Testing for terror: how labs should respond to biocrime
Training to fight bioterrorism
One pathologist’s disaster preparations
William Check, PhD
Here is how the threat of bioterrorism presented to six U.S. clinical microbiology laboratories:
- Three years ago, at approximately 3 PM on Nov. 18, 1998, an infection control nurse stopped by the office of Susan Sharp, PhD, director of microbiology at Mt. Sinai Medical Center/Miami Heart Institute, and told her there had been an anthrax scare in a building on South Beach. People who may have been exposed—and perhaps the suspected source powder itself—were being brought to Mt. Sinai. About 30 minutes later, the head of infectious diseases called Dr. Sharp and asked her if she would evaluate some powdery material in an envelope that a handwritten note claimed was anthrax.
- In the early morning hours of Oct. 2 of this year, a patient presented to the emergency department of JFK Medical Center in Palm Beach County, Fla., with what the ED physician interpreted as bacterial meningitis. Gram stain of the patient’s cerebrospinal fluid, performed at the hospital, showed Gram-variable rods. Since the hospital was part of a consolidated laboratory system, Integrated Regional Laboratories of Florida, the pathology medical director at the hospital called the manager of the central microbiology laboratory, Anne Beall, who told him to forward the specimen immediately. "I had trained the laboratory to be prepared for any bioterror agents," says James A. Robb, MD, medical director of Integrated Regional Laboratories of Florida. "So when Anne heard Gram-variable rods and spinal fluid, right away she thought anthrax."
- After the first death from inhalation anthrax was identified in Florida, public health officials started looking for the source of the organism. Since the victim had traveled to North Carolina before he became ill, it was possible that he had contracted the infection there. As a result, says Jared Schwartz, MD, PhD, pathologist and immediate past director of the Department of Pathology at Presbyterian Health Care System, Charlotte, NC, "CDC, in conjunction with local health officials, requested local hospitals, including ours, to do retrospective and prospective review and evaluation of laboratory information to see if we had any cases suggestive of anthrax."
- In mid-October, Joseph Campos, PhD, director of the microbiology laboratory and the section of laboratory informatics at Children’s National Medical Center, Washington, DC, was asked by the "highest levels" of administration at his institution whether it would be advisable to do culturing for Bacillus anthracis in the hospital mailroom and whether he could do such sampling. It was known that mail containing anthrax spores had passed through Washington’s Brentwood Road postal facility, which handles all mail for the District of Columbia. Workers in the hospital mailroom were concerned they may have been exposed to anthrax.
- Although no anthrax appeared in the Midwest, "people in Chicago were very concerned about that possibility," says Richard Thomson, PhD, director of microbiology and virology at Evanston (Ill.) Northwestern Healthcare. State and local public health laboratories quickly became overwhelmed with environmental samples. "One of the health departments in this area called and asked if we could evaluate specimens people brought in thinking they might contain anthrax," Dr. Thomson says.
- A similar request, but from a different source, came to James Snyder, PhD, director of clinical microbiology and professor of pathology and laboratory medicine at the University of Louisville (Ky.) School of Medicine and Hospital. "Because of our being an integral participant in the local emergency planning and response group, the FBI requested that, if necessary, we examine environmental substances—powders, et cetera—with a creditable risk of containing a biothreat agent such as anthrax spores," Dr. Snyder says.
Both laboratorians had to make their decisions knowing that the Laboratory Response Network, headed by the Centers for Disease Control and Prevention, recommends that nonpublic health laboratories refuse nonhuman specimens.
These real-life incidents, in which hospital-based clinical microbiology laboratories confronted bioterrorism, paint a different picture from the bioterrorism exercises conducted during the past few years. In those exercises, simulated releases of smallpox virus or weaponized strains of anthrax or plague bacilli typically evolved into societal and health care nightmares. Panic, confusion, and misdiagnosis led to extensive spread of disease and high casualty rates. Although no one would call the preceding real-life incidents "routine," they have not occurred in the context of the frantic overload that has characterized bioterrorism war games.
