2021 microbiology columns - Healthcare Hygiene magazine

What is Herd Immunity? A Public Health Expert and a Medical Laboratory Scientist Explain

By Rodney E. Rohde, PhD, MS, SM(ASCP) CMSV CM,MBCM, FACSc, and Ryan McNamara, PhD

This content originally appeared on The Conversation blog.

The term herd immunity means that enough of a population has gained immunity to stifle a pathogen’s spread. You can think of herd immunity as being similar to fire starting in a field: If the field is dry and filled with weeds, the fire will catch and spread quickly. However, if the field is well-maintained with watering and trimming, the fire will fizzle out. Future embers that might land there will be far less likely to ignite.

The embers are much like SARS-CoV-2, the coronavirus that causes COVID-19.

Herd immunity can theoretically be achieved either through infection and recovery or by vaccination. The danger of trying to achieve herd immunity through infection is that many people will die or be forced to live with post-recovery disabilities. Moreover, research has shown that the immune response resulting from infection does not always provide strong enough long-term protection against COVID-19 and its evolving strains. Thus, public health experts still recommend vaccination against the coronavirus to achieve the strongest and most reliable protection.

When the COVID-19 pandemic erupted, scientists quickly began to develop vaccines so that populations could develop immunity to slow the fire-like spread of the coronavirus. In the meantime, nearly all countries mandated or encouraged social distancing, masking and other public health measures.

Unfortunately, the disjointed implementation of these efforts, coupled with large-scale surges and the emergence of the highly transmissible delta variant, has forced public health experts to recalculate what it would take to reach “herd immunity” for COVID-19.

Prior experience with respiratory pathogens that were comparable to the new coronavirus allowed public health experts to make educated estimates of what would be needed to reach the lower threshold of herd immunity for COVID-19. Initially they believed that around 70% of the population would need to be vaccinated to effectively slow or stop the spread of SARS-CoV-2.

But with the delta variant continuing to spread rapidly around the world, experts revised that estimate. Now, epidemiologists and other public health officials estimate that closer to 90% of the U.S. population would need to be vaccinated to reach herd immunity for COVID-19.

Viruses like those that cause polio and measles required decades of education and vaccination programs to achieve herd immunity and to ultimately eliminate them in the U.S. But given that new U.S. cases of COVID-19 continue to number in the tens of thousands daily, it’s become clear that COVID-19 is going to stick around.

There are several reasons it will take some time to achieve COVID-19 herd immunity. The COVID-19 vaccines are currently authorized for some age groups but not others. For perspective, roughly 90 percent of the U.S. population receives the measles, mumps and rubella vaccine – or MMR – as children, and 93 percent of the population is vaccinated against polio; both of these have been routine childhood immunizations for decades. Since children make up more than 20% of U.S. residents, the country likely cannot reach COVID-19 herd immunity without widespread childhood vaccination, even if all eligible adults were vaccinated.

As of Nov. 1, 2021, only 67.8 percent of the total U.S. population ages 12 and up that are vaccine-eligible had been fully vaccinated. Experts have attributed this to multiple factors including vaccine hesitancy and the politicization of the pandemic.

Of course, no vaccine is perfect. Vaccinated people can have breakthrough infections, although the COVID-19 vaccines continue to effectively reduce the most severe cases of COVID-19. In addition, research suggests that those who experience COVID-19 after vaccination may transmit the virus at lower transmission rates than those who are unvaccinated.

Rodney E. Rohde, PhD, MS, SM(ASCP) CMSV CM,MBCM, FACSc, is professor of clinical laboratory science at Texas State University.

Ryan McNamara, PhD, is a research associate of microbiology and immunology at University of North Carolina at Chapel Hill.

Abiotrophia defective: Quit Being So Difficult

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the November 2021 issue of Healthcare Hygiene magazine.

In 1961, Frenkel and Hirsch described strains of streptococci isolated from cases of bacterial endocarditis that grew only in the presence of other bacteria, around which they formed satellite colonies, or in media enriched with sulfhydryl compounds, such as cysteine. These nutritionally variant streptococci were eventually assigned the species Streptococcus defectivus (Latin for “deficient”) and S. adjacens (because it grows adjacent to other bacteria). Later research placed them in a new genus Abiotrophia (Greek a, “un-,” + bios, “life,” + trophe, “nutrition”) as A. adiacens and A. defectiva. The genus contains four species of coccus shaped species – A. adiacens, A. defective, A. balaenopterae and A. elegans. In 2000, Collins and Lawsons further differentiated A. adiacens, A. balaenopterae and A. elegans from A. defectiva by placing them into the new genus Granulicatella (Henry R. Etymologia: Granulicatella. Emerg Infect Dis. 2018;24(9):1704. https://doi.org/10.3201/eid2409.et2409 and Wikipedia).

In this column, I will focus on the Abiotrophia defectiva as it relates to important and dangerous cases of endocarditis. Infective endocarditis (IE) refers to an infection involving the endocardial surface of the heart.

Most IE cases are caused by viridans Streptococci or Staphylococci species. Abiotrophia defectiva is known to cause less than 1 percent of cases of IE. Though rare, it can cause life-threatening complications such as septic embolization, destruction of heart valves, and heart failure especially if not detected and treated quickly. A. defectiva is a part of the normal flora of the oral cavity, the urogenital and the intestinal tracts. For both physicians and medical laboratory professionals, this difficult bacterium causes many headaches and difficulties as to diagnosis and treatment. Though rare, nutritionally variant Streptococci (NVS) are estimated to cause approximately 5 percent to 6 percent of all cases of IE, including being a major cause of blood culture-negative IE. Importantly, this can result in early misdiagnosis or non-diagnosis.

Abiotrophia and Granulicatella spp. often appear as Gram-positive cocci in pairs or chains but can be pleomorphic. Sometimes however, they can appear more like coccobacilli or stain as Gram variable. Gram stain pleomorphism can be particularly apparent with suboptimal nutritional conditions. Gram stains consistent with a streptococcal-like morphology that are not detected by common used commercially available panels should raise suspicions for Abiotrophia or Granulicatella, among other organisms.

There have only been about 125 published cases of A. defective in the research literature. They do not synthesize pyridoxine, L-cysteine or other essential nutrients required for growth and depend on other bacteria (satellite) or enriched media for enhanced growth. The fastidious nature of this microbe often means that initial cultures appear to be sterile. A. defective is a pleomorphic organism, appearing as Gram-positive cocci, coccobacilli, and bacilli forms depending on the culture media. Literature suggests that due to the production of a considerable amount exopolysaccharides, the organism has a higher affinity for the endocardium and the ability to bind with fibronectin in the extracellular matrix, further contributing to their virulence.

