Pandemic preparation: Lessons learned from H1N1

History tends to repeat itself … and disease pandemics are part of history. Malaria, smallpox, and bubonic plague rank among the most serious. So, it is not a question of if another pandemic will occur, but when.

The years 2009 and 2010 added another pandemic to the list: H1N1. Now, laboratory professionals look back on lessons learned in diagnosing this influenza and contemplate how they can better brace themselves for the next event.
Do not delay in preparing the lab for the next pandemic.

Susan M. Poutanen, MD, MPH, F(RCPC), microbiologist/infectious-disease consultant, University Health Network and Mount Sinai Hospital, and assistant professor, departments of Laboratory Medicine and Pathobiology (Microbiology) and Medicine (Infectious Diseases), University of Toronto, Ontario, Canada, offers these suggestions.

Have a preparedness plan. Review how you coped with H1N1, and document lessons learned. Create a plan to take these lessons into account to better prepare for the next pandemic.

Prepare for biosafety. Ensure annual biosafety education and focus on practicing healthy hand and respiratory hygiene in an effort to reduce transmission of respiratory infections. Stockpile personal protective equipment, and consider stockpiling antivirals for influenza pandemic preparedness. Be prepared to modify biosafety protocols as necessary, depending on public-health advice.

Prepare for increased demands for testing. Review testing priorities, and be prepared to defer lower priority tests in order to free up personnel to be able to respond to increased demands of priority testing. Cross train personnel on anticipated higher priority tests.

Prepare to introduce new tests with little notice. Be prepared to find space for new equipment, validate new tests, train personnel, and implement new tests with little notice.

Follow metrics in real-time electronically. Ensure that data can be captured on the number of tests, number of positive tests, incremental costs, and workload related to the laboratory’s response to a pandemic in real time. This will help infection-control and hospital administrators make real-time decisions regarding implementing their preparedness plans that often are triggered by key laboratory results, among other things. It will also facilitate being able to justify requests for additional laboratory costs such as testing equipment, supplies, and personnel in response to a pandemic.

Have psychosocial support. Be prepared to support staff concerned about fear of the unknown, or death or sickness in a relative, friend, or colleague. Have resources available ahead of time that staff can call upon.

Connect with public-health officials
In addition to getting the previously stated items in place, develop a communications plan. “Be prepared to communicate to your lab in real time,” Poutanen says. “Connect now with public-health officials to ensure that you will be updated in real time of any events of concern relevant to your region.”

Bill Nauschuetz, PhD, clinical laboratory biopreparedness coordinator, U.S. Army Medical Command, Fort Sam Houston, TX, advises being familiar with the hospital’s pandemic influenza (PI) response plan and being prepared for rapid changes to that plan. Many hospitals have PI plans that were originally based on H5N1, and several features of those plans were modified for the unexpected emergence of 2009’s H1N1. Many of the changes are released in a coordinated effort from the Centers for Disease Control and Prevention (CDC) to the states’ public-health labs. If the pathogen is a novel virus, it is likely that the CDC will develop an assay and disseminate the assay to state public-health labs.

Tracking state/territory public-health laboratory guidance on testing provides a mechanism for coordinated responses and actions for labs within a particular state. For instance, does the state public-health lab recommend performing rapid antigen assays on patient respiratory specimens? Will the state public-health lab accept patient specimens based upon antigen results, clinical presentation, or a combination of both? Is the new pathogen safe to culture in hospital virology laboratories? Which specimens are optimal for viral isolation?

In addition, follow publications of CDC/state guidance on

• new biosafety recommendations for collecting, processing, testing, or shipping specimens or isolates;
• new infection-control recommendations for collecting, processing, testing, or shipping specimens or isolates;
• new requirements for reporting results or shipping specimens; and
• recommendations on who (e.g., inpatients, pediatrics patients) to test.

What if
If there were a potential pandemic, a top priority would be to determine supply/logistics requirements, Nauschuetz says. National supplies of consumables such as rapid antigen kits, viral transport media, and cell-culture tubes and shell vials for cultures media can quickly drop in a surge/pandemic scenario. Does the lab have enough on hand or the ability to quickly obtain more prior to depletion?

Make sure that the lab staff is familiar with the lab diagnostic section (Supplement 2) of the Department of Health and Human Services (HHS) Pandemic Influenza Plan1 and hospital and state plans based upon the HHS document. Maintain constant communication with the lab and hospital leadership. Ensure that lab-testing guidance supports and is coordinated with outpatient-testing guidance. Keep in mind that influenza-related staff illness and absences might occur, or there could be an increased need to test nurses, physicians, and clinical-support and lab staff.

Also take a look at staffing needs, Poutanen says. Are there enough staff members to complete priority testing? Is staff cross trained sufficiently to respond if there was a shortage of staff? If not, get started now. Educate staff with updated information regarding the pandemic, using reliable resources such as the local public-health department. Review biosafety protocols, and reassure staff that everything possible is being done to provide a safe work environment. Remind staff of psychosocial support resources.

Dealing with the H1N1 outbreak
Reflecting on her lab’s experience with H1N1, Poutanen says that many key stakeholders (i.e., treating teams, infection-control teams, and hospital administrators) were dependent upon real-time accurate data from the lab in order to make treatment, control, and administrative decisions. “We anticipated this but had not yet changed over to testing that would meet this demand until after the pandemic started,” she says.

There might only be little lead time to a dramatic increase in test demand and yet, “The H1N1 pandemic could just be a teaser to a more transmissible or virulent pandemic,” Poutanen says. It is possible to validate new assays in little time, but it requires expertise and dedicated methods and development personnel. Poutanen’s lab relied on research personnel associated with its academic lab to facilitate rapid validation of new assays; smaller laboratories may not have this resource.

Implemented changes
Poutanen says that as a result of dealing with H1N1, the lab has changed to routine molecular respiratory testing which meets the needed sensitivity and turnaround time demands of key stakeholders. The lab is in the process of training all staff to ensure that there is a full complement of staff who can provide molecular testing.

“We will reinforce to laboratory administrators the importance of maintaining methods-development and research staff as part of our laboratory to assure we have the expertise to implement new tests as needed with short notice,” Poutanen concludes.

Nauschuetz says Army medical center laboratories purchased equipment specific to the Emergency Use Authorization (EUA) for identification of the 2009 H1N1 using the CDC-developed assay. The EUA testing was primarily done on a platform (ABI 7500FAST) which most Army medical center labs did not have at the beginning of the surge. That resulted in hardware purchases to gain capability mid-pandemic.

Act now
Do not delay in preparing the lab for the next pandemic. Perhaps it will not be right around the corner, but if it is, be the lab with a plan.

Karen Lynn is a freelance medical writer.