In our new, post-terrorism world, any laboratory could face the questions and challenges that confronted these labs. How many hospital microbiology laboratories would know which of these challenges they are qualified to accept and which they should pass to the next higher level? How many laboratories would know how to rule out a bioterrorism agent in samples, how to handle such samples safely, when to send suspicious specimens to the laboratory at the next higher level, where the nearest public health laboratory is, and how to safely transport a potentially hazardous specimen to that laboratory? Here is how these six laboratories responded.
In response to the request from the head of infectious diseases to examine powdery material that might contain anthrax spores, Dr. Sharp declined. Such work should be done at the state laboratory, she told him, not a community hospital. But the head of ID called her later at home, saying that the FBI wouldn’t go away until something was done. He asked Dr. Sharp for permission to use her laboratory’s biosafety level 3 facility, ordinarily used for work with Mycobacterium tuberculosis isolates. Realizing that if she didn’t do the testing, the head of infectious diseases would, Dr. Sharp returned to her laboratory.
There she encountered a worried crowd—the head of the local FBI office; the chief of the Miami police department; several hospital administrators, including the CEO; and the chief of infectious diseases. All wanted to accompany her into the biosafety facility. "One of you can come with me," she told them. The FBI field agent carrying the suspect material in a hazard bag was chosen. Dr. Sharp and the agent donned full protective gear and entered the biosafety area. The agent, a chemist by training, suggested putting the powder in water to see if it would dissolve. It did not. Dr. Sharp made a wet preparation and looked at it under the microscope. "It looked like sheets of crystalline material, not bacterial spores," she says. "Although, to be honest, I had never seen anthrax spores." When Dr. Sharp attempted to do a Gram stain, the material washed off the slide. Ultimately, Dr. Sharp reported "no organism."
"After that incident," Dr. Sharp says, "I decided to get more involved in the bioterrorism effort. Primarily I wanted to find out what I should have done and whether I should ever do it again." Dr. Sharp now speaks at symposiums and teleconferences on the role of the hospital microbiology laboratory in ruling out bioterrorism agents.
When the cerebrospinal fluid sample from Palm Beach County arrived at Dr. Robb’s laboratory in October, the microbiology manager, Anne Beall, repeated the Gram stain using an instrument. Manual Gram stains can decolorize unevenly, which might explain the Gram-variable appearance seen at the hospital. Gram-positive rods appeared on the stain, and a motility test showed a nonmotile organism, both consistent with B. anthracis. The expected capsule, however, was not seen in India ink. But young organisms, which would result from rapid growth in CSF, may not have capsules, so Beall plated the organism to repeat the test.
In the meantime, she told the referring physician they had not been able to rule out anthrax, and she informed the Jacksonville state public health laboratory that she was forwarding all specimens. Shipping complied with the CDC’s triple packaging guidelines for suspect specimens, which the laboratory used to send hard-to-identify organisms to the state laboratory.
It happened that Dr. Robb was in Cardiff, Wales, at a CAP SNOMED editorial board meeting, when the anthrax incident occurred. "On Thursday morning I saw a small insert in the Cardiff paper about the inhalation anthrax case, and that evening I saw my hospital on BBC-1 TV," he recalls. "What I really liked was that the whole system worked well without me. They didn’t even phone. I give Anne Beall tremendous credit."
Previously, Dr. Robb’s colleagues had not appreciated his focus on bioterrorism. "Everybody thought I was crazy for bringing up bioterrorism scenarios," he says, "but I kept pounding them. You have to be thinking all the time it is going to happen or you will miss it." He took bioterrorism seriously largely because of his research in molecular virology. "I have been very aware of what can be done with bacteria and viruses," he says. To learn about laboratory planning for bioterrorism, he attended all-day seminars at meetings of the American Society for Microbiology and consulted with CDC officials, especially J. Michael Miller, PhD.
In performing the requested record review, Dr. Schwartz’s laboratory scanned reports of cultures and Gram stains for specific phrases, such as growth of Bacillus sp from sterile body site—particularly blood or CSF—or Gram-positive rods. "We didn’t do any active culturing or testing," says Steven Dallas, PhD, microbiology director at Presbyterian Health Care System. For records containing key phrases, patient outcome was sought. No anthrax was found.