Due to the difficulty in culturing this organism, one may need to utilize molecular diagnostic tools to raise sensitivity and specificity for quicker diagnosis, which can often lead to better patient outcomes. For example, Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) with the Vitek MS using library v3.2 can assist in the detection of Abiotrophia defectiva. Clinical suspicion regarding this organism should arise in cases of culture-negative endocarditis and additional testing with supplemented media (e.g., chocolate agar) should be performed to encourage growth of colonies. Further, susceptibility testing may be required via broth microdilution at a reference laboratory and interpreted by Clinical and Laboratory Standards Institute (CLSI) guidelines for proper treatment.

Ultimately, A. defectiva and similar organisms require an approach through multiple paths for detection – including cultures, serology, histopathology, and molecular methods, with blood cultures being the critical foundation. If surgery is considered, histopathologic analysis and culture of the explanted heart valve is critical because it may assist with confirmation of valve involvement and help inform duration of antimicrobials. Often culture of the valve is negative which may be due to the use of antimicrobial therapy prior to surgery. Abiotrophia and Granulicatella may also cause “culture-negative” endocarditis when antimicrobial therapy is administered during or prior to the drawing of blood cultures.

Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc, serves as chair and professor of the Clinical Laboratory Science Program at Texas State University. Follow him on Twitter @RodneyRohde / @TXST_CLS, or on his website: http://rodneyerohde.wp.txstate.edu/

References:
Agrawal U, Prabhu MM. Abiotrophia defectiva: A Rare but Critical Cause of Infective Endocarditis. Cureus. 2019;11(12):e6492. 2019 Dec 28. doi:10.7759/cureus.6492

Dumm RE, Wing A, Richterman A, Jacob J, Glaser LJ, Rodino KG. 2021. The Brief Case: A variant on a classic—Abiotrophia defective endocarditis with discitis. J Clin Microbiol 59:e03093-20.https://doi.org/10.1128/JCM.03093-20.

Burkholderia cepacia Complex Triggers Recall

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the October 2021 issue of Healthcare Hygiene magazine.

In September's column, I discussed B. pseudomallei and the recent outbreak in four states. This genus, Burkholderia, unfortunately packs quite a punch with several species. A member of the Proteobacteria, its pathogenic members include a diverse group of species responsible for several dangerous and often deadly infections.

For our medical laboratory professionals, it can be difficult to isolate and differentiate in the typical clinical microbiology laboratory, which sometimes leads to issues of misidentification or other laboratory tests to assist in understanding the case. Finally, like many other groups of bacteria that I have written about this genus can create biofilms, which interact with environmental and human surfaces. Biofilms play a significant role in mediating cell-to-cell communication. During this type of interaction, bacteria release protein toxins in the environment. Cells with a corresponding protective protein (usually bacteria of the same strain) are not inhibited to grow or die. Lastly, recipient cells with the corresponding protein undergo gene expression changes and phenotype, which augments biofilm communities. Importantly, even if the recipient cell was not of the same bacterial strain this can happen showing the critical importance this genus can have in the environment.

Ultimately, biofilms create “persister” cells, which can share antimicrobial resistance and other factors detrimental to human health.

In this column, I will focus on the B. cepacia complex (Bcc) as it relates to outbreaks as a dangerous contaminant in water-based pharmaceutical products.

BCC and water-based products
On July 7, 2021, the Food and Drug Administration (FDA) advised drug manufacturers of non-sterile, water-based drug products that Burkholderia cepacia complex (Bcc or B. cepacia) continues to pose a risk of contamination. BCC is a group of Gram-negative bacteria comprising more than 20 species that has been linked to multiple instances of opportunistic infections. For example, Paroex® Chlorhexidine was recalled in 2020 due to objectionable microbial contamination including the BCC species B. lata. Inadequate design, control, or maintenance of pharmaceutical water systems have led to contamination with BCC and other water-borne opportunistic pathogens.

Multistate Outbreak of Burkholderia cepacia Infections Associated with Contaminated Ultrasound Gel
Following the FDA advisement in July, on Aug. 18, 2021, FDA requested healthcare providers, healthcare facility risk managers, and procurement staff to immediately stop using and discard all ultrasound gels and lotions manufactured by Eco-Med Pharmaceutical, Inc., due to risk of bacterial contamination with Bcc.
Background via Centers for Disease Control and Prevention (CDC)

CDC is assisting the FDA and several state and local health departments with ongoing investigations of this issue. Patients have developed Bcc infections, including bloodstream infections, after likely having undergone ultrasound-guided procedures in which MediChoice® M500812 ultrasound gel was used. This ultrasound gel was likely used to guide ultrasonography in preparation for or during placement of central and peripheral intravenous catheters, and transcutaneous procedures, such as paracentesis.

As of Aug. 18, 2021, CDC is aware of at least 59 patients in six states with Burkholderia stabilis infection. The species strain genetically matches the B. stabilis strain identified in four lots of MediChoice M500812 ultrasound gel. At least 48 cases are bloodstream infections, and many had undergone ultrasound-guided procedures prior to their infections. Ongoing investigations at the local public health level are being conducted to gather additional data on these cases.

Recommendations from CDC include:
• All healthcare facilities under manufacturer order should identify the affected products by lot number and immediately destroy or return products. Additionally, Eco-Med is instructing all healthcare facilities to immediately stop use and quarantine all lots of the ultrasound gels distributed under these brand names. Refer to https://eco-med.com/recall/ for additional information.
• CDC advises that healthcare facilities should always use single-use, sterile ultrasound gel packets for ultrasonography used in preparation for or during transcutaneous procedures.
o This includes avoiding use of bottles of nonsterile ultrasound gel for visualization prior to such procedures (such as vein marking, visualizing ascites).
o Healthcare facilities should also review facility practices related to ultrasound probe reprocessing to ensure they are aligned with manufacturer’s instructions for use and appropriate professional society guidelines.
• Healthcare facilities should completely clean and appropriately disinfect ultrasound devices and any warming devices that may have had contact with the product after removing the potentially contaminated ultrasound gel from use in the facility.
• Healthcare facilities should report any patient infections related to the use of potentially contaminated medical products to FDA’s MedWatch Adverse Event Reporting

References:
https://www.cdc.gov/hai/outbreaks/b-cepacia-ultrasound-gel/index.html
https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-drug-manufacturers-burkholderia-cepacia-complex-poses-contamination-risk-non-sterile
American Institute of Ultrasound in Medicine (AIUM). Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as well as Safe Handling and Use of Ultrasound Coupling Gel. March 5, 2021. Available at: https://www.aium.org/officialstatements/57

Sounding the Alarm About Burkholderia spp.

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the September 2021 issue of Healthcare Hygiene magazine.

