CE Is your laboratory prepared for a bioterrorism attack?: In the wake of recent anthrax infections, laboratories must play a key role in identifying and preventing the spread of biological and chemical agents. (Cover Story).

The growing number of anthrax cases in the United States has placed the population on alert, wary of what has become a frightening reality. Bioterrorism attacks involve the deliberate release of pathogens or their toxins into a civilian population, causing illness or even death. More recent incidents on domestic soil involve the spread of Bacillus antbracis through the U.S. mail system.

The last few months have proven especially challenging for the public health system, which many experts say is woefully underprepared to deal with widespread bioterrorism events. While the effects of a biological attack may not become apparent for days or weeks after release of a hazardous agent, it is important that officials respond within a matter of hours - while a disease is still treatable and before the first wave of infections spreads through the population.

Clinical laboratories in both the public and private sectors play a key role in helping to identify biological and chemical agents and preventing their spread. In many ways, the nation's laboratories are among those healthcare providers that serve as the first line of defense against such attacks.

Recent guidelines from the Centers for Disease Control and Prevention (CDC) point out that "clinical lab personnel will most likely be the first ones to perform preliminary testing on clinical specimens from patients who may have been intentionally exposed to the organism, and will play a critical role in facilitating rapid identification of B. antbracis."

To respond rapidly to acts of bioterrorism, CDC urges clinical laboratory personnel to familiarize themselves with the CDC protocols for hazardous agents such as B. antbracis. It also is important to follow specific procedures CDC has devised in the event a laboratory may have a case or isolate.

Disseminating protocols to laboratories

To deal with the crisis at hand, the nation's laboratories have mobilized quickly to get the word out on the procedures that must be followed to pinpoint possible hazardous agents.

A consensus statement published in the Journal of the American Medical Association points out that the most useful microbiologic test for the organism is the standard blood culture, which should show growth in six to 24 hours. Further, it states that if the laboratory has been alerted to the possibility of B. antbracis, biochemical testing and review of colonial morphology should provide a preliminary diagnosis some 12 to 24 hours later. (1)

The CDC advises raising the index of suspicion for B. antbracis when the clinical picture provided by the clinician involves a rapidly progressive respiratory illness of unknown cause in a previously healthy person.

In the presumptive identification of B. antbracis with direct smears from clinical specimens, encapsulated broad rods in short chains of two to four cells appear. The two primary criteria for B. antbracis are that the specimen is nonhemolytic and nonmotile. B. antbracis will not usually be present in clinical specimens until late in the course of the disease.

If B. antbracis is suspected, the specimen should be shipped to the state public health laboratory following specific packaging and transporting protocol. (Directions are provided on "CDC Guidelines for State Health Departments," which is available on the American Society of Microbiology website (www.asmusa.org). An India ink stain should be used to further visualize the capsule microscopically. After receiving the specimen, a Level B laboratory performs various tests to obtain a definitive diagnosis.

Hospital and independent laboratories are designated as Level A laboratories, state health laboratories as Level B, CDC laboratories as Level C, and CDC and the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) as Level D.

In addition to contacting the public health laboratory, the laboratory should immediately contact the healthcare provider and the local law enforcement department. The CDC advises not performing further tests once a lethal agent is suspected. The CDC also says clinical laboratories should not attempt to handle or process environmental specimens or envelopes containing powders. These should be referred to the nearest Level B or C Laboratory Response Network facility after consulting with the state public health laboratory.

An evolving communication network

As is evident from the nation's experience with B. anthracis, once hospital and independent laboratories cannot rule out the presence of a bioterrorism agent, the county's public health laboratories are called into action.

In today's public health infrastructure, the Laboratory Response Network (LRN) plays a major role in actually identifying bioterrorism agents. The network is a collaborative partnership designed to link state and local public health laboratories with advanced capacity clinical, military, veterinary, agriculture, water, and food-testing laboratories.

LRN is made up of more than 80 state and local public health and military laboratories located throughout the country. These laboratories have protocols and reagents, which enable them to rapidly identify B. anthracis as well as other potential agents of bioterrorism.

