Biosafety Challenges in Alaska

Transcript

Date of session: 07/18/2023

Facilitator

Sabrina DeBose, DHSc, MS, RBP

Centers for Disease Control and Prevention

DLSbiosafety@cdc.gov

Didactic Speaker

John Laurance IV, BS

Public Health Microbiologist

State of Alaska Public Health

john.laurance@alaska.gov

Sabrina DeBose: Hello, everyone. Good afternoon, good morning, and good evening. My name is Commander Sabrina DeBose. And want to extend a warm welcome from the Centers for Disease Control and Prevention in Atlanta. I'm the Safety Team Lead in CDC's Division of Laboratory Systems.

We want to thank you all for joining our seventh ECHO Biosafety session. The topic for this interactive discussion is Biosafety Challenges in Alaska. And today's subject matter expert is John Laurance from Alaska State Public Health Laboratories.

To foster a stronger sense of community and facilitate networking amongst biosafety professionals, we encourage everyone to turn on their cameras during today's session. We understand that this may not be feasible for everyone. So please feel free to join with or without your camera, since our aim with the ECHO Biosafety Project is to connect names with faces and to build a community of practice.

So I would like to ask everyone a quick icebreaker question. Let me stop sharing here, all right. With the temperatures in your area– and we know it's summertime. It's really hot outside.

So we want to give you all an opportunity to come on camera and to see who has the warmest weather in your area. And tell us, what are you doing to stay cool other than sitting in front of the air conditioner? So just tell us, how are you getting through this heat? And let's see what's the warmest temperature we have out there in in our community. And, as, I mentioned we're in Atlanta. So today, our high is supposed to be 94. Can anyone beat 94?

Come on. Please feel free to jump in. I know, John, you're in Alaska, right? What's your temperature there?

John Laurance: It is a delightful 53 degrees Fahrenheit this morning. And we are having the coldest summer in a very long time.

Sabrina DeBose: The coldest summer– I like it. Any participants or anyone want to tell us how warm it is? Can anyone beat our 94 in Atlanta? 117, that's a little warm, blazing. OK, 94 in Savannah, our neighbor.

All right, give everyone a couple of seconds to see who else we have. 84 in Wyoming. It's not too bad. It's my kind of weather. In Reno? Yep.

All right, so that sounded like we have a variety of temperatures. I think John beat us with the coolest. And Atlanta, as we know, it's hot.

But we will go ahead and keep going with our session. Let's go ahead and get to—all right. So I do want to thank you all for participating in our icebreaker. But before we continue, I'd like to address some technical aspects of our ECHO Biosafety session.

As we mentioned, please use your video capabilities from your device for this session. Currently all audience microphones are muted. When engaging in a discussion, please unmute yourself to speak.

So if you are experiencing technical difficulties during the session, please send a private chat message to George Xiang, who is labeled as CDC ECHO Tech. And George will do his best to respond to your issue.

If you're connecting to Zoom by phone only, at the time of the discussion, we ask that you introduce yourself by stating your name and institution before speaking.

And how do these ECHO sessions differ from other presentations? So the sessions are different from webinars that the main feature is a discussion of cases or clinical laboratory challenges.

Our subject matter experts aim to share some applicable solutions that can be implemented in your individual laboratories. We encourage your active participation by sharing your knowledge and expertise. As you know, each laboratory is unique. And your skill sets are unique. So your contributions to the discussions are highly valuable.

And here's a brief overview of today's session. So I'll introduce our subject matter expert, which is John Laurance, who will provide a didactic presentation and real case discussions. Then my colleague, Dr. Mary Casey-Moore, will summarize today's discussions. Closing comments and reminders will follow this. And then we will adjourn this session.

Today's session is being recorded. So if you prefer not to be recorded, please disconnect now.

Closed captioning is provided for this session. And you can find that link in the chat. And after today's session, the transcript, the audio recording, the presentation slides, and other resources will be posted on the DLS ECHO Biosafety website.

All right, now it is my pleasure to introduce John Laurance. John is the responsible official, biosafety officer, and training coordinator at the State of Alaska Laboratory– I'm sorry, the State of Alaska Public Health Laboratory. He has been with the State of Alaska Public Health Laboratory since 2015, working in the Laboratory Response Network diagnostic section performing clinical diagnostic testing for potential biothreat agents. He has been involved in laboratory biosafety, clinical outreach, and training since 2016.

John received a Bachelor of Science in Microbiology and Biotechnology from Washington State University and is currently working on completing his Master's in Public Health with the University of Alaska Anchorage. John, I would like to turn the presentation over to you. The floor is yours.

