The COVID-19 pandemic challenged the US public health system in new ways, underscoring the critical roles of timely and reliable data for decision making, resilient supply chains, a strong workforce and support for flexible testing and diagnostic options. Above all, the experiences of the last few years have exposed the vital importance of coordination across multiple sectors, from local to national levels and among healthcare facilities, public health laboratories, state and local governments, manufacturers and federal agencies.

“With something of this scope and longevity, it has become very apparent that there’s a need for better connectivity and clearer understanding of roles and responsibilities across the laboratory system,” said Jill Taylor, PhD, senior advisor for scientific affairs at APHL.

“We know there are underserved populations we didn’t reach during the pandemic.”

 

– Jill Taylor, PhD, Senior Advisor, Scientific Affairs, APHL

Public health laboratories have always played an essential first-responder role in their communities, best positioned to pivot quickly and respond to emerging threats. Yet “we know there are traditionally underserved populations we didn’t reach during the pandemic,” Taylor said.

“There will always be a huge need for complex, high-throughput laboratory testing during large disease outbreaks. But we also need to make the walls of our laboratories more porous and incorporate more outreach efforts to serve the communities we live in,” she notes.

CDC and APHL are guiding early conversations about what an effective national laboratory system could look like, said Taylor. She serves on the CDC Advisory Committee to the Director and co-chaired a workgroup focused on evaluating CDC’s laboratory systems and response. One encouraging step that CDC has made to strengthen its laboratories is the creation of an Office of Laboratory Systems and Response within the immediate Office of the Director.

APHL and its partners are now taking the opportunity to apply lessons learned from the past few years to redefine what readiness looks like for public health, ensuring that laboratories will be ready to respond to the inevitable next outbreak quickly and effectively.

Applying lessons from the LRN-B

In these efforts, APHL staff can draw on existing resources and expertise, including the Laboratory Response Network for Biological Threats (LRN-B). Over the past 20 years, the LRN-B has become an essential tool for supporting rapid responses to pathogens and other emerging biological threats. “We’re exploring how the LRN can further evolve to be a useful resource for larger-scale responses,” said Chris Mangal, MPH, APHL’s director of public health preparedness and response.

Successes and lessons from its long history can inform thinking about a more comprehensive national laboratory system, she said. The Zika response 10 years ago offered lessons in handling surge capacity, as jurisdictions stepped up to support areas overwhelmed with demand for testing. And the mpox outbreak in 2022 and 2023 showed the importance of scalability and quick access to testing.

One place the LRN-B has particularly excelled is in linking public and private laboratories, Mangal says. Hospital laboratories, often the first to encounter new threats, play an integral role in referring specimens to state or local public health laboratories for further testing. “It’s a true partnership,” she said. “The LRN-B has been known for facilitating those linkages, and it’s ongoing work.”

Any national network should similarly build connections that leverage the strengths of different sectors—the responsiveness and community focus of public health laboratories, the scale and automation of commercial facilities, the coordination of federal agencies. Toward this end, a group of APHL members under the leadership of Andrew Cannons, PhD, director of the Florida Bureau of Public Health Laboratories, and Sara Vetter, PhD, assistant director of the Minnesota Public Health Laboratory, identified actionable steps for strengthening national laboratory coordination in an April 2023 report.

Establishing this type of collaborative mentality can help “institutions understand that they are an equal and integral part of a larger system,” Mangal said. At the same time, it’s important to acknowledge that different sectors have different missions. “That’s where I think APHL and CDC really have an opportunity, to find a sweet spot where these mission spaces intersect and to create ways they can support each other.”

Turning Data Into Decisions

APHL also has a wealth of public health laboratory data that can inform coordination and preparedness efforts.

The Public Health Laboratory Systems Database (PHLSD), for example, is a member-driven resource that supports knowledge sharing, surge support, continuity planning and cross-jurisdiction collaboration. With information about laboratories’ testing capabilities, equipment platforms, LIMS and other systems, the database gives laboratory directors and staff “kind of a one-stop shop” to identify nearby expertise and backup support, said Lorelei Kurimski, MS, APHL’s director of quality systems and analytics. A newly streamlined interface launched this year aims to make data input and access faster and easier.

With more than 100 laboratories represented in the PHLSD, APHL program staff can use aggregated data to track trends in workforce, facilities, platform usage and more. They also use laboratory data submitted annually through the All-Hazards Laboratory Preparedness Survey to assess capabilities and capacity to respond to a wide variety of public health concerns.

The data provided by member laboratories are critical for informing broader coordination efforts. “It allows us to get a comprehensive picture of what’s happening nationally,” Kurimski said. “The data can inform what we’re seeing in terms of trends, where there are gaps and where there are strengths.” At the same time, individual laboratories can use the data to benchmark their own preparedness.

The information also helps fulfill data requests and guide programmatic decision making by APHL, CDC and other partners. For example, the data might inform APHL’s work with CDC to assemble a data package to the US Food and Drug Administration (FDA) for 510(k) clearance for a widely used technology, or they might guide platform choice for developing a new test.

“Data inform decisions,” Kurimski says. “They allow us to see not only where we are, but where we need to go.”

Importantly, the data also reveal a reliance on federal funding for laboratory preparedness. “Almost 90% of preparedness efforts at the state and local level are covered by federal funds through the CDC Public Health Emergency Preparedness (PHEP) cooperative agreement,” Mangal says. What this means is that “when we talk about any type of laboratory system at the national level, it will not work without federal support.

A Playbook for Effective Coordination

In addition to funding, that federal-level support should include high-level leadership and decision making based on accurate data. The new Testing Playbook for Biological Emergencies, released in October 2023, lays out a framework for achieving this type of effective national laboratory coordination.

“Testing will always be at the center of response to an outbreak involving a contagious pathogen,” the playbook preface states. The document provides evidence-based guidance for public health leaders to respond to an emerging biological threat in a way that ensures rapid and equitable access to testing.

Co-led by APHL and Jennifer Nuzzo, DrPH, of the Pandemic Center at the Brown University School of Public Health, the playbook outlines six phases of a biological public health emergency, from initial pathogen detection through control of the outbreak. It also describes a “ready state”—an optimal baseline in which a laboratory network is resourced and ready to respond to an emerging pathogen.

“Testing will always be at the center of response to an outbreak involving a contagious pathogen”

 

Testing Playbook for Biological Emergencies

The playbook’s development was structured around the question, “what information do I need to know to be ready to make decisions?” says Ewa King, PhD, one of APHL’s co-authors, along with Taylor and Scott Becker, MS. “The point of the playbook was to be very pragmatic and practical. These are the questions you need to ask, and this is the information that you need to have at the ready to make sound decisions.”

For each of the six phases, the playbook lays out which sectors should be involved and prioritizes needed actions and questions. For example, how many laboratories in your region have a specific testing capability? Who leads the laboratories, and how do you reach them? What testing platforms do the local hospitals have, and what data systems are they using? However, the framework is intentionally flexible, King says, to be relevant to a broad range of potential scenarios, including novel pathogens.

Achieving the steps outlined in the playbook will require a high degree of coordination across the laboratory system, Mangal says. “It really lays a solid framework for how public health laboratories and the LRN-B can evolve to be part of a national system in place to respond to the next biological threat.”

This first version of the playbook is designed to be used by executive decision makers at the federal level, and the developers are now working on a more regionalized version to be used at state and local levels. The team is actively seeking feedback on the initial iteration, Taylor says. “This is not a dusty file that sits on a shelf. This is a living, evolving document.”

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