So that the nation's laboratories can continue to quickly and accurately fulfill their role in identifying potential dangerous agents such as B. anthracis, LRN is disseminating vital information to laboratories, including protocols for agents that pose the most immediate threat, such as anthrax, plague, and tularemia. The protocols are available on a number of websites, including the American Society for Microbiology site. (See "Helpful websites and other resources" on page 16.) In most cases, the protocol information is designed for Level A laboratories.

On the drawing board is an effort to establish a National Laboratory System that would strengthen the links among federal, state, and local public laboratories, as well as independent, hospital, and physician office laboratories.

The National Laboratory System would enable laboratories to rapidly share information electronically. Such communication would contribute to early detection and effective monitoring of bioterrorism events. The system is seen as a key weapon in fighting bioterrorism.

"It would facilitate identification of unusual clusters of illnesses and the ability to put together the pieces of a puzzle that involve distinct locations all across the country," says Vickie Baselski, Ph.D., professor of pathology and clinical laboratory sciences at the University of Tennessee in Memphis.

Unfortunately, the public health system is not currently on the electronic superhighway. The National Laboratory System is the piece that is missing and needs funding, she adds. As it stands now, some local public health laboratories don't even have access to the Internet.

But experts believe this situation could change. Says David Sundwald, M.D., president of the American Clinical Laboratory Association, "There probably has never been a better argument for getting the National Laboratory System up and going than our current crisis.

Laboratory safety and security

Laboratories also must have a series of safety and security procedures in place, not only to protect laboratory personnel handling dangerous agents, but also to avoid potential breaches in security.

Most laboratories are already aware that a number of precautions are required to avoid laboratory contamination when handling lethal agents. Mark Birenbaum, Ph.D., administrator for the American Association of Bioanalysts (AAB), says laboratories should be following "a universal procedure in which all specimens are treated as if they are infected with pathogens." AAB is a national professional association whose members are directors, owners, managers, and supervisors of community clinical laboratories.

In addition, the CDC recently provided a list of steps laboratory personnel should follow if B. anthracis is involved. These include:

* Wearing gloves and protective gowns when handling clinical specimens.

* Washing immediately with soap and water if there is direct contact with a clinical or lab specimen.

* Making sure to avoid splashing or creating aerosols.

* Performing lab tests in an annually certified Class II Biological Safety Cabinet; if that is not possible, then use standard lab protective eyewear and a mask.

* Making sure that blood cultures are maintained in a closed system (blood culture bottles).

* Keeping culture plates covered at all times; minimizing exposure when extracting specimens for testing.

* Working on a smooth surface that can be cleaned easily and wiped with bleach regularly.

In addition to laboratory safety, laboratory security must be reviewed. Up-to-date guidance on laboratory security is available in the latest edition of the U.S. Department of Health and Human Services' Biosafety in Microbiological and Biomedical Laboratories. It contains seven recommendations for laboratories using biologic agents or toxins capable of causing serious or fatal illness in humans or animals.

Stephen A. Morse, MSPH, Ph.D., of the Atlanta-based National Center for Infectious Diseases, Centers for Disease Control and Prevention, says research, clinical, and production laboratories working with human or animal pathogens should follow a number of guidelines to minimize opportunities for accidental or intentional removal of these agents from the laboratory. The guidelines include:

* Recognizing that laboratory security is related to but different from laboratory safety. It is important to review safety policies and procedures regularly especially after an incident occurs or a new threat is identified.

* Making sure to control access to areas where biologic agents or toxins are used or stored. Laboratories should be separate from public areas in the buildings in which they are located and should be locked at all times. Card keys or similar devices should be used to permit entry to the laboratory.

* Knowing who is in the laboratory area. A background check may be appropriate before new employees are assigned to the laboratory area. In addition, all personnel should wear visible identification badges with clearance indicated for restricted areas.

* Making sure that you know what materials are being brought into the laboratory area. All packages should be screened before being brought in.

* Knowing what materials are being removed from the laboratory area.

* Taking steps to put an emergency plan in place. Control of access to laboratory areas can make an emergency response more difficult.

* Being sure to have a protocol for reporting incidents. It is important to have policies in place for reporting and investigating incidents such as undocumented visitors and missing cultures. (2)

More help for laboratory preparedness

Because the likelihood of additional bioterrorism attacks will continue to be a major concern for the nation, the Laboratory Response Network is advocating more training of personnel in Level A laboratory protocols for bioterrorism agents. The National Laboratory Training Network (NLTN) is spearheading these training efforts in a number of states. Baselski is assisting with the training effort in Tennessee.