John Laurance: All right. Good morning, everybody. Just so you know, Alaska is four hours behind the East Coast. So it's definitely a solid morning for me. And I would love it if you could share a little bit of that heat with me because it has been chilly up here.

So I'm going to be talking about the challenges that I face in the state of Alaska for delivering biosafety training. A lot of these is going to seem like a more extreme version of what you might face in your own states. But a lot of the lessons, I'm hoping, are actually applicable to the challenges that you would see as well.

Alaska is a perfectly normal state. We have shopping malls, as much as they are. Amazon delivery takes an extra day or two. And we've got a reasonable population base, roads, highways, all the normal things that the Lower 48 has. So we are just like everybody else. But we do experience some what I think are unique challenges in delivering public health services as well as training that are really going to be based on the geography of the state.

So we have limitations in our road systems. Our highway system only covers a fraction of the actual land mass that is Alaska. And a lot of our major villages and towns are separated by vast distances, some of which you can only fly to. So a lot of Alaska works on a hub-and-spoke community type system, where we have larger communities and then a lot of smaller villages around those communities that are mostly served by air travel. Sometimes they're served by boats. And then in the southeast of Alaska and through the Aleutians, we have the Alaska Marine Highway, which is a ferry system that will connect some larger communities and some of the smaller communities.

But a lot of our stuff flies in between– in between in that hub-and-spoke system. So our samples fly, and our patients fly. And that does create some challenges in terms of moving and transporting diagnostic specimens.

We also have internet connectivity issues. So I will apologize if I cut out or get slow because there is essentially one pipe that connects all of Alaska to the Lower 48 states and the rest of the world. And right now, a lot of Western Alaska is experiencing a major outage because their single fiber optic cable was cut due to Bering Sea ice grinding up against the shoreline. So, again, some of these issues are things that we have to deal with all the time, cuts in communication to the rural areas. And satellite communication has not really penetrated a lot of our smaller villages and even some of our hub.

We also have to deal with influx of seasonal workers that is up to a third to just below a half of our total population size annually. So Alaska grows extremely during commercial fishing seasons and the tourism seasons.

And then we just, yeah, we have the same issues with delivering training that everybody else does. And it's the question of, do we try to deliver in-person training? How do we deliver that in-person training? How much do we rely on virtual, particularly given our other issues, right?

When we have to fly, doing in-person training is difficult. When we have slow internet connections and other IT issues, sometimes associated with just the way the state of Alaska banks and houses some of our training modules so that people can have asynchronous access, there's issues with that.

Alaska has 20 sentinel laboratories. And I say 20ish because there are always consolidation of medical facilities and providers, discussions of laboratories actually closing. And sometimes people just fall off our sentinel laboratory list because they can no longer provide certain services because we have seasonal staff, or we have staff who just get tired of living in remote places and leave. And then it's difficult to backfill those positions.

Of those 20ish sentinel laboratories, we have nine that are connected by highways. And these nine sentinel laboratories have a total geographic span of about 750 miles or maybe a little bit less than that, with Fairbanks being in the far north and our Homer– actually, I didn't highlight Homer– our Homer laboratory being in the far south. And so those are the only labs that can deliver any sort of samples by ground or move patients by ground if there's an issue. And even then, most of those are still being flown just because when you have a single highway leading to a town 400 miles away, it's a lot simpler to put people and samples on an airplane than to rely on that single mode of transportation.

This is kind of a visual of what that state of Alaska looks like. All of those little stars are the locations of our sentinel laboratories. The red lines are arterial highways. And so we do have highways that do, in fact, go all the way out of Alaska through Canada and connect us to the Lower 48. But down in the southeast portion of Alaska, the panhandle, we have several laboratories that are only available to– you can only access them by airplane or boat. One of them isn't even included on the map.

We do not have any laboratories in the Aleutian chain. So that is a hub, again, in Kodiak or in Dillingham. And any of those residents that have issues would have to fly in or have samples transported into our Western Alaska.

And you see there's just a lot of empty expanse in the western portion of the state away from the highways. There are villages along the major waterways. And those villages are fairly small.

So how do we get things around in Alaska? All of those starred places do have jet service. So an actual, about full-sized, airplane flies in and out typically on a daily basis, weather-depending.

