Burton W. Wilcke

The State Public Health Laboratory System

This article describes the development since 2000 of the State Public Health Laboratory System in the United States. These state systems collectively are related to several other recent public health laboratory (PHL) initiatives. The first is the Core Functions and Capabilities of State Public Health Laboratories, a white paper that defined the basic responsibilities of the state PHL. Another is the Centers for Disease Control and Prevention National Laboratory System (NLS) initiative, the goal of which is to promote public-private collaboration to assure quality laboratory services and public health surveillance. To enhance the realization of the NLS, the Association of Public Health Laboratories (APHL) launched in 2004 a State Public Health Laboratory System Improvement Program. In the same year, APHL developed a Comprehensive Laboratory Services Survey, a tool to measure improvement through the decade to assure that essential PHL services are provided.

A comprehensive Laboratory Services Survey of State Public Health Laboratories.

In November 2004, the Association of Public Health Laboratories (APHL) conducted a Comprehensive Laboratory Services Survey of State Public Health Laboratories (SPHLs) in order to establish the baseline data necessary for Healthy People 2010 Objective 23-13. This objective aims to measure the increase in the proportion of health agencies that provide or assure access to comprehensive laboratory services to support essential public health services. This assessment addressed only SPHLs and served as a baseline to periodically evaluate the level of improvement in the provision of laboratory services over the decade ending 2010. The 2004 survey used selected questions that were identified as key indicators of provision of comprehensive laboratory services. The survey was developed in consultation with the Centers for Disease Control and Prevention National Center for Health Statistics, based on newly developed data sources. Forty-seven states and one territory responded to the survey. The survey was based on the 11 core functions of SPHLs as previously defined by APHL. The range of performance among individual laboratories for the 11 core functions (subobjectives) reflects the challenging issues that have confronted SPHLs in the first half of this decade. APHL is now working on a coordinated effort with other stakeholders to create seamless state and national systems for the provision of laboratory services in support of public health programs. These services are necessary to help face the threats raised by the specter of terrorism, emerging infections, and natural disasters.

Laboratory Services in Support of Public Health: A Status Report

Objectives. To assess Healthy People 2010 Objective 23–13 and its related sub-objectives measuring comprehensive laboratory services in support of essential public health programs, the Association of Public Health Laboratories (APHL) collaborated with the Centers for Disease Control and Prevention (CDC) to create and administer a survey of state public health laboratories (PHLs). Methods. A committee of APHL, with representation from CDC, constructed the survey based on the 11 Core Functions of State Public Health Laboratories (hereafter, Core Functions)—the premise being that the extent to which they fulfilled these Core Functions would represent their level of providing or assuring comprehensive laboratory services in support of public health. The survey was distributed biennially to all state health agencies from 2004 to 2008, and respondents were given two months to complete it. Results. The response rate for all surveys was ≥90.2%. State PHLs were more likely to meet the sub-objectives relating to traditional functions (e.g., disease surveillance and reference testing) than other areas (e.g., food safety and environmental testing). Emergency preparedness fell in between. Overall, but most notably in the areas of food safety and training and education, there was improvement from 2006 to 2008, with the percentage of respondents who met more than half of the sub-objectives increasing from 58.7% in 2006 to 61.2% in 2008. Conclusions. The comprehensive laboratory services survey has been a valuable tool in measuring the laboratory infrastructure that underpins public health in the U.S. It will be necessary to continue monitoring laboratory infrastructure in this way to determine where the gaps in services exist and how they can best be addressed.

Looking at Health Through a “One Health” Lens

A number of years ago I was working for the Michigan Department of Health in the Division of Epidemiologic and Laboratory Services. My role involved the oversight of one of the divisions of the Michigan state public health laboratory. My interests were focused on communicable diseases and their impact on human health from a public health perspective. This was an era when Legionnaire’s Disease had just been recognized, toxic shock syndrome was still relatively new, and of course, HIV/ AIDs was just coming onto the scene. To avoid becoming too isolated within the state health department, I became affiliated with the Michigan State University (MSU) College of Human Medicine. I had an adjunct faculty appointment in the Department of Pediatrics. One of my favorite professional activities at the time was to attend the Infectious Disease Seminars at MSU. At these sessions, infectious disease cases were presented and the participants were all encouraged to be a part of the discussion sorting out the nuances of each unique case. I had been a participant in similar infectious disease seminars when I was in graduate school and also when I was in my postdoctoral training. The significant difference with the MSU infectious disease seminars was that they were attended not only by physicians, laboratorians, epidemiologists, and infection preventionists but also by veterinarians and animal scientists. MSU had the distinction of being the only university in the world at the time where there was a college of human medicine, a college of osteopathic medicine and a college of veterinary medicine all co-located at the same campus. When the cases were discussed, it was interesting to see the various perspectives of the individuals representing different disciplines. Only years later did I realize that I was participating in one of the earliest examples of the application of a “One Health” approach. After the outbreak of West Nile Virus (WNV) in the New York City area in 1999, I had the good fortune to attend a National Academy of Sciences Symposium on Emerging Zoonotic Diseases. Zoonotic diseases are those communicable diseases, which can be spread from animals to humans, as well as from humans to animals. The symposium was chaired by the Nobel Prize recipient and renowned scientist, Dr. Joshua Lederberg. This symposium was quite unique because, as was seen in the 1999 outbreak in New York City, WNV afflicts not only humans but also horses, crows, and exotic birds like those housed in the Bronx Zoo. There were many individuals representing a variety of disciplines in attendance. There were, of course, physicians, veterinarians, epidemiologists, virologists, and others interested in zoonotic diseases, but the meeting also included evolutionary biologists, climatologists, geographers, mathematical modeling experts, and others. It was truly one of the most intellectually stimulating symposia I had ever attended and it was because of the diversity of the backgrounds among the attendees. At this symposium, I was also getting a foretaste of the “One Health” approach to studying infectious diseases. “One Health” captures that diversity of thought and perspective and incorporates it into an approach that is truly transdisciplinary. The concept of “One Health” simply stated is “the integrative effort of multiple disciplines working locally, nationally, and globally to attain optimal health for people, animals, and the environment” (American Veterinary Medical Association, n.d.). In 2007, the American Veterinary Medical Association and the American Medical Association joined forces to create the One Health Initiative (http://www. onehealthinitiative.com/). Most of the credit for initiating this movement goes to the veterinary community. They are still very much in the forefront. Since 2007, several other entities that support and promote the “One Health” approach have come into existence. These include the One Health