"Our goal is to have 100 percent of microbiology laboratories in the state retrained on bioterrorism agent protocols," says Baselski who is teaching many of the classes for NLTN in Tennessee. "This is information every one has learned in medical technology school, but a refresher course is needed since you don't often have to use that knowledge base." This type of training, she maintains, "enhances the awareness and makes sure that the capabilities are standard across all kinds of laboratory environments."

Dave Smalley, Ph.D., professor of pathology and clinical laboratory sciences, also at the University Tennessee in Memphis, agrees with this assessment. "Each area of the country should be doing some training to enhance the awareness, making sure the laboratories are at a point where they can comply with Level A Laboratory training," he says.

Both believe that federal lawmakers will provide the additional funding for training and expanding laboratory capacities to meet the surge in demand when thousands of specimens are sent for tests.

Says Baselski: "The funding won't be wasted. This kind of infrastructure enhancement will help the country deal with any kind of biologic event, whether it be salmonella in ice cream or anthrax in the mail."

References

(1.) "Anthrax as a Biological Weapon," Thomas V. Inglesby, MD; Donald A. Henderson, MD, MPH; et al., JAMA. 1999:281:1735-1745. Available at the JAMA website (www.jama.com)

(2.) CDC Guidelines for State Health Departments, Revised Oct. 14, 2001. Available on the American Society of Microbiology web site (www.asmusa.org)

(3.) "Bioterrersim: Laboratory Security, Stephen A. Morse, MSPH, Ph.D. From the Bioterrorism Preparedness and Response Program, National Center for Infectious Diseases, Center for Disease Control and Prevention, Atlanta, Ga. Published in Laboratory Medicine, June 2001, No.6, vol. 32.

[Graph omitted]

Table 1

Summary of recommended biosafety levels for infectious agents

Biosafety  Agents                         Practices
level

1          Not known to consistently      Standard microbiological
           cause disease in healthy       practices
           adults

2          Associated with human          BSL-1 practice plus:
           disease, hazard =              * Limited access
           percutaneous injury,           * Biohazard warning signs
           ingestion, mucous              * "Sharps" precautions
           membrane exposure              * Biosafety manual defining
                                            any needed waste
                                            decontamination or medical
                                            surveillance policies


3          Indigenous or exotic           BSL-2 practice plus:
           agents with potential for      * Controlled access
           aerosol transmission;          * Decontamination of all waste
           disease may have serious or      clothing before laundering
           lethal consequences            * Baseline serum




4          Dangerous/exotic agents which  BSL-3 practices plus:
           pose high risk of life-        * Clothing change before
           threatening disease,             entering
           aerosoltransmitted lab         * Shower on exit
           infections; or related agents  * All material decontaminated
           with unknown risk of             on exit from facility
           transmission

Biosafety  Safety equipment
level      (primary barriers)

1          None required



2          Primary barriers = Class I or
           II BScs or other physical
           containment devices used for
           all manipulations of agents
           that cause splashes or
           aerosols of infectious
           materials; PPEs: laboratory
           coats; gloves; face protection
           as needed

3          Primary barriers = Class I or
           II BSCs or other physical
           containment deveices used for
           all open mainpulations of
           agents; PPEs: protective lab
           clothing; gloves; respiratory
           protection as needed


4          Primary barriers = All
           procedures conducted in Class
           III BSCs or Class I or II
           BSCs in combination with
           full-body, air-supplied,
           positive pressure personnel
           suit

Biosafety  Facilities
level      (secondary barriers)

1          Open benchtop sink required



2          BSL-1 plus:
           Autoclave available.








3          BSL-2 plus:
           * Physical separation form
             access corridors
           * Self-closing, double door
             access
           * Exhausted air not
             recirculated
           * Negative airflow into lab

4          BSL-3 plus:
           * Separate building or isolatd
             zona
           * Dedicated supply and exhaus,
             vecuum and decon systems
           * Other requirements outlined
             in the text

HHS Biosafety in Microbiological and Biomedical Laboratories, 4th
Edition, April 1999, p. 64-65

RELATED ARTICLE: Understanding anthrax

An aerobic, spore-forming, gram-positive rod called Bacillus anthracis causes anthrax. It is usually found in cattle, sheep, and horses. Research on anthrax as a biological weapon began more than 80 years ago. Spores grow readily on all ordinary laboratory media at 37 degrees Centigrade, with a "jointed bamboo-rod" cellular appearance and a unique "curled-hair" colonial appearance, and display no hemolysis on sheep agar.