And I will tell you that the interface between the north Pacific Ocean and the Bering Sea does produce some pretty nasty weather. So if we're talking fall through the winter and into the spring, the conditions can be pretty dicey in terms of actually getting that airline access in and out of there on a daily basis. And then that's only exacerbated when we're talking about the smaller communities that rely on much smaller planes to get out of there.

So a lot of our small villages rely on this type of system. That's actually a fairly big plane, the Grand Caravan. This is not a minivan, but it's more of a flying-type minivan. These will go in and out of some of the larger villages that have gravel landing strips.

That plane holds about nine passengers or, as one pilot told me once, about two walruses– not alive walruses. That would be a little bit of too much trouble on an airplane. And that's how a lot of goods and services go out.

And as far as specimen transports, one of my favorite things that I've seen in remote regions of Alaska is the Pelican case. It's kind of the ultimate Category B shipper, if you ask me. And they put that sticker on there.

And they put it in a little tiny sleeve. And on one side, it's blank. And on the other side, it's the Category B shipper. And when the specimens are traveling in the container, they have the UN or the Category B marking facing out.

And when they return the Pelican cases empty to pick up more samples from the remote villages, they just flip that card over to indicate that it's empty. And that's actually a pretty slick system that I've seen in use. And those things are incredibly durable. It'll actually probably survive a plane crash when those happen.

And just to reiterate, we've got ground shipments that are only available really near Anchorage, which is not the capital city, but it is the largest city in the state of Alaska. And most shipments fly, even for communities that are connected to the road and the highway system. FedEx, UPS serve only a handful of communities off the road system. And that is at pretty significant cost.

So what we do is we typically rely on air cargo. So Alaska Airlines does have cargo services that with an office in all of the hub communities. So between me and in anchorage and a lot of those hubs, we rely heavily on Alaska Air GoldStreak. So that's what I'll be referring to as their shipping service. And that's the most effective way to transport goods to Anchorage or from Anchorage out to those communities.

And then probably the most significant hurdle is Category A shipments. Just like shippers in laboratories, so in my laboratory and in every sentinel laboratory, where the shipper needs to be trained and certified to ship Category A, that is also true of freight offices. Somebody has to be trained and certified to accept and evaluate Category A packages before they will allow it on an airplane. And only three of our communities have people in any cargo office.

We're talking GoldStreak, Alaska Air, Alaska Air Cargo, FedEx, UPS, it kind of doesn't matter. Only Fairbanks, Juneau, and Anchorage have people in their shipping offices who will accept Category A shipments. And so that does create a lot of challenges for my rural hospitals in getting samples to me.

And, as I mentioned before, one of our other issues is a large seasonal influx of workers. So the total state population is somewhere in the area of 736,000 residents, with more than half of those residents living in three regions of the state. Anchorage is the largest city. The Mat-Su Valley is a region immediately adjacent to Anchorage or the municipality of Anchorage. So, really, South Central Alaska holds half of the state's population, for sure, with Fairbanks being the second-largest city at 32,000 people and also the home of our second-largest university.

Most of the hub communities average around 4,000 to 5,000 residents, permanent residents. And then on top of that, our seasonal workers can be up to 330,000 people between commercial fishing and tourism. So we gain almost 50% of our state's population every year just for the summer. And then they all go away.

So the communities also have to hire seasonal workers for health care, right? So we need health care workers that come up during tourism season, during fishing season to support the influx of tourists and commercial fishermen. And so we do have a large transient population. And that's not even counting the oil field workers that live and work on the North Slope and may live out of state for some period of time during the year.

So when it comes down to the training that I deliver, I have several options that I rely on. There is remote training. So that is delivered online.

I typically do live trainings, but I'm working on my capacity to do asynchronous. So I think this is kind of everybody's struggle. As we went pre-COVID, where I think a lot of our trainings were either hosted at the public health laboratories or we would do site visits, we transitioned to a lot more remote training during the pandemic because that was the only way we could continue to deliver those types of services.

And some laboratories were lucky in that they had systems that could bank their trainings and create training modules to deliver asynchronous training. The State of Alaska was not one of those that had a had a particularly good system that I could tap into. And so a lot of the training that I offer remote is still live, right? So I get a call, and I set up a time, and we sit down and we do a discussion, kind of like right now.

And in-person trainings are still heavily relied on. And that's for a couple of reasons. One, we host them at the public health laboratories. We'll do that annually. And then my favorite is the on-site roadshow that I will take to those laboratories. So that is actually what I'll be discussing a little bit about today.