Burkholderia is a genus of Proteobacteria whose pathogenic members include a diverse group of species responsible for several dangerous and often deadly infections. Unfortunately, this group of bacteria can be difficult to isolate and differentiate in the typical clinical microbiology laboratory. Examples from this genus include the Burkholderia cepacia complex (Bcc), which attacks humans and Burkholderia mallei, responsible for glanders, a disease that occurs mostly in horses and related animals.

Burkholderia pseudomallei, the causative agent of melioidosis and a recent multi-state investigation of non-travel associated Burkholderia pseudomallei infections in four patients: Georgia, Kansas, Minnesota, and Texas—2021 via Centers for Disease Prevention and Control (CDC) Health Alert Network (CDCHAN-00448, August 9, 2021). Lastly, Burkholderia cepacia, an important pathogen of pulmonary infections in people with cystic fibrosis. This group is known for antibiotic resistance and a high mortality rate from their associated diseases, B. mallei and B. pseudomallei are considered to be potential biological warfare agents, targeting livestock and humans.

As many of you know, I have discussed many forms of antimicrobial resistance (AMR) in this column. Surfaces and biofilms intersect with AMR. Burkholderia research focused on interbacterial signaling has shown that contact-dependent growth inhibition plays a significant role in mediating cell-to-cell communication specifically in B. thailandensis. During this type of interaction, bacteria release protein toxins in the environment. Cells with a corresponding protective protein (usually bacteria of the same strain) are not inhibited to grow or die. Lastly, recipient cells that have the corresponding protein then undergo changes to gene expression and phenotype which advances community formation of biofilms. Unfortunately, this occurs even if the recipient cell was not of the same bacterial strain showing the critical importance this genus can have in the environment.

For this column, I will focus on B. pseudomallei and the recent outbreak in four states. In my next column (October), I will focus on the B. cepacia complex (Bcc) as it relates to outbreaks to a dangerous contaminant in water-based pharmaceutical products.

In a recent CDC Health Alert Network, four cases of melioidosis from Georgia, Kansas, Minnesota and Texas were identified and characterized. The first case (fatal) identified in March 2021 occurred in Kansas. The second and third cases, both identified in May 2021 in Minnesota and Texas, were hospitalized for extended periods of time before being discharged to transitional care facilities. The most recent case died in the hospital and was identified post-mortem in late July 2021 in Georgia. All cases had no history of traveling abroad from the United States. Melioidosis signs and symptoms are varied and nonspecific, and may include pneumonia, abscess formation, and blood infections.

All four melioidosis cases initially presented with symptoms ranging from cough and shortness of breath to weakness, fatigue, nausea, vomiting, intermittent fever, and rash on the trunk, abdomen, and face. Two cases, one fatal, had several risk factors for melioidosis, including COPD and cirrhosis. The other two cases had no known risk factors for melioidosis. Genomic analysis of the strains strongly suggests a common source (e.g., imported product or animal). The source is unknown to date despite environmental sampling, serological testing, and family interviews.

Importantly, B. pseudomallei may be misidentified by some automated identification methods in laboratory settings.

Recommendations from CDC include:
• Consider melioidosis diagnosis in patients with a compatible illness, even if they do not have a travel history to a disease-endemic country.
• Culture of B. pseudomallei from any clinical specimen is considered diagnostic for melioidosis. Ideal specimens for culture include blood, urine, throat swab, and, when relevant, respiratory specimens, abscesses, or wound swabs.
• When ordering specimen cultures to diagnose melioidosis, advise the laboratory that cultures may grow B. pseudomallei, and that appropriate laboratory safety precautions should be observed by the laboratory personnel.
• Laboratory testing involving automated identification algorithms (e.g., MALDI-TOF, 16s, VITEK-2) may misidentify B. pseudomallei as another bacterium. The isolate from the Texas case was initially misidentified as B. thailandensis by MALDI-TOF. Consider re-evaluating patients with isolates identified on automated systems as Burkholderia spp. (specifically B. cepacia and B. thailandensis), Chromobacterium violaceum, Ochrobactrum anthropi; and, possibly, Pseudomonas spp., Acinetobacter spp., and Aeromonas spp.
• Treat melioidosis with IV antibiotics (e.g., ceftazidime or meropenem) for at least two weeks. Depending on the response to therapy, IV treatment may be extended for up to eight weeks. Intravenous treatment is followed by oral trimethoprim-sulfamethoxazole (TMP/SMX) for three to six months to prevent relapse. Amoxicillin/clavulanic acid can be used in persons with a contraindication to, or who cannot tolerate, TMP/SMX. 5
• If B. pseudomallei is identified or an organism is suspicious for B. pseudomallei, contact your state or local public health department immediately. The health department can facilitate forwarding the isolate for confirmation to the closest reference laboratory and initiate a public health investigation.

For more information, see: https://emergency.cdc.gov/han/2021/han00448.asp

Fungal Infections Worldwide are Becoming Resistant to Drugs and are More Deadly

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This originally appeared originally in the June 28, 2021 The Conversation and is reprinted under Creative Commons.

Say “fungus” and most people in the world would probably visualize a mushroom. But this fascinating and beautiful group of microbes has offered the world more than just foods like edible mushrooms. Fungi are also a source of antibiotics – for example, penicillin from penicillium – as well as the yeasts and other fermentation agents that make bread rise, give cheese its flavor and put the alcohol in wine and beer.

Many people may also not realize that some fungi can cause disease. However, athlete’s foot, thrush, ringworm and other ailments are caused by fungi, and some are serious risks to health and life. That’s why the rise of antifungal resistance is a problem that needs more widespread attention – one equal to the better-recognized crises of multidrug-resistant microbes like the bacteria that cause tuberculosis.

I’ve worked in public health and medical laboratories for over three decades, specializing in public health and clinical microbiology, antimicrobial resistance and accurate science communication and health literacy. I’ve been paying close attention to the growing resistance of a pathogenic fungus called Candida auris to limited and commonly used anti-fungal agents. Since fungi have traditionally not caused major diseases, the emergence of drug-resistant fungi that can cause serious illness rarely receives funding for medical research.

But the facts suggest that this needs to change.

Fungi-caused ailments are treated with specifically anti-fungal medications because these organisms are such a unique form of life. Fungi are spore-producing organisms, including molds, yeast, mushrooms and toadstools. Among their unique characteristics, fungi feed on organic matter by decomposing it, rather than ingesting it like animals do, or absorbing nutrients through roots, as plants do. Unlike bacteria, which have simple prokaryotic cells, or cells without a true nucleus, fungi have complex eukaryotic cells cells, which do have a nucleus surrounded by a membrane like animals and plants. In the multi-level taxonomy, or naming system, that biologists use to classify life forms, fungi are in their own kingdom under the domain of Eukarya.