Once the source of the Florida case was identified, North Carolina laboratories returned to routine surveillance. "Now if a patient had certain clinical findings," Dr. Schwartz says, "the physician would ask for culture. And if B. anthracis was in there, we would find it through routine techniques, typically on blood culture or CSF." Although Dr. Dallas, like most laboratorians, has never seen a case of anthrax, culturing for it would be "nothing out of the ordinary," he says. "We would use common methods looking for an uncommon organism. The techniques are routine. We are just looking for a very dangerous organism."
Adds Dr. Schwartz: "You can suddenly find yourself in a situation where your laboratory is being asked to look for bioterrorism organisms," such as anthrax or Yersinia. For laboratories that do not yet have a plan, he says, "The College’s Web site has links to other sites that would be helpful to pathologists," particularly the CDC Web site, www.cdc.gov.
Dr. Campos agreed to culture his facility’s mailroom, mainly to reassure mailroom employees and others in the hospital that anthrax spores had not entered the building with the mail. Local public health laboratories were "massively overwhelmed," he says, and environmental culturing companies had waiting lists of potential customers and were charging premium prices. Furthermore, the risk of mailroom contamination was low. "If it had been the Brentwood Road facility, I would not have done it myself," he says.
Wearing protective gear, Dr. Campos sampled the mailroom air with a mechanical air sampler and sampled dusty surfaces with moistened culture collection swabs. More than 50 samples were cultured according to standard techniques, and overnight growth was evaluated for B. anthracis. Culture plates were incubated for an additional 48 hours in case slower growing "atypical" B. anthracis was present.
As Dr. Campos expected, "I found no indication whatsoever of anthrax spores in our hospital. What was impressed on me by this experience," he says, "was that the level A protocols for identifying B. anthracis worked extremely well." He also found information on the CDC and ASM Websites very helpful as he examined the culture plates. Dr. Campos later learned other microbiologists had cultured their hospitals’ mailrooms. In a Nov. 9 teleconference, Dr. Campos heard the CDC’s Dr. Miller say it was acceptable for level A laboratories to engage in this type of environmental sampling if suspicion was low. "I felt somewhat vindicated when I heard that," he says.
(Dr. Miller, chief of the Epidemiology and Laboratory Branch, Division of Healthcare Quality Promotion [formerly Hospital Infections Program], told CAP TODAY, "I think the skills are available in level A laboratories to handle superficial environmental samples, such as a mailroom, where there has been no risk reported. However, any hospital where patients are involved should not be testing powders or doing environmental sampling beyond surface swabs.")
To help him decide whether to culture environmental samples, Dr. Thomson called a friend who works for the public health department. "I realized our facilities exceeded those needed to process specimens safely," he says. Dr. Thomson explained the situation to the technologists, reviewed anthrax-handling procedures, and asked the technologists if they would be comfortable doing the work. "We had a nice discussion revolving around our scientific ability to help and our duty to the community," he says. Several technologists volunteered. Dr. Thomson wrote a procedure for processing nonclinical specimens, and he and the laboratory manager trained the technologists. He also got clearance from hospital administrators.
One hurdle remained. Since the CDC had said hospital laboratories should not do environmental testing, Dr. Thomson called the local health department and asked for a specific request from the state health department. An e-mailed request arrived the next day. Over three weeks, the laboratory tested about 50 specimens, mostly envelopes or other enclosures. Many had dust or powdery substances on them or came from a suspicious address, but, in Dr. Thomson’s view, most didn’t pose a credible bioterrorism threat. No item tested positive. Eventually the local health department called and said the laboratory’s support was no longer needed.
Dr. Snyder also agreed to process environmental samples, with the assistance of three highly skilled medical microbiology technologists. Hospital administration knew his laboratory would be a primary resource if a bioterrorism event occurred. "Preplanning really paid off," he says. "We created a team here. Administration, security, infection control, infectious disease specialists, risk management—all have come into play in this incident."