And so all of all of these challenges that I face, they should be very similar challenges to what a lot of particularly western states may face that just have larger geographic areas, but for also other states that just have places that are difficult to get to or are understaffed or have an influx of seasonal workers. These should all be challenges that you face. Alaska might be on a more extreme scale, but all of these notes should have some level of applicability for your facilities.

The components of my in-person training that I take– this is my road show. I typically do DOT and IATA infectious material shipping training. That is absolutely key that I keep the staff out in these remote areas trained up for shipping infectious materials to reference laboratories out of state, to their hub or the hub laboratories in the bigger communities, and then definitely to the state public health lab for me to do any testing on.

I try to convince these laboratories to do risk assessments, but I feel like that's been a struggle all along. It is difficult for that to capture their attention.

I will work on principles of laboratory biosafety and biosecurity. Definitely with the seasonal population of workers moving in and out of those states, it does it does help that when I can catch them during the summer months, we can kind of discuss because a lot of these people are from outside of Alaska. And they're very familiar with general laboratory safety. But there are some unique qualities to living and working in Alaska. And so I'll work with them on that.

One of the favorites is definitely BSC operation, right? I have a smoke machine that I will take with me as I go out to these communities to discuss how to properly use the biosafety cabinets. And that is that is certainly one of the key, I think, services that I can provide in person that is not otherwise well-served.

And I know that there are definitely online modules that go over biosafety cabinet operation and safety. And they're very good. The Division of Laboratory Systems, their module online is excellent. But I can tell you that if you are– if you are working with a physical element, like a biosafety cabinet, doing it live with their cabinet in their lab is kind of unparalleled in terms of, I think, the quality of delivery.

And then my absolute favorite thing to do is my wet workshop roadshow, where I take surrogate BT organisms, very similar to what they would receive if they're doing the CAP LPX. And I fly out there with them. And we actually go through the ASM and APHL Bluebook, rule-out algorithms. We perform the biochemical tests.

We also focus specifically on what we have endemically in Alaska. And we discuss differences that might exist between the surrogates that I'm bringing out there and the wild-types. And then we really hammer on Gram stains because it is the simplest and most effective tool that we have available in order to– that quick evaluation of potential biothreat organisms.

And because Alaska is, again, geographically separated from a lot of people, and we have supply chain issues, I do encourage them, particularly when shipping, to use what they've got. And I want to stop for a moment because as I was reviewing my slides this morning, I realized that these boxes have certainly a very specific problem with them besides the fact that they're– we call these lovingly fish boxes. These hold about 600 COVID sample tubes in each one. So it was a depressing day when we would get multiple fish boxes in. So if you see one of the issues with the boxes, please put that into the chat.

I have to open up my screen to actually be able to see the chat. And if somebody could review the chat log for me because I'm unable to see it right now the way I've got my screen set up.

Sabrina DeBose: So, John, this is Sabrina. One of the responses, it says, UN number. And while we're waiting for additional responses, John, there was a poll question. Did you want to use your poll now?

John Laurance: Yeah, actually, sorry. I flew right by it.

Sabrina DeBose: I think it's two slides back, yes. OK, and then also in the chat, we have arrow. So I guess the arrow is missing on the box in the biohazard symbol.

John Laurance: Yeah, so I'll address that. Yes, the arrows, since the total volume in there and the total weight is definitely more than 50 mils, 50 grams, the orientation arrows are, in fact, missing.

And then what I had noticed– and I'll skip forward a couple of slides just so we can discuss it before we get the poll up– I noticed that the UN number is not in the correct orientation nor on the correct side of the box. And, actually, there are up arrows on there now that I see them. They are little, tiny, and up in the top corners of that box.

And these boxes typically weigh about 25 pounds with the insulated coolers inside. But you can see that the UN 3373 arrow, they're kind of just slapped on haphazardly. And it is supposed to be in the orientation so that you could read the UN 3373 as a horizontal line. So those are just kind of stuck on there.

That is both a blessing and the curse of living in Alaska. I will point out that sometimes it's difficult to get things right, even when you're out there providing training. And I think the pandemic was a unique situation where a lot of people were doing the best they could with what they had, which is why we're using fish boxes as shippers.

But then also we're dealing with– I mean, I hate to say it, but it's a bit– it's still the wild west out there. Right, you've got shippers, even when they should have rejected a box, just are not probably well trained themselves. And have definitely asked if I could have access to some of the staff and employees at those cargo offices and provide shipping training to them so they could recognize Category A specimens and if they could be a better reviewer of those Category B boxes that go out. And the airlines have been pretty firm in their no thank you.