Most fungal infections worldwide are caused by a genus of fungi called Candida, particularly the species called Candida albicans. But there are others, including Candida auris, which was first identified from an external ear canal discharge in 2009 in Japan, and given its name for the Latin term for ear, “auris.”

Candida normally lives on the skin and inside the body, such as in the mouth, throat, gut and vagina, without causing any problems. It exists as a yeast and is thought of as normal flora, or the microbes that are part of humans. Only if our bodies are immuno-compromised do these fungi become opportunistic and cause disease. That is what’s happening worldwide with multidrug-resistant C. auris.

Infections by C. auris, sometimes called fungemia, have been reported in 30 or more countries, including the United States. They are often found in the blood, urine, sputum, ear discharge, cerebrospinal fluid and soft tissue, and occur in people of all ages. According to the Centers for Disease Control and Prevention (CDC), the mortality rate in the U.S. has been reported to be between 30 percent to 60 percent in many patients who had other serious illnesses. In a 2018 overview of research to date about the global spread of the fungus, researchers estimated mortality rates of 30 percent to 70 percent in C. auris outbreaks among critically ill patients in intensive care.

Research data shows that risk factors include recent surgery, diabetes and broad-spectrum antibiotic and antifungal use. People who are immuno-compromised are at greater risk than those with healthy immune systems.

C. auris can be difficult to identify with conventional microbiological culture techniques, which leads to frequent misidentification and under recognition. This yeast is also known for its tenacity to easily colonize the human body and environment, including medical devices. People in nursing homes and patients who have lines and tubes that go into their bodies – like breathing tubes, feeding tubes and central venous catheters – seem to be at highest risk.

The Centers for Disease Control and Prevention have set C. auris infections at an “urgent” threat level because 90 percent are resistant to at least one antifungal, 30 percent to two antifungals, and some are resistant to all three available classes of antifungals. This multidrug resistance has led to outbreaks in healthcare settings, especially hospitals and nursing homes, that are extremely difficult to control.

For hospitalized COVID-19 patients, antimicrobial-resistant infections may be a particularly devastating risk of hospitalization. The mechanical ventilators often used to treat serious COVID-19 are breeding grounds and highways for entry of environmental microbes like C. auris. Further, according to a September 2020 paper authored by researchers Anuradha Chowdhary and Amit Sharma, hospitals in India treating COVID-19 have detected C. auris on surfaces including “bed rails, IV poles, beds, air conditioner ducts, windows and hospital floors.” The researchers termed the fungus a “lurking scourge” amid the COVID-19 pandemic. The same researchers reported in a November 2020 publication that of 596 COVID-19-confirmed patients in a New Delhi ICU from April 2020 to July 2020, 420 patients required mechanical ventilation. Fifteen of these patients were infected with candidemia fungal disease and eight of those infected (53%) died. Ten of the 15 patients were infected with C. auris; six of them died (60 percent).

With the options for effective antifungals narrowing, CDC is recommending a focus on stopping C. auris infections before they start. These steps include better hand hygiene and improving infection prevention and control in medical care settings, judicious and thoughtful use of antimicrobial medications, and stronger regulation limiting the over-the-counter availability of antibiotics.

Antibiotic Resistance and the Medical Laboratory

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the July 2021 issue of Healthcare Hygiene magazine.

In the 2019 Antibiotic Resistance (AR) Threats Report (www.cdc.gov/DrugResistance/Biggest-Threats.htm), former Centers for Disease Control and Prevention (CDC) director, Robert R. Redfield, MD, discusses the radical change that has occurred over the history of antibiotic use from the 1940’s until today. In the foreword, he states to stop antibiotic resistance, the U.S. must:
• Stop referring to a coming post-antibiotic era—it is here. We are living in a time where miracle drugs no longer perform miracles and a microscopic enemy is ripping families apart. The time for action is now and we can be part of the solution.
• Stop playing the blame game. Each person, industry, and country can affect the development of antibiotic resistance. We each have a role to play and should be accountable to make meaningful progress against AR.
• Stop relying only on new antibiotics that are slow getting to market and that, sadly, these germs will one day render ineffective. We need to adopt aggressive strategies to keep germs away and infections from occurring in the first place.
• Stop believing that antibiotic resistance is a problem “over there” in someone else’s hospital, state, or country—and not in our own backyard. AR is in every U.S. state and in every country globally. There is no safe place from antibiotic resistance, but everyone can take action against it, from handwashing to improving antibiotic use.

Whether one is discussing AR or more generally antimicrobial resistance (AMR), together they represent a slow-burning global emergency. The World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and other agencies have predicted that AMR could lead to an economic impact of $100 trillion causing 10 million deaths annually by 2050 without action. AMR can become a slow-burning pandemic leading the world in mortality over longtime leaders like cancer and other health conditions.

How can we help? What can those of us who work in public health, the medical laboratory and healthcare do to help curb this global emergency?

In an April 2021 research study, Langford, et al. conclude that laboratory reporting of antibiotic susceptibility results for urine cultures is associated with empirical and directed prescribing of the reported antibiotics. Laboratories can play an important role in guiding appropriate antibiotic selection for urinary indications. Briefly, after a patient specimen is identified as a bacterial pathogen, the medical laboratory/clinical microbiology professional will perform an antibiotic susceptibility test (AST) on the pathogen. Testing determines the potential effectiveness of specific antibiotics on the bacteria and/or determines if the bacteria show resistance to certain antibiotics. Used properly, AST results help select the drug(s) that will likely be most effective in treating an infection.

This research study has important and practical findings for antibiotic stewardship programs (ASP). “Nudging” is a term used to describe the concept of modifying “choice architecture” to augment decision-making, without introducing incentives or inhibiting personal decisions by physicians (or other decision maker). Research shows that nudging is a promising intervention in the microbiology and medical laboratory. Selective reporting via nudging is a process whereby only certain culture and antibiotic susceptibility results are reported back to the clinician; the strategy aims to help guide appropriate antimicrobial prescribing. Selective reporting can take multiple forms, ranging from not reporting any susceptibility results at all to reporting only ﬁrst-line antibiotics or agents with lower adverse risks. While national and international guidelines recommend the use of selective reporting, speciﬁc reporting policies are discretionary for individual laboratories, resulting in a high degree of variability.

Ultimately, the goal of nudging can influence how a physician does or does not select and/or utilize a particular antibiotic. Langford’s ﬁndings conﬁrm their hypothesis that laboratory variability exists in selective reporting which inﬂuences antibiotic prescribing decisions. Approximately three-fold odds of directed antibiotic prescribing occurred when an antibiotic agent was listed on the susceptibility report and an association between laboratory antibiotic susceptibility reporting and prescribing in the empirical window. This suggests that the microbiology / medical laboratory can be highly inﬂuential in antibiotic prescribing choices, even when the prescriber is making decisions in the absence of a urine culture result (empirical or syndromic decisions).

