Lab Matters Spring 2017 - Page 26

infectious diseases The Best Defense: Routine Public Health Testing by Kim Krisberg, writer Late last fall, China entered its fifth epidemic wave of H7N9 influenza, with nearly 600 cases as of April. About 40 percent of people who become infected die as a result. The virus’s re-emergence has US public health laboratories on alert. I n this case, however, that heightened awareness isn’t part of a larger emergency response effort, like the ones public health workers are waging against Zika virus. If H7N9 evolved into a strain that could easily pass from person to person—a capability the virus does not currently have—public health laboratories are prepared to quickly scale up their response systems. Such a scenario makes clear the importance of well-funded public health preparedness programs. But in its current form, what the H7N9 threat really underscores is the critical nature of routine, everyday public health work— work that typically goes unnoticed and unknown. “Looking for the usual is where we find the unusual,” said Peter Shult, PhD, interim laboratory director at the Wisconsin State Laboratory of Hygiene. “We’re always monitoring for novel viruses. But in the final analysis, it’s about routine surveillance—that’s the capacity and capability that we need to keep well funded.” I  t’s critical that public health laboratories be on the cutting edge of detecting new and emerging conditions and diseases. H7N9 has been on Wisconsin’s radar since it first emerged in China in 2013. Since then, the World Health Organization has reported more than 1,300 human cases in China, with fifth wave case counts the highest so far. Evidence suggests that most people become infected after contact with infected poultry or contaminated environments, such as live poultry markets. There is no evidence of sustained person-to-person transmission of the virus, but WHO has reported signs of antiviral resistance. In Wisconsin, monitoring for H7N9 is part of its routine surveillance of seasonal flu strains. During flu season, Shult said the laboratory typically tests a few thousand flu specimens, gathering data on which strains are in circulation and monitoring for potential pandemic threats. If scientists are unable to subtype a specimen, it indicates a potential novel strain such as H7N9 and further testing is conducted. Wisconsin is also one of three National Influenza Surveillance Reference Centers, which means it conducts additional, higher-level molecular testing that informs the following year’s flu vaccine planning. News of H7N9’s fifth wave didn’t trigger a surge in the laboratory’s activities, Shult reported, though identifying a case in the US would be significant. He noted that the laboratory has been doing year-round flu surveillance for a while now, monitoring for travel-related flu strains and responding to novel strains closer to home, such as the human cases of H3N2v flu, which arise from swine contact, that were detected in Wisconsin in 2012. Right now, Shult said the Wisconsin laboratory is prepared and capable of confronting multiple outbreaks and threats. But the laboratory needs adequate funding to sustain that capacity. 24 LAB MATTERS Spring 2017 “For instance, if we had an outbreak of flu and vaccine-preventable disease, we could handle that given current staffing and equipment,” he said. “But if I take a hit in dollars, I’d say at that point, all bets are off.” At the federal level, monies from the Affordable Care Act’s (ACA) Prevention and Public Health Fund have become wholly entwined with the Centers for Disease Control and Prevention’s (CDC) base budget and core activities. Since the ACA’s enactment, the fund has invested $40 million annually into CDC’s Epidemiology and Laboratory Capacity (ELC) program, which funds all 50 state health departments. Of particular importance, ACA ELC funds are flexible—as opposed to disease- specific—and that means laboratories can use them to build, maintain and improve all-hazards readiness. On the ground in Wisconsin, for example, the ELC helps fund 20 of 40 bench-level scientists in the laboratory’s communicable diseases division. If an ACA repeal eliminated the Prevention and Public Health Fund, “it would cripple us,” Shult said. Victor Waddell, PhD, MS, bureau chief of the Arizona State Public Health Laboratory, agreed: “The (ACA) ELC funding has become extremely important to us.” In Arizona, the funds support mosquito-borne virus testing, equipment maintenance, scaled-up food-borne disease testing and, of course, flu surveillance. The Arizona laboratory conducts routine seasonal flu testing, rapidly identifying circulating flu strains, monitoring for signs of antiviral resistance, and forwarding rare specimens to CDC for further testing.  isconsin is also one of three National W Influenza Surveillance Reference Centers, which means it conducts additional, higher-level molecular testing that informs the following year’s flu vaccine planning. PublicHealthLabs @APHL APHL.org