Once Dr. Snyder agreed to provide laboratory support for the FBI, other agencies—fire, EMS, police—were directed by the FBI to refer all "creditable threat specimens" to his laboratory, he says. Eventually he had to make it clear that he was contravening CDC directives. "I am walking a line," he told agency representatives, "trying to provide a service but also trying to comply with CDC guidelines." An FBI agent said, "As far as we are concerned, you are the laboratory. We will support you." Dr. Snyder also contracted to do culturing for private companies. In the first three weeks, his team looked at about 255 specimens, including specimens from agencies in southern Indiana and throughout Kentucky. "We had 18 suspicious isolates, which we sent to the state health laboratory," he says. All were ruled out for anthrax.
Like Dr. Thomson, Dr. Snyder believes that most samples didn’t warrant testing; he is now accepting only grade one samples, which has reduced his workload by 80 percent. "We were getting everything," he says, "even lint on underwear. It is all psychological. Common sense has been put on the shelf—temporarily, I hope."
Dr. Snyder has learned a few lessons from his involvement. One has been that the state laboratory responds rapidly. "They have provided us with confirmation of suspicious isolates in less than 24 hours," he says.
Another lesson has been that the public reacts strongly. "It is hard to convince people that they are not a target," he says. To help educate the public, he has done many interviews with radio, newspapers, and local television, which have been broadcast from his laboratory. He has accepted only interviews that will not disrupt work. "Our first and foremost mission is patient service," he says. "It has been a big challenge."
Dr. Snyder says he also learned "the value of preplanning, the importance of communication and cooperation with local and state health departments, and that the [CDC’s Laboratory Response Network] is a good concept and is accessible to all nonpublic health laboratories."
For Dr. Robb, the biggest message is, "Our system is in place and it worked." His laboratory has been inundated by requests from across the United States and other countries about how to prepare for bioterrorism. As references, Dr. Robb provides the Web sites of the CDC and the Association for Professionals in Infection Control and Epidemiology. The latter has a template for a bioterrorism policy. Dr. Robb, meanwhile, has expanded his own bioterrorism policy from five pages to 61, adding "56 pages of attachments with details."
He cites three main actions as essential in a bioterrorism incident:
- Keep transmitting information, including facts about risk, to pathologists, ID physicians, and other hospital staff.
- Stop rumors. Dr. Robb had daily meetings for all three shifts and made an anthrax fact sheet. As a result, he says, "anxiety started to fall in a couple of days and productivity stayed high."
- Shield laboratory workers from distracting publicity. He declined hospital administrators’ requests to advertise how well the laboratory performed. "We got credit from our colleagues eventually," he says, "and in the meantime, we could take care of patients."
What did not work well, he learned, was the backside of the response system—getting information from the public health laboratory to the referring laboratory. "We didn’t know that anthrax was officially confirmed until Friday when we saw it on television," Dr. Robb says. "Things kind of fell apart because it was the first time this had happened." The FBI, in particular, was more of a hindrance than a help. "They jumped in with both feet," Dr. Robb says. "They didn’t come to our hospital or laboratory, just issued warnings not to talk to anyone. Our laboratory people were afraid even to talk to each other. We have to modify that."
Keeping staff informed is a top priority for Dr. Schwartz as well. "It is very important for laboratory directors and microbiologists not only to keep themselves updated on the situation, but to communicate with technologists and staff," he says. He believes it is a mistake to assume that technologists will be "cool" about handling possible bioterrorism organisms. "They are going to be anxious about it," he says, "especially if they are being asked to work with organisms they haven’t worked with or seen for a long time."
One positive outcome of the anthrax attack is that it will create experts, predicts Dr. Schwartz, who was chosen to chair the CAP’s new Ad Hoc Committee on Preparedness for National Emergency. "Right now there are no real experts," he says. "There are many people who have a lot of knowledge based on reading and research. But as we have found out over the last several weeks, the only way you become an expert on something is by dealing with it."
The CDC’s Dr. Miller agrees. "We have learned that until we actually have direct experience with something as sinister as a biocrime, we may not appreciate all the details required to address these outbreaks," he says.
Dr. Thomson draws three lessons from his experience. First, he believes his laboratory would be more prepared in the event of a more virulent release. "This served as a way of finding out what we can and can’t do," he says, "and a way of introducing us to procedures we hadn’t done."