Lastly, ongoing and growing development of rapid diagnostics (MALDI-TOF, PNA-FISH, qPCR, NGS, etc.) will continue to offer powerful discriminatory methods for pathogen identification and genes that may confer resistance to antimicrobial drugs. It is critical the experts on laboratory testing (medical laboratory professionals) are at the table for test selection and proper interpretation to aid physicians, pharmacists, and other healthcare professionals. Another important tool for hospitals to utilize will be the newly created doctorate of clinical laboratory science (DCLS). The DCLS will be the future of diagnostic management teams and laboratory test utilization at the intersection of open communication with the entire healthcare team, including physicians.

The Medical Laboratory Professional

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

In my recent, article “Who is doing all those COVID-19 tests? Why you should care about medical laboratory professionals” with The Conversation, I unpack why one should care about medical laboratory and public health professionals. Who do you think performs your medical laboratory tests for COVID-19 or any other test? If you answered “my doctor” or “my nurse” or a robot, you would be completely wrong. To put it bluntly, your life is in the hands of medical laboratory professionals. We perform an estimated 13 billion laboratory tests in the U.S. annually. That means that laboratory testing is the single highest-volume medical activity in the lives of Americans. Why should you care? Those 13 billion tests help drive approximately two-thirds of all medical decisions made by your doctor and other healthcare professionals from cradle to grave. There are only 337,800 practicing medical laboratory professionals for a population of just over 330 million people in the U.S.

As of May 14, 2021, our professionals have conducted 462,798,339 tests for COVID-19 infections since the pandemic began. What about all the other testing conducted each day? We are also running tests for people who are having babies, heart attacks, cancer, antibiotic-resistant infections, strep throat and other illness or diseases. Just because a novel virus showed up in our world and demanded to be tested for does not mean all other health issues stop.

A medical, or clinical, laboratory science degree often requires an average of five years of college education. Medical laboratory scientists all have bachelor’s degrees and have certification or a license to practice. I, and many of my colleagues, have a master’s degree, and a doctorate. These complex qualifications are reflected in our education and clinical background.

A degree in medical laboratory testing requires mastery of several areas of medicine including the study of hematology, molecular diagnostics, immunology, urine analysis, microbiology, chemistry, parasitology, toxicology, immunohematology (blood banking), coagulation and transfusion, and laboratory safety and operation. I often tell my students that this degree is like having to complete four majors.

Our profession can also start toward a laboratory science career at an entry level with a bit less education and clinical training – even as a technician, which requires only a two-year associate’s medical laboratory technician degree. These technicians often move up the career ladder by obtaining other degrees. Like any health care professional degree, ours is externally accredited through the National Accreditation Agency for Clinical Laboratory Sciences.

Currently there are an estimated 337,800 employed medical laboratory professionals in the U.S., according to the Bureau of Labor Statistics. This is an estimate, because without licenses in every state, an accurate number of practicing laboratory professionals is not available. But the demand for these professionals is expected to grow by 25,000 between 2019 and 2029, according to the Bureau of Labor Statistics. But that doesn’t include the number of jobs that will become vacant when workers retire or leave the profession during the pandemic.

What is frightening to me is that while the demand for clinical laboratory personnel is growing, the number of training programs is declining. Currently, there are 235 medical laboratory scientist and 240 medical laboratory technician training programs in the U.S. This is a 7 percent decline from the year 2000. In some states, there are no programs.

Fewer training programs, coupled with greater demand for laboratory professionals, could impact patient care, notes Jim Flanigan, executive vice president of the American Society for Clinical Laboratory Science. He is concerned by the lack of federal programs supporting medical laboratory education as compared to all other health programs. Vacancy rates are exceeding the number of medical laboratory scientist and medical laboratory technician graduates.

A number of other factors help explain our low workforce numbers. Training laboratory personnel is expensive, and there are few scholarship or loan programs available for prospective students. Salaries are also problematic. Compared to nursing, physical therapists or pharmacists, our professionals are paid 40 percent to 60 percent less on average for annual salaries.

The American Society for Clinical Laboratory Science is calling for expansion of the Title VII health professions program – which provides education and training opportunities in high-demand disciplines – to include medical (clinical) laboratory science. The organization also supports efforts to improve visibility of the profession by engaging in community outreach opportunities and by partnering with middle and high school STEM programs to show young people that laboratory medicine is a viable career path.

Lastly, with competition for laboratory personnel intensifying over the last year, turnover rates for some categories of laboratory personnel now exceed 20 percent. Because of the difficulty in finding qualified staff, medical laboratories are increasingly turning to temporary staff to handle the patient testing workload. In a sense, the pandemic has exacerbated a “free-agent” effect for traveling medical laboratory professionals that hurts continuity and quality in healthcare.

We hope that you see us and hear us. Your life or that of a loved one depends on it.

Originally published in The Conversation: https://theconversation.com/who-is-doing-all-those-covid-19-tests-why-you-should-care-about-medical-laboratory-professionals-151725

Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc, serves as chair and professor of the Clinical Laboratory Science Program at Texas State; associate director for the Translational Health Research Initiative; as well as associate dean for research in the College of Health Professions. Follow him on Twitter @RodneyRohde / @TXST_CLS, or on his website: http://rodneyerohde.wp.txstate.edu/

Microplastics and Antibiotic Resistance

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the May 2021 issue of Healthcare Hygiene magazine.

Antibiotic and antimicrobial resistance (AMR) continues to be a slow burning pandemic. It is not as recognized as the SARS-CoV-2 / COVID-19 pandemic. Even before the current ongoing global pandemic, AMR was a major global emergency, and we must not forget about this very dangerous public health threat. Most experts agree that AMR is a multifaceted complex problem. Resistance happens when germs (any microbe) defeat the drugs designed to kill them. Any antibiotic or antimicrobial use—in people, animals, or crops—can lead to resistance. Resistant germs are a One Health problem—they can spread between people, animals, and the environment.

The Centers for Disease Control and Prevention (CDC) tells us that antibiotic resistance is one of the biggest public health challenges of our time. Each year in the United States, at least 2.8 million people get an antibiotic-resistant infection, and more than 35,000 people die. Fighting this threat is a public health priority that requires a collaborative global approach.

As many of you know, I have discussed many forms of AMR in this column. Surfaces and biofilms are intersect with AMR. Now, we have another hidden surface to consider regarding the problem of resistance. In a recent Elsevier Journal of Hazardous Materials Letters, researchers found certain strains of bacteria elevated antibiotic resistance by up to 30 times while living on microplastic biofilms that can form inside activated sludge units at municipal wastewater treatment plants.