So I was told that– and I totally forgot about this– that there was a poll. Was it for this side?

Sabrina DeBose: Yeah. And I did have one more before we go to the poll. In the box, in the chat box, it does say, "Too many markings would be confusing" and "Infectious substance label missing."

John Laurance: Yeah, we'll go back and review that.

Sabrina DeBose: OK, so are you ready for the chat now or the poll question?

John Laurance: Yes, the poll, yeah.

Sabrina DeBose: OK. All right. Can you see that, John?

John Laurance: I can see it. Yes.

Sabrina DeBose: OK. Almost there. Looking for a few more participants.

John Laurance: Yeah, I've done a little bit of work with some of the other sentinel lab trainers. I was recently at the APHL conference for training. And there is a push towards more remote trainings and offerings because it works better with the busy lifestyles of lab employees. It works better for employees within our own laboratories.

But I think, by and large, it is rarely– I think the poll shows this, it's usually not our favorite way to deliver training. We much prefer to go and do in person and travel to sentinel laboratories and meet these people face to face. And that gives you a better idea of what their training needs are. I feel like most written communication, there's a lot that is sometimes uninterpreted or misinterpreted or even left out. And so once you get there, you get a better idea of what it is they actually need.

Now, this is not always feasible. From our own, from the standpoint of us as trainers, it is difficult to find time in our own schedules to travel, to go out there. I can tell you when I go to most of my sentinel labs, for the ones that I have to fly into in Western Alaska, there is either one flight a day or maybe two flights a day.

If I've got a fairly simple menu of things that I'm going to be teaching them, and they still want me to be in person, sometimes I can fly there in the morning, do a training, and fly home in the evening. But my typical schedule is I fly out on an evening flight, I stay the night, and then I have the full next day. I start early in the morning. And then I will fly home on the next night. So my travel trainings are round trip and usually one or two overnights.

Southeast Alaska is particularly difficult because the access to that by plane is what's called the Milk Run, which starts in Anchorage and then has up to three or four stops in those communities. It's basically like a flying bus. And it goes through once, maybe twice a day.

So I end up spending about two to three days per site with travel. So if I want to do three of those communities, it takes me the whole week, flying from Anchorage to the first community, conducting training the next day. I might be able to fly out that evening, then get up the next morning, go to the next one. So as much as I love in-person traveling to sentinel laboratories, it is a very difficult thing to schedule into my work with all the other things that I have to do. But I'm glad to see that people are still appreciating that engagement.

One of the other things that I like is because our communities are so remote, they also really appreciate having somebody take the time to come to them. It's difficult for them to leave just as much as it's difficult for me to get there. And I do find that the response of just being in person is so much better.

So we're going to move back forward to this box. And I think I mostly addressed the question. So particularly with these, there is only supposed to be one label marking. So there's one sticker per box.

Biohazard stickers are not required on the exterior of the box for shipping Category B. So that is not necessarily a requirement. Orientation arrows are required. Otherwise, it is two from label and markings. So that is the UN 3373 and then the biological substance Category B that is up there.

But it should not be on top of the box. It is supposed to be on the side because, obviously, when you stack your boxes, you can't actually see that sticker. And that was a picture of one of our COVID employees that came in and worked with us during the height of the pandemic, very excited to see about 1,200 samples on the table that we were going to have to process that day.

So this is one of the second aspects of the in-person training that I provide, and that is my portable fog machine that I'm taking out. So this is a biosafety cabinet in the micro lab in Bethel, Alaska, or the Yukon-Kuskokwim Delta Regional Hospital. This is definitely one of the best parts of the training. And I really enjoy it. We get a lot out of this.

One, we work with their hood. We kind of see, yeah, there's a lot of questions, like, OK, well, how much material in a biosafety cabinet is too much? When is it impinging airflow, causing turbulence and disturbances, and could be creating an unsafe situation?

So when I go in, we discuss that. And not only do we discuss it in an academic way, I've got the fog machine to actually swirl around in there. And we can go around each one of those items. And we can rearrange their cabinet as I'm there, not only to better meet their needs ergonomically, but also meet the needs of the actual biosafety of that cabinet. This has been definitely like one of the most valuable components of the training that I can take out to sentinel laboratories in person.

And then we discuss work services, where to place samples, and then how to safely open those plates up and where best to utilize that cabinet space. And I'll raise and lower the fog machine to demonstrate, all right, if we're generating aerosols or we have the potential for aerosols, where is the most risky areas? Up high, down close to the deck, far to the back, close to the front? And I'll move that around to simulate all the different areas that they might functionally be working with plates or with or performing certain aerosol-generating procedures.