Workforce Challenges in Our Public Health Laboratory System

Public health laboratories lie at the intersection of 2 vital components of the United States health system (ie, the public health system and the national laboratory system). Unfortunately, both of these components of the health system are somewhat hidden from public view and from the eye of policymakers. The public health system with its focus on populations, disease prevention, environmental protection, and emergency response is overshadowed by the more visible and resource-intensive health care system that deals with personal health. Likewise, the clinical and public health laboratory professionals who make up our national laboratory system are frequently overshadowed by the more visible health professions such as medicine and nursing. Much has been written about the critical workforce challenges and shortages facing public health generally 1-6 and clinical laboratories 7-16 but not about public health laboratories. Although public health laboratories in the United States are found in federal, state, and local health agencies, the description of their core functions has only been formally defined for states. Public health laboratories play a vital role in the support of essential public health services such as disease surveillance, environmental protection, food safety, and emergency response including terrorism response. 17 Specific steps must be taken to ensure that vital public health laboratory workforce needs are addressed.

Public health laboratory systems: at the crossroads.

Twenty years ago, Walter Dowdle1 observed that the word “laboratory” did not even appear in the index of the now classic 1988 Institute of Medicine (IOM) report, “The Future of Public Health.”2 It was Dr. Dowdle’s contention that despite the significant role of laboratories dating back more than 100 years to the earliest days of public health, a point had been reached where laboratories and their many contributions to public health were being taken for granted. During the last 20 years, much has changed to elevate the visibility of public health laboratories (PHLs). Their expanded roles, their engagement with partners, and their core functions have all been described and reaffirmed.3,4 This special supplement of Public Health Reports (PHR) is devoted to PHL systems, with an emphasis on activities and approaches that represent managing and improving the system across many different dimensions. It has become clear that, to meet the broad array of laboratory services required to support both public health and health care in the United States, PHLs have been and will continue operating within systems, especially state public health laboratory (SPHL) systems.5 How those systems are set up and funded and which entities are included vary by state or locality. Irrespective of how laboratory systems are put together, the evidence confirms that the laboratory services provided by these systems go well beyond the mere performance of laboratory tests and analyses. These systems are critical in their support of the 10 Essential Public Health Services (hereafter, Essential Services).6 PHLs at all levels, along with their respective leaders and partners, have in the past maintained and will continue to maintain the important linkages required to strengthen and sustain their respective systems. In 2010, PHR published a supplement on PHLs that focused on their many evolving roles and how they provide unique and ever-changing functions in support of public health and health care. The evolution of PHL systems, which was primarily influenced by emerging diseases, threats, programs, technologies, and innovation, is now being driven by a convergence of health reform, state and federal funding cuts, and the evolving role of public health.7,8

Measuring the Application of Quality System Essentials in Vermont Clinical Laboratories

Objective: Clinical laboratorians perform critical testing on patient samples to provide vital information used to aid in medical diagnoses, influence therapeutic treatment, and potentially impact public health. The goal of this study was to determine laboratorians’ knowledge of quality measures in their workplace. Methods: A survey of clinical laboratorians was conducted in a small, predominantly rural state regarding their awareness of different components of quality assurance systems in their workplace, whether the effectiveness of these quality assurance (QA) systems was measured, and whether it was perceived to contribute to quality outcomes in the laboratory. This article examines the relationship between job title, years of experience, and knowledge of QA measures in the laboratory. Results: Laboratory supervisors were most likely to know about the quality assurance procedures in the laboratory, while inexperienced laboratorians with 0 to 10 years of experience were most likely to not know whether the effectiveness of the quality assurance procedures was being assessed, and whether the implementation of the quality assurance procedures contributed to quality of testing in the laboratory. Conclusion: Further education and training are needed so all laboratorians performing critical medical tests are aware of the quality assurance systems in place in their laboratories.