These ultra-fine plastic particles, less than 5 m in length, are in everything from cosmetics, toothpaste and clothing microfibers, to our food, air and drinking water. News Medical reports that estimates show an average-sized wastewater treatment plant serving roughly 400,000 residents will discharge up to 2,000,000 microplastic particles into the environment daily. Researchers are still learning the environmental and human health impact of these ultra-fine plastic particles.

The authors of the study discuss that some research focuses on the negative impacts that millions of tons of microplastic waste a year is having on our freshwater and ocean environments. Only recently, have studies started looking into the role of microplastics in towns and cities’ wastewater treatment processes which means we do not really know much there. The wastewater treatment plants may be hotspots where various chemicals, antibiotic-resistant bacteria and pathogens converge. The authors believe this is what their study documents regarding microplastics serving as their (AMR) carriers and posing hazards to aquatic biota and human health if they bypass the water treatment process.

The study was designed to collect batches of sludge samples from three domestic wastewater treatment plants in northern New Jersey, inoculating the samples in the laboratory with two widespread commercial microplastics – polyethylene and polystyrene. Quantitative PCR and next-generation sequencing techniques identified the species of bacteria that tend to grow on the microplastics. These powerful molecular techniques allowed them to track and detect how the bacteria adapted and changed in real time.

The study revealed that three genes in particular – sul1, sul2 and intI1 – known to aid resistance to common antibiotics, sulfonamides, were up to 30 times greater on the microplastic biofilms than in the experimental controls after just three days. Further, when they spiked the samples with the antibiotic, sulfamethoxazole, it amplified the antibiotic resistance genes an additional 4.5 times. The authors think the presence of antibiotics would be necessary to enhance AMR genes in these microplastic-associated bacteria, but it seems microplastics can naturally allow for uptake of these resistance genes on their own. However, it does appear that the presence of antibiotics can have significant amplification.

The study revealed eight different species of bacteria were highly enriched on the microplastics. Two of those species were emerging human pathogens typically linked with respiratory infection, Raoultella ornithinolytica and Stenotrophomonas maltophilia. The most common strain found on the microplastics was, Novosphingobium pokkalii, and is likely a key initiator in forming the sticky biofilm that attracts such pathogens because it leads to breakdown of the plastic and expands the biofilm. The study also highlighted the role of the gene, intI1, a mobile genetic element chiefly responsible for enabling the exchange of antibiotic resistance genes among the microplastic-bound microbes.

Most people likely think that these tiny microplastic “bead-like” materials are unseen and not a problem. However, what this study has shown us is that microbes always find a way to develop a niche and take advantage of their environment and surfaces. When a bacterium like Novosphingobium accidentally attaches to a microplastic surface and secretes glue-like extracellular substances (biofilms), it can allow other bacteria to stick to surfaces and grow. More worrisome is that it will offer them the opportunity to exchange DNA. This is how the antibiotic resistance genes are being spread among the community. Ultimately, this study and others may bring new regulations on the use of microplastics in consumer products.

The Infection Prevention and Environmental Services Professions

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the April 2021 issue of Healthcare Hygiene magazine.

For those who know my career journey, you probably realize that I often advocate for several critical professions that often go unnoticed. For example, I write, speak and interview often to discuss the medical laboratory and how #WeSaveLivesEveryday in the shadows of healthcare. For this month’s article, I want to briefly discuss two other professions that many people do now know about, including many healthcare professionals.

In my 30-year career journey, I have worked in public health, medical laboratory and academia. I discovered very early in these paths that many individuals in the public as well as other professional environments did not understand or made aware of hidden professions that have profoundly important roles in saving lives. These two professions – infection prevention and environmental services – have ongoing powerful roles in preventing infections in healthcare and community settings.
The first profession I would like to discuss is the role of an infection preventionist (IP). I am starting with this career because I have several alumni from our Texas State University Clinical (medical) Laboratory Science Program who have gone on to amazing IP careers after their medical laboratory journey. In fact, these two careers have synergistic and complimentary coursework and healthcare environment education / training.

According to the Centers for Disease Control and Prevention (CDC), 1 in 25 hospitalized patients will get an infection because of the care they receive, and an estimated 75,000 patients will die each year. Because healthcare-associated infections (HAIs) are a threat to patient safety, many hospitals and healthcare facilities have made the prevention and reduction of these infections a top priority. The IP is on the frontlines of preventing HAIs as well as community infections in some career slants.

What does an IP actually do? How do you become an IP? According to the Association for Professionals in Infection Control and Epidemiology (APIC), IPs are the professionals who ensure that healthcare workers (physicians, nurses and others) and patients are doing everything they should to prevent infections. Most IPs are nurses, epidemiologists, public health professionals, medical laboratorians, microbiologists, doctors, or other health professionals who work to prevent germs from spreading within healthcare facilities. They look for patterns of infection within the facility; observe practices; educate healthcare teams; advise hospital leaders and other professionals; compile infection data; develop policies and procedures; and coordinate with local and national public health agencies.

Usually, when one decides to work in the field of infection prevention, they probably were working in one of the healthcare fields mentioned (nurse, medical laboratory, etc.) and find that they have a passion and talent for this area. This is how several of my alumni ended up working in the IP world. APIC discusses the ever-changing requirements of the profession demand that IPs constantly update their knowledge base and expand their skill set. The updated APIC Competency Model (May 2019) has four career stages, defined as follows: novice, becoming proficient, proficient, and expert. As one progress through these stages, typically when the proficient state is reached an individual will want to obtain the CIC® credential [see: https://www.cbic.org/CBIC/CIC-Certification/About-the-Examination.htm].

IPs are in the trenches of curbing and prevention life-threatening antimicrobial resistant HAIs and other dangerous pathogens. Truly, a wonderful career for those interested in this area.

The second career path that I love to discuss to raise awareness for is the environmental services professional (EVS). In a 2014 article, I wrote for Elsevier Connect titled “A secret weapon for preventing HAIs,” I mention that when I teach a microbiology class for future nurses or medical laboratory professionals, I often start a complex discussion of microbial control. As an aside, I happened to tell my students of what I believe to be an overlooked "secret weapon" in reducing and preventing HAIs in hospitals: the housekeepers – or more accurately, the environmental services staff.