Second, like Dr. Snyder, Dr. Thomson was impressed by the intensity of concern in the community. "It was immense," he says. Much of this concern came from people not understanding bacteria or bioterrorism, Dr. Thomson believes. "I felt that there was a pressing need for those of us with an education in microbiology to participate in this process," he says, "to educate and calm the community as we were qualified."
Third, Dr. Thomson was struck by how public response overloaded the health care system. "Our health care system was capable of handling all the real disease," he says, "but panic and pseudo-events overwhelmed the system and impeded its ability to investigate and pursue real disease and real threats."
To alleviate overload in future events, Dr. Schwartz says, "Hospital laboratories can help take the burden off public health laboratories, particularly for low-risk specimens. If enough laboratories help, public health laboratories can focus on cultures in which something is growing that might be significant."
Improvements to the system top Dr. Sharp’s list of conclusions:
- More effective information flow is needed from the top down—from CDC and public health laboratories to level A laboratories. It was "totally inappropriate," Dr. Sharp says, for Dr. Robb to find out from television that the sample his laboratory sent was positive for anthrax.
- It is sometimes difficult for level A laboratories to reach public health officials or the Laboratory Response Network to obtain information or to refer isolates. "We need to be able to do this efficiently," she says.
In her talks, Dr. Sharp stresses the importance of all level A laboratories—essentially all community hospital laboratories—being educated and trained in the appropriate protocols to rule out potential bioterrorism agents on clinical specimens. The agents of most concern are anthrax, plague, tularemia, brucellosis, botulinum toxin, and smallpox. The protocol to rule out anthrax is posted on the ASM’s Web site; other protocols are under review. "All laboratories should make sure they have that information in their procedure manuals," Dr. Sharp says. If tests do not rule out a bioterrorism agent, the role of the level A laboratory is to immediately send all specimens to a level B laboratory, which is typically the local or state public health facility.
In most cases, Dr. Sharp says, a technologist needs to have an index of suspicion before invoking protocols, so heightened awareness by bench technologists is essential. "I have given several inservices to my staff so they know what to look for," she says. For instance, Francisella and Brucella show up out of blood cultures as very small Gram-negative rods (coccobacilli). "These are very rare for us," Dr. Sharp says, "so technologists are instructed to call the supervisor or me if they see this."
Suspicion of a bioterrorism agent often arises only after the laboratory has already handled a patient specimen. This is another reason why technologists should handle all specimens as though they were dangerous and use standard precautions. Moreover, each laboratory must ask whether it is willing to do rule-out tests when one of the more dangerous agents, especially smallpox, is suspected. Immediately shipping all such specimens to a level B or C laboratory could be a prudent step.
Dr. Dallas describes another safety issue. "We have dangerous organisms in our laboratory that we did not have under lock and key because we didn’t think of them as possible weapons," he says. "Now they are locked." Examples include multidrug-resistant Salmonella, Listeria, and M. tuberculosis. In the future, the CDC may make registries of anthrax and other potential bioterrorism organisms. "We are trying to be proactive before there are laws," Dr. Dallas says.
For extremely dangerous bioterrorism agents, a more serious concern may arise—aerosolization during specimen processing. "I don’t worry about anthrax so much," says Thomas Cooper, MD, pathologist at Centinela Hospital Medical Center, Los Angeles. "We might get in trouble with smallpox. But I’m even more worried about hemorrhagic fever viruses, which have a greater propensity to be disseminated by aerosol transmitted via droplets."
Dr. Cooper has been active in biowarfare issues since serving on a biological warfare decontamination team in the Navy. As a member of a bioterrorism task force for the Los Angeles County Medical Association, he was invited to an Oct. 4 local bioterrorism conference. There he asked a consultant for the California Department of Health Services, who spoke on hospital safety and decontamination procedures, what precautions are taken if blood samples are contaminated and become aerosolized. "I got a blank look," he says. Later he asked the same question of a CDC epidemiologist who, he says, told him, "We haven’t thought about that."
Dr. Cooper wonders whether any part of chemistry, coagulation, or hematology instruments can create aerosols. "Most slide stainers now are centrifugal and would probably make an aerosol," he says. "And what if a tube breaks in a centrifuge? There is no easy solution to this thing."
William Check is a medical writer in Wilmette, Ill.