So we see, again, live in that, in their home environment, what the effects are. And that has definitely changed how people interact with their cabinets in a lot of these areas. In some places, it has changed drastically.

And one of the first times I actually performed this demonstration was in a hospital. They had a much older biosafety cabinet. It was nearing the end of their life. And they did know that.

And you have to remember that a biosafety cabinet certification means that it functions according to manufacturers' specifications in terms of air flow, filtration, and other quality metrics that they assess for. But from a practical standpoint, you the user don't see a lot of those things.

So the times that I have done this for a laboratory, the first thing I always do is I will close the hood down and let the whole hood fill up with smoke. And that gives a visual representation of how fast their biosafety cabinet actually comes up to optimal operating, operating parameters.

The instructions say five minutes, right? You should always turn on your cabinet, let it run five minutes. After five minutes, then you're ready to go.

Practically how many microbiologists in these laboratories actually do that? Probably a lot less than we would really like. And the question is, does that always matter? And sometimes it absolutely does.

So in this particular demonstration, I filled the cabinet up with smoke. I opened up the sash to the appropriate height, turned the switch on. And the smoke didn't move. And it continued to not move.

And the Magnehelic gauge indicated that it was up to where it was supposed to be, where the cabinet was certified at. And the smoke still hadn't fully cleared the hood. And it took roughly 90 seconds for that smoke to actually completely clear inside of their biosafety cabinet, at which point I asked them, when you sit down at your biosafety cabinet, when you're setting up to do sterile cultures or using this, your cabinet is off. And I've already seen that you turn it on when you start your day.

So what is the timeline? Your real life, what is your actual timeline in utilizing your biosafety cabinet? Because I had a suspicion because I used to be a young microbiologist as well, and I made the exact same mistake. And they admitted that typically they turn on their biosafety cabinet, they grab the materials they need, they immediately set it in the hood.

Probably within 20 to 30 seconds, they've got plates open or samples open. They're starting to streak plates, set up cultures, perform whatever assay they're going to be in there. And then usually it's pretty minimal workflow. So they might be done in less than a minute or two.

And so what this demonstration actually showed them is they were sitting down at their biosafety cabinet, completing almost all of their work before their biosafety cabinet had actually even cleared the air that was sitting in it. And as far as they could tell, it was up to operating standards, right, the Magnehelic gauge indicating that it was operating. You could hear the fan going.

But, obviously, from our test, the smoke had not actually moved in that amount of time. So it's not that the cabinet was not functioning correctly. It's that theirs was one of those cabinets where if you didn't let it sit and run for five minutes or so, you were not actually getting the correct functionality of it.

It was not providing protection to you from the samples. It was not providing protection of the samples from you. It was simply not performing the way a biosafety cabinet should perform while they were using it. So that actually gave them the information they needed to really put pressure on hospital administration and the lab manager to buy a new cabinet, not just get it fixed, not just get a recertification person out there, but to get it out of there and get a new one in.

So the rest of the workshop, the roadshow that I bring out there, it hinges on basically going over the type of review like a CAP LPX would. And it's very similar to the workshop that we will do in-house in our public health laboratory. So we take surrogate strains, the exact same organisms that might be sent out for the LPX. I grow them up in my lab and get them in plates. I seal up the plates.

I put them in a Category B shipper. And then I put them on the airplane. And typically, it's on the airplane with me that I'm using to fly out there. And I ship them to the sentinel lab care myself.

So once we get out there, we've got plates. They've typically got 24 hours of growth. So they are ready to go. We can go straight into the lab, into the hood. We can start discussing colony morphology, looking at the growth characteristics on those plates.

We can look at blood. Typically for Francisella, I'll put it on chocolate because it's the better one. For ones that can grow on Mac, I will put it on Mac. If it doesn't grow, I'm not going to put it on a plate that it doesn't grow on. I mean, there's no value in showing them an empty plate just to prove that it doesn't grow there.

We'll do Gram stain practice. We review the available biochemical tests. And we'll discuss the nuances of each. We'll take a look at what they have in stock. We might talk about better manufacturers that might give them a more reliable test. And we'll talk about any issues they might be having with it.

Sometimes they don't have great QC strains. And we can discuss QC issues if they're having any of those.

We go through the ASM or APHL, rule-out algorithms. Sometimes we'll go through both just to see the difference and discuss the fine points of each one because the information is the same but just presented in a different way.

