-Caveat Lector- http://www.asmusa.org/memonly/asmnews/aug99/forum.html American Society for Microbiology (ASM) James W. Snyder is Professor of Pathology and Director of Microbiology in the Department of Pathology, Division of Laboratory Medicine, University of Louisville School of Medicine and Hospital, Louisville, Ky. He serves on the ASM Professional Affairs Committee. Links to Other ASM Pages: Table of Contents ASM News Issues Responding to Bioterrorism: the Role of the Microbiology Laboratory The Clinical Microbiology Laboratory will play a critical role in countering bioterrorism; what is the level of preparedness required to respond to such an event? James W. Snyder Bioterrorism poses a formidable new challenge to the clinical microbiology laboratory. The detection and recognition of the agents predicted to be used in acts of terrorism will, without a doubt, challenge the capacity and capability of many clinical microbiology laboratories in obtaining as much information as is possible in the shortest period of time. For example, the detection of Bacillus anthracis, the agent of anthrax, is not complex and its recovery in blood cultures during the active pneumonic form of the disease is common. However, most laboratories, when encountering Bacillus spp. in blood cultures, commonly regard such isolates as contaminants and do not pursue further identification or consider the possibility of the isolate being B. anthracis. Even greater problems would occur for viruses and toxins which are not normally examined for in the clinical microbiology laboratory. There is a significant need for reagents and rapid detection procedures for the detection of such agents. The role that the clinical microbiology laboratory will play is of great importance to the frontline clinicians and emergency personnel who are dependent upon this information for guiding therapy, assessing the need for decontamination and isolation of patients, instituting preventive measures, and maintaining a safe environment. Its major responsibility will be to detect, recover, and identify the etiological agent. Three scenarios have been identified that will require the involvement of the clinical microbiology laboratory: 1) an overt act of bioterrorism in which the Federal Bureau of Investigation would request the assistance of the local microbiology laboratory to provide a preliminary analysis of an environmental sample suspected of containing a biological agent; 2) a covert act leading to a disease outbreak during the early stages of which the laboratory would receive samples from patients exhibiting varying disease etiologies and apply routine diagnostic procedures that are not targeted to the detection of biothreat agents; 3) a confrmed outbreak (late stage), in which specimens would be received from patients who are suspected of having been exposed to a biological agent and the laboratory would be requested to identify the specific agent. Due to the disparity in expertise and levels of diagnostic capabilities that exist among clinical microbiology laboratories throughout the United States, strategies for dealing with biological agents must be identified and directed to increasing the capacity of the laboratory in countering bioterrorism. Such strategies should not be strictly focused on the laboratory but rather developed and designed as part of a total plan to facilitate integration with surveillance and epidemiology programs, and most importantly, communication between laboratories. These and other related issues were addressed at the recent Partnership Meeting on Responding to Bioterrorism convened by the Center for Infectious Diseases and held at the Centers for Disease Control and Prevention in Atlanta, Georgia. The current assessment is that most clinical microbiology laboratories do not possess the capacity or the expertise to detect and accurately identify those biological agents classified as high priority, namely the agents causing anthrax, brucellosis, botulism, cholera, plague, and smallpox. Several reasons can be identified to account for this lack of capacity and expertise: (1) restriction of the level of service to the recovery and identification of bacteria and not the detection of toxins and viruses; (2) the lack of a biosafety level III facility for the handling of biological agents in many laboratories; (3) the dilution of the pool of microbiologists who are trained in classical microbiology; (4) the outsourcing of microbiology tests by some facilities which thus are in no position to respond to a bioterrorist act; (5) the lack of reliable and rapid diagnostic tests and culture media for the detection and recovery of the targeted biological agents; (6) the lack of communication between laboratories, resulting in failure to notify other laboratories within the local or regional area that a bioterrorist act has occurred or to supply information regarding the suspected agent; and (7) the unwillingness of some facilities, due in part to fear, to provide any form of support. The following strategies, many of which were identified at the recent Partnership Meeting on Bioterrorism, should be considered in an effort to provide support and assistance in preparing the clinical microbiology laboratory for carrying out its role in countering bioterrorism: (1) increase federal, state, and private funding for developing and supporting training programs focusing on safety issues related to the transport and handling of specimens and the classical and molecular characteristics of the targeted biological agents, including viruses and toxin-producing agents; (2) obtain funding to support research and development of new and rapid diagnostic tests, encourage industry to improve current testing methods and develop state-of-the-art commercial assays, ensure the maintenance of adequate inventories of test kits and reagents in preparation for large-scale outbreaks, and utilize the expertise and resources available in the clinical microbiology community; (3) identify the testing capacity of all laboratories, including public health laboratories, and establish a nationwide tiered laboratory infrastructure by designating laboratories as either level 1 (no capability), level 2 (``rule-out'' capability), level 3 (limited identification), or level 4 (definitive identification); (4) develop protocols for specimen collection and transport with an emphasis on safety during shipment; (5) develop a model for the management and analysis of environmental samples (e.g., letters suspected of containing anthrax), including coordination with the FBI and Department of Defense; (6) establish a fully integrated national surveillance and epidemiology network for tracking and identifying clusters of disease syndromes associated with a biological agent, a 24-hour reporting system including a program for the continuous monitoring of health-related events that occur in intensive care units or reported via 911 calls to emergency medical services; (7) continuously update lists of notifiable diseases; (8) establish competency assessment and certification programs for laboratory personnel; (9) establish formal training programs for clinicians and emergency medicine personnel for the recognition of clinical features of disease syndromes caused by biological agents; (10) improve the infrastructure and communication links between public health and private laboratories; (11) include clinical microbiology laboratories in the recently created Health Alert Network; (12) provide medical examiners with better access to microbiology services; 13) encourage partnering between ASM, the Infectious Disease Society of America, the Centers for Disease Control, the National Laboratory Training Network, regional clinical microbiology associations, the Association of Practitioners in Infection Control, and the Society for Healthcare Epidemiology of America for the purpose of developing training and education programs for the recognition of clinical syndromes, laboratory testing, and management of outbreaks, including infection control and prevention guidelines. All of these strategies can be easily integrated into a functional system beginning with the local laboratories and extending to the state, regional, and national levels. We must be prepared to accept the fact that it is impossible to fully protect against biological weapons and that people will die in spite of efforts to quickly recognize, detect, and identify biological agents and their associated disease syndromes. The clinical microbiology laboratory must forego the convenience of isolationism and preservation of individual identity in order to become part of a team effort in responding to acts of bioterrorism. Never before has there been a need for improving the laboratory infrastructure with the goal being to integrate all laboratories into the testing and communication network regardless of their diagnostic capacity. Clinical microbiologists are encouraged to meet the challenges of bioterrorism by preparing themselves and their laboratories for the inevitable day when they are called upon to examine either environmental or human samples for the presence of a biological agent. By creating and supporting an infrastructure comprised of training and education, surveillance, early warning, and communication networks, the frontline responders will be better prepared to recognize and respond to acts of terrorism involving the use of biological agents. Last Modified: August 4, 1999 Email: [EMAIL PROTECTED] Copyright © 1999 American Society for MicrobiologyAll rights reserved ================================= Robert F. Tatman [EMAIL PROTECTED] [EMAIL PROTECTED] Remove "nospam" from the address to reply. NOTICE: In accordance with Title 17 U.S.C. 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