After all, as I often tell my medical/clinical laboratory science students, "clean does not necessarily mean microbially clean." In other words, just because a healthcare or community setting looks and smells clean does not always mean that it is free from dangerous pathogens! These bugs do not read the textbooks when it comes to following any rules about infection prevention and control. We must all ensure that the EVS profession and its professionals are known and respected entities in controlling the chain of infection. Unfortunately, the environmental services staff rarely appear on the radar of hospital administrators except when there is a need for budget cuts. It is our job and professional duty to make sure EVS professionals remain on the radar of everyone involved in reducing HAIs and other pathogen transmission. I like to tell those who are not aware of EVS staff, #SurfacesMatter all the time to everyone. Learn more about this lifesaving profession with the CDC: https://www.cdc.gov/infectioncontrol/training/evs-battle-infection.html and other professional organizations.

AMR and COVID-19: The Intersection of the Pandemic

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the March 2021 issue of Healthcare Hygiene magazine.

For the past 15-plus years, I have discussed (screamed) about the dangers of empirical antibiotic use in treating infections. Most of us who conduct research in the realm of antibiotic and antimicrobial resistance (AMR), understand that there is a time when a physician or others in the healthcare team may need to utilize empirical treatment. For example, if an individual enters an emergency department and are suffering from sepsis leading to organ (e.g., kidney) failure. A physician must start that patient on a broad-spectrum antibiotic to protect their life. Unfortunately, the pandemic and prior has led to patient treatment with antibiotics minus a confirmatory laboratory test to identify the pathogen and the all-important antibiotic susceptibility test to predict effective antibiotic(s) use.

The ongoing SARS-CoV-2 pandemic has been at the forefront of everyone’s mind, including dominating healthcare and public health. Rightfully and arguably so, it is the most important global health emergency in the last century. However, just under the radar we find that the concern of treating COVID-19 patients may be amplifying an ongoing, slow-burning global pandemic that has been here decades – the antimicrobial resistance pandemic.

In a recent Open Forum Infectious Diseases study conducted in five hospitals in the Johns Hopkins Health System between March 1, 2020, and May 31, 2020 [Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study], 1016 adult patients were evaluated for possible bacterial co-infection at time of presentation of COVID-19. Briefly, recent research tends to show that bacterial co-infection with COVID-19 is uncommon at the time of presentation. However, these data were based on microbiology results only. The investigators sought to develop and apply consensus definitions, incorporating clinical criteria to better understand the rate of co-infections and antibiotic use in COVID-19. Primary results indicated bacterial respiratory co-infections were infrequent (1.2 percent); one patient had proven bacterial community-acquired pneumonia (bCAP), and 11 (1.1 percent) probable bCAP. Two patients (0.2 percent) had viral respiratory co-infections. Yet, and frighteningly so, 69 percent of patients received antibiotics for pneumonia. Most were halted within 48 hours in patients with possible or no evidence of bCAP.

For emphasis, in everyday language this means that seven out of 10 patients were treated empirically with antibiotics when they did NOT have bacterial respiratory infections or bCAP. We can and must do better.

I recently discussed this issue in a Forbes article regarding a recent Bulletin from the WHO. Experts discussed dangers of the ongoing COVID-19 pandemic amplifying antibiotic resistance. Too many people have been receiving antibiotics when presenting with mild cases of COVID-19, but no pneumonia or even a moderate case with pneumonia. Antibiotics should not be used here. The article goes on to note that studies “published on hospitalized COVID-19 patients identified that while 72 percent (1,450/2,010) of patients received antibiotics, only 8 percent (62/806) demonstrated superimposed bacterial or fungal co-infections.” The WHO also reports that azithromycin is being widely used with the hydroxychloroquine treatment as problematic for AMR.

I go on to argue that the recent CDC 2019 Antibiotic Resistance Threats in the United States article, states that despite improvements in recent years, “the number of people facing antibiotic resistance in the United States is still too high. More than 2.8 million antibiotic-resistant infections occur in the US each year, and more than 35,000 people die as a result. In addition, nearly 223,900 people in the US required hospital care for C. difficile and at least 12,800 people died in 2017.” Likewise, public health experts from the United Nations, international agencies and others released a report in April of 2019 stating that if no action is taken, “drug-resistant diseases could cause 10 million deaths each year by 2050 and damage to the economy as catastrophic as the 2008-2009 global financial crisis. By 2030, antimicrobial resistance could force up to 24 million people into extreme poverty.”

Proactive, prevention of disease is much more cost effective and logical for the treatment of disease rather than being reactive. Simply stated, the nation’s (and world) public health system has been underfunded for decades. Until we get serious about prioritizing public health in an ongoing, logical, purposeful way, we will continue to fight these deadly causes with fewer people in the public health and medical laboratory spaces. People will be overworked and perhaps rushed on to the “battlefields” too soon because of non-sustained pipelines of highly trained professionals in the lean workforce. Cutting funding for new research on vaccines and creative ways of attacking disease will suffer. Cutting educational scholarships and programs for ushering in a new generation of these professionals is shortsighted. Utilizing simulations and modeling to try to prepare better for the next outbreak is critical.

Public health and healthcare funding is smart and pays dividends. It meets the long-standing adage of “an ounce of prevention is worth a pound of cure.”

What Does a SARS-CoV-2 Variant Mean?

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the February 2021 issue of Healthcare Hygiene magazine.

Just when we were all starting to breathe a (small) sigh of relief with the news of successful therapies (antivirals, steroids, and monoclonal antibodies) and multiple vaccines for the SARS-CoV-2 virus to help with prevention of a COVID19 infection, we started seeing new headlines about a new virus variant (strain) emerging in the United Kingdom (UK). Scientists and public health officials began reporting what appeared to be a COVID19 surge in December caused by a SARS-CoV-2 variant. While it is likely too early to know, this new strain appears to be transmitting faster than earlier strains.

The UK sequences 5 percent to 10 percent of all COVID-19 cases for epidemiological surveillance. In 117 of 255 sequenced cases, roughly 50 percent of them were detected to be in a unique phylogenetic cluster. In common language a distinct cluster of viruses just means that they are very similar to each other (genetically) versus to other strains of the virus. The “new” detected viruses were initially designated as Variant Under Investigation (VUI) – 202012/01 upon detection, but on further review given its rapid spread has been re-designated as Variant of Concern (VOC-202012/01) or B.1.1.7 (a name derived from its phylogenetic heritage). It is important to understand that the terms “variant,” “strain,” and “lineage” are synonyms. Currently, the general media and scientists are using them in addition, for their reporting.

Global reports (https://cov-lineages.org/global_report_B.1.1.7.html#table2link) by Public Health England have illustrated that the B.1.1.7 strain has quickly spread outside of England and the UK. At the time of writing this column, almost 50 countries have detected this new variant, including the United States. While the world still awaits the analysis of a stronger (more cases) data set for more certainty, early statistical modeling by the Centre for Mathematical Modelling of Infectious Diseases at the London School of Hygiene and Tropical Medicine implies the transmission of this variant may be 56 percent greater. The data also exhibits a higher Rt (reproductive rate is the number of secondary infections that occur from a single infection) of 0.7 versus 0.4 from early strains.