And then the biggest issue that we talk about is the difference between the surrogates that I'm bringing and what they might see in the CAP LPX versus wild-type strains. Having worked with the state public health lab for eight years, I have seen the wild-types many times. And some of these labs have also seen them. So we can discuss the nuance of those.

And then sometimes they haven't, and so I can share that information in person with them. As much as I would love to bring out material to actually show them what a wild-type looks like, that would be just too difficult and would have safety issues and regulatory issues along with that. So that is not going to happen.

And then the last question I always ask because I want them to have a good connection to what happens to laboratory waste when it leaves their facility is where does their lab trash go? And sometimes they're very familiar with their overall environmental procedures within their facility. And sometimes they're like, man, I have no idea. And it does spark a discussion about how they're handling their waste and what they're doing and what they could be doing different.

And then we talk specifically about when identify– when they identify select agents and what they're doing with that waste. And we can in person go over that information. And so this is just a selection of plates that I took out there to discuss colony morphology. They're just standard old blood plates. And we got our Gram stain practice here.

So we do end up focusing a lot in our common BT, biothreat agents that we see in Alaska. So we have brucellosis in Alaska caribou herds, particularly in Western Alaska. And the wild-type cell morphology is typically much, much larger than any surrogates we see or the Brucella canis that I bring out there to show them.

Francisella tularensis we see in not just our Arctic hares, but in the general bunny rabbit population. And that's, thankfully, a typical morphology that they might see. So we just discuss the fine points of the both of those, both of those organisms.

And because Alaska is one of the states with leading cases of Clostridium botulinum and botulinum neurotoxin, we always discuss it. From the laboratory perspective, there is not a lot that they do in a clinical laboratory to identify Clostridium botulinum. They're not going to be doing anaerobic culture. A lot of this is just moving samples to the state lab for that testing after people get treated with– after patients get treated with a heptavalent antitoxin.

And we predominantly see neurotoxin type E being produced, which is found in traditional Alaska native foods and other fermented marine animal products. Type E seems to like an enriched protein and fats environment. So this is going to be in seal oil, muktuk, or anything fermented. In fact, I got notified this morning that we've got what are referred to as stink heads, a case of botulism potentially connected to stink heads in one of the villages. And, again, that is a fermented fish product.

When you're living in Western Alaska, particularly traditional foods really relied on unlocking as many nutrients as were possible. And there's not a lot of trees out there. It is a tundra environment. So cooking is not necessarily– cooking with heat or over wood or fire is not necessarily a part of that traditional cooking method. So fermentation has been used extensively throughout rural Alaska as a way of not just preserving food, but kind of breaking down food sources to get all of the nutrients that were potentially available in there.

In some rare cases, I've seen poor canning of salmon. There was one notable case from about 2018 or 2019 in which improperly canned fish were implicated in a botulism case.

And we see a very rare infant type A cases. We might get one every two or three years. And the source of that is unknown. We're not really sure where that's coming from.

But kind of in the beginning, I mentioned how our samples can be an issue. And some of it is just the size of the material that we get. So this is an example of seal oil that we received in the spring of 2023. This is about a 2-and-1/2-gallon plastic bucket with a sealed lid. It's got about a gallon of seal oil and seal meat in it and a coffee cup that would act as a dipper so they could get seal oil out of there.

And in these remote areas, when they get a potential botulism case, we ask them to collect all of the food. And sometimes all of the food is not an insignificant quantity. And so there are definitely issues of how do you get something this large transported safely into your biosafety cabinet and protect the staff at my lab from some of these things?

So in our talk about botulism safety, we do talk about the challenges involved in sample handling. It is, like I said, usually not laboratory staff there. They might be just a go-between. So their job is to figure out how to take the materials that have been collected from patients' homes, which is mostly handled by our public health nursing or community health aid staff. They will go to patient homes and do interviews with family, anybody else who might have eaten the meal, and help in collecting any remaining food that was left behind after potential botulism case.

And so the clinical staff at hospitals, they've brought sometimes very large quantities of things, gallons of seal oil. I've gotten a whole walrus flipper, 20-pound chunks of beluga whale. And so as much of a challenge it is for me in a testing standpoint as an LRN microbiologist, it is also difficult for them to kind of create the various wrappings and layers to safely ship all of that material to Anchorage.

