, if one laboratory started to see patients with a mysterious ailment, other laboratories could be alerted to look for that same condition. The state is also working with a secure password-protected website for distributing important information to laboratories.

In addition, the state is pursuing what Crouch calls “active surveillance,” for example, “sending out a message every morning to all these clinical laboratories to ask them to report back immediately” whether they have found any suspicious specimens that could be related to anthrax.

Crouch said that the state is also trying to develop a reliable courier system and a “surge plan” so the state laboratory can expand its capacity to handle an extremely large volume of testing. The state laboratory could be overwhelmed by the demand for testing but could use its database to identify other laboratories, such as Level A labs with special capabilities, where it could quickly distribute the load of unexpected samples for testing.