In humans, three types of anthrax infection occur: inhalational, cutaneous, and gastrointestinal. Inhalational anthrax accounts for the most morbidity. Before the current anthrax scare, inhalational anthrax was last reported in the U.S. in 1978. In fact, anthrax in humans was considered relatively rare in the U.S. There were just 236 cases of all types reported between 1955 and 1999. However, the accidental aerosolized release of anthrax spores from a military microbiology facility in Sverdlovsk in the former Soviet Union in 1979 resulted in at least 79 cases of inhalational anthrax. Of those cases, 68 deaths were reported.

The CDC indicates that inhalational anthrax, the most lethal form of anthrax, results from inhalation of 8,000 to 40,000 spores of B. anthracis. The incubation of inhalational anthrax among humans is unclear, but it is reported to range between one and seven days, possibly ranging up to 60 days.

Initial symptoms for inhalational anthrax include fever, malaise, fatigue, cough, and mild chest pain, which quickly progress to severe respiratory distress, then shock and death within 24 to 36 hours after the initial symptoms.

While many health professionals in the U.S. have had little experience with the disease, hundreds of laboratories around the world maintain stocks of the anthrax bacterium for research and to assist in diagnosing cases of the disease.

Even though the impression exists that B. anthracis is an organism that will last forever, health experts say the disease could actually be eradicated if all cattle were vaccinated and if infected carcasses were burned, not buried.

Congress moves to beef up nation's ability to respond to bioterrorism

Washington is taking steps to strengthen the nation's public health infrastructure so it is better able to handle a widespread bioterrorism attack. A recent study from the General Accounting Office (GAO) warned that state and local health departments are not adequately prepared to deal with a biological assault, even though they would be the first to respond.

Scott Becker, executive director of the Association of Public Health Laboratories (APHL) agrees that public health laboratories continue to be "underprepared." They need additional support "for scientific staff, equipment, and in some cases, renovation of facilities," he says.

The GAO found that federal efforts are fragmented and that state and local preparedness needs assistance. It also revealed that the government operates 11 research programs to improve the detection of biological agents and 10 programs that aim to educate or prepare for an attack, with little attempt to coordinate efforts.

To help address this problem, Senators Bill Frist, R-TN, and Ted Kennedy, D-MA, want $1.4 billion of the $40 billion emergency-spending packaging already enacted by Congress to be earmarked to fight anti-biological and chemical terrorism. They not only want to strengthen the nation's public health system, but improve hospital response capabilities, upgrade the Centers for Disease Control's rapid identification and early warning systems, and assure adequate staffing and training of health professionals to diagnose and care for victims of bioterrorism.

The two senators have introduced legislation that would revitalize the nation's ability to monitor and fight outbreaks of infectious disease, control the spread of microorganism resistant to antibiotics, and protect the nation more effectively against bioterrorism.

In a press statement, Frist pointed out that "a biological or chemical attack on our soil could be even more deadly and destructive than the recent attacks on the World Trade Center and Pentagon."

The Kennedy-Frist bill, known as the Public Health Threats and Emergencies Act, would authorize the Secretary of Health and Human Services (HHS) to respond swiftly and effectively to a public health emergency. The HHS Secretary would establish a national monitoring plan for dangerous infections resistant to antibiotics, and work closely with state and local public health agencies to ensure that the peril is contained.

The measure also would improve coordination among federal agencies responsible for all aspects of a bioterrorist attack.

The legislation also would provide more funding to train healthcare personnel to recognize bioterrorism agents. Most physicians and nurses have never seen diseases such as anthrax, smallpox, plague, and botulism. The funds would also be used to upgrade public laboratories, pursue new vaccines and therapies, and secure overseas stocks of biological weapons.

Becker says he is hopeful in this time of crisis that lawmakers will see fit to provide the nation's public laboratories with the funding they need to protect citizens against further biological catastrophes.