Is it normal for viruses to change?

Viruses, especially RNA viruses, change rapidly (mutate). All viruses do this over time and the coronaviridae (SARS-CoV-2 belongs) is no different. Mutations occur in the sequence of nucleic acids by base changes. Sometimes these mutation events during virus evolution will be “silent” which means the changes do not produce anything of concern to its host (in this case, humans).

On the other hand, sometimes the mutation is not silent and can result in the virus producing new or changed proteins or features that produce changes resulting in a new or related phenotype. Scientists refer to minor changes in a microbial phenotype as resulting in an antigenic drift, while major changes are known as an antigenic shift. A drift is usually less problematic, for example, because the human immune system will likely still recognize the microbe and mount a response.
Many people may understand this situation with the ongoing changes of influenza viruses, which means each year we receive (usually) a new cocktail of vaccine for protection due to flu virus mutations. Fortunately, coronaviruses mutate slower than other RNA viruses. The scientific community has already documented SARS-CoV-2 variants that differ from the original Wuhan strain and involved the well know spike protein that is critical for virus cell-mediated entry.

What are some of the major concerns about this variant?

While there are always concerns with virus mutation, I believe there are primary issues the scientific, public health and healthcare community should focus on. Probably the biggest concern on everyone’s mind is whether the new vaccines will be effective on B.1.1.7 strain. Preliminary data has not shown that B.1.1.7 causes more severe illness than other strains. Likewise, it appears that the mutations to the virus spike protein have not shown new vaccines will not provide immunological protection (efficacy) but we must continue to monitor data with continued efforts of understanding the effect, if any, on all vaccines produced for SARS-CoV-2.

My medical laboratory and public health colleagues are also concerned with how changes in the virus spike protein or other mutation events may affect the laboratory detection of new strains. Briefly, when a virus mutates, sometimes it can decrease the ability for a laboratory test (antigenic or molecular) to “pickup” the new strain that could create false negatives. Lastly, the Centers for Disease Control and Prevention (CDC) reports that only 51,000 of 17 million (0.3 percent) cases are sequenced in the U.S.

It is critical to our national and global public health security that we put into place a more comprehensive effort to sequence more virus specimens to follow viral changes. To address this concern, the CDC has launched the National SARS-CoV-2 Strain Surveillance program, requiring each state to send them at least 10 samples bi-weekly for sequencing and characterization, which will identify B.1.1.7 and any other SARS-CoV-2 variants.

Acknowledgement: Dr. Rose Lee, https://asm.org/Articles/2021/January/B-1-1-7-What-We-Know-About-the-Novel-SARS-CoV-2

2020: It Has Been Quite a Year!

By Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc

This column originally appeared in the January 2021 issue of Healthcare Hygiene magazine.

When I look back over the past year, I remember seeing first reports of a new viral respiratory agent popping up in Wuhan, China. Like many experts, I mentally noted it and moved on to other items of my workweek. That was in December of 2019. How little we knew of the coming tsunami of change for not only the United States but the entire global population.
As I opened my email today, I noticed so many stories about the “year in review” – both good and bad. Understandably, the global COVID-19 pandemic caused by the novel SARS-CoV-2 virus dominated the headlines daily during the past year, there are both pandemic and other stories that we have all witnessed.

IntraHealth’s Katherine Seaton writes that these were some of the following major news items this past year. In January, WHO launches the first-ever Year of the Nurse and the Midwife. March brings us the news that COVID-19 is officially declared a pandemic. Who can forget May? George Floyd is murdered. In July, the Trump Administration announces the U.S. will withdraw from the World Health Organization. Here comes August when we learn that Africa becomes free of wild polio. In the fall, October lets us know that The World Food Program wins the Nobel Peace Prize. November brings the U.S. unforgettable election (with plenty of ongoing controversy) as it ushers in new leadership and a renewed focus on global health. As I type these words for my monthly column, December unfolds an amazing and developing medical and public health event – The U.K. and the U.S. administer their first coronavirus vaccines.

This pandemic is arguably the most significant and devastating public health event. Globally, it will be remembered as an event that changed how we view microbes. I, like many of my colleagues, have been screaming for decades about the dangers of these invisible invaders. Like 9/11 changed air travel, this pandemic will change how everyone views the invisible world of the microbe. Now, there are new ways of thinking about our space, or the surfaces we touch, and what being in an overly crowded space can feel like. We use terms and phrases like “flatten the curve,” “physical distancing,” “reproduction number,” “false positive / negative” and “twindemic” like they are normal, everyday language.

As I sit her today, Dec. 17, 2020, there are approximately 74,695,618 cases and 1,658,588 deaths globally. In the U.S. alone, there are 17,401,787 cases and 314,694 deaths. My amazing colleagues in the medical laboratory and public health laboratory have tested approximately 226,751,534 specimens for COVID-19. Amazingly, there are only 337,800 practicing medical laboratory professionals for a population of just over 330 million people in the U.S. As I wrote in my recent article, “Who is doing all those COVID-19 tests? Why you should care about medical laboratory professionals,” for The Conversation, I’ve worked in public health and medical laboratories for three decades, specializing in the study of viruses and other microbes while also educating the next generation of medical laboratory scientists. In 2014, I coined the phrase “the hidden profession that saves lives.” With COVID-19, these unsung professionals are now in the limelight. Unfortunately, this pandemic has led to a nationwide burnout of these professionals, causing dangerous shortages in the U.S. healthcare infrastructure. Other public health and healthcare professionals show dangerous shortages and burnout as well.

I also wrote that most people in the public do not understand who performs medical laboratory tests for COVID-19 or any other test. It is not your doctor, nurse or a robot. It is a medical laboratory or public health laboratory professional. To put it bluntly, your life is in the hands of medical laboratory professionals. We perform an estimated 13 billion laboratory tests in the U.S. annually. That means that laboratory testing is the single highest-volume medical activity in your life. Why should you care? Those 13 billion tests drive roughly two-thirds of all medical decisions from cradle to grave. Our professionals have mad respect for physicians, nurses, respiratory therapists, pharmacists and all healthcare professionals. We just want you to understand that we save lives every day even though you do not necessarily see us in the shadows of healthcare.
Yet, as I sit her, I am reminded that we have come together to produce not one, but multiple vaccines that will help us end this pandemic. Our collective creativity, insight and brilliance has led to monoclonal antibodies, antivirals, and ongoing medical interventions, which save countless lives. Yes, it has been one of the worst years of our lives. However, I also believe this year is one of the most monumental, phenomenal, and significant public health and healthcare achievements of all time. Let us turn the page to 2021 and get to work! Happy New Year, everyone!