There's also the issue of cultural sensitivity. These are predominantly traditional Alaska Native foods and traditional preparation methods. And throughout Alaska history, there has been trouble with kind of a Western European mindset being applied to these traditional food sources and what is and isn't appropriate for people to be doing in terms of food processing and food consumption. And there has definitely been some challenges in the past in not just messaging with these communities but getting them to be open and honest about some of their foods, remaining foods that are left after consumption and potential cases.

And I do feel like we're gaining and doing a better job with that communication aspect. But that is potentially something that all of us face in our own ways, where we have different communities within our states. And each one of those communities potentially brings a variety of health issues.

So how do we get the message to them? How do we work with them? And how do we as microbiologists better understand their conditions and work with them to make food safer, specifically in Alaska, is one of my– one of the things that I'm trying to do, but also have better dialogue and communication about the need for testing without having communities become overly reliant on using my lab specifically as a food safety laboratory.

These are not commercial operations. So this is people's food in their homes. And we don't want them looking to the state public health lab to test every batch of seal oil because we just don't have the capacity for that.

And then we discuss the disposal of contaminated foods. Again, if we're talking large quantities and quantities that can't be shipped to us, how are they getting rid of contaminated foods that aren't going to negatively impact other people in the community or the environment?

So this next and last portion is going to be moving into a case study. And I like reviewing case studies with people just because it's interesting.

Sabrina DeBose: John?

John Laurance: I feel like we can all relate. Yes?

Sabrina DeBose: Sorry. One moment. I just wanted to remind you that we had a poll question for slide 13.

John Laurance: Oh, I'm missing those. Oh man, I am cruising past all of these. This should be a multiple-select answer. So you should be able to–

And definitely if there are other trainings that your facility sees requests for, put them in there because I'm always cruising for new training material as well. yeah. I think as a trainer, the DOT and IATA shipping, it's the gateway. I use that in order to get into the labs because they are required to have staff that are trained and certified.

And I'm actually seeing a lot more people requesting Category-B-specific training. Right, they do not have staff or do they do not receive the type of samples that they would ever have to ship Category A, but they still want that more in-depth training than what is the minimum requirement.

It's good to see that people are still getting risk assessments, requests for risk assessment training because that's an incredibly valuable tool that we need to be sharing with laboratories everywhere and even in our own labs if we're a state public health lab. And then bioterrorism rule-out training is also good. That is interesting. Yeah, it's kind of a shame that there aren't other interesting trainings that people are getting out there requests for.

Sabrina DeBose: I just wanted to share with you what was in the chat. The technology updates and new equipment testing was a response in the chat.

John Laurance: And, actually, that's an interesting one. Sometimes I feel like as a state public health laboratory employee that we're a little bit behind the curve in terms of technology updates and new equipment. I myself am so limited in some of the things that I can purchase.

And, of course, we're very locked down for doing CLIA testing the way LRN testing is conducted that we're very much set on certain instrumentation. And it is difficult to expand beyond what is prescribed to us.

And when laboratories do reach out to us on questions on that, I usually tell them, I'm not necessarily your best source. In fact, our public health laboratory in particular is not a good resource for you because we're not going to be at the forefront of that technological aspect.

And Alaska does not have a really great infrastructure for research at the universities. Most of our universities are not necessarily heavy into research. And so they're not necessarily at that forefront of equipment either.

So it is difficult. And I haven't really found a way other than just spending a lot of time whenever I get those questions helping people out. I haven't found a good way to present that information or share that information on a regular basis. It's more one-off requests.

If anybody has hints or tips, tricks in that area, I would definitely appreciate hearing it. Were there any more comments or questions in the chat concerning that?

Sabrina DeBose: That's all we have at this time.

John Laurance: OK. Going to move back ahead. And this one, I do know that I've got poll questions that should be coming up. So the interesting things about case studies when you present these is I feel like as a community, in general, we're not presenting case studies where it turns out to be nothing. We usually present a case study where it turns out to be the real deal, and there was an issue. So it's awfully presumptive in some of these questions. So, please, when the polls come up, don't let your knowledge of essentially how a case study presentation typically ends up working drive you towards an answer that you may not otherwise have used.

So in this particular case study, it occurred in 2017. In one of our rural hospitals, a patient presented to the ER with a wound from a cat bite on his hand that was not healing. And the ER ordered a wound culture.

And this particular laboratory, they've got a really good line of communication with me. They have invited me down numerous times to conduct training with them. And so I do appreciate that they let me share this particular experience. And I believe I do have a poll question on this one. I will not skip ahead.

And just based on this information, if you are working in a clinical laboratory, would you find this minimal amount of information enough to create a biosafety concern that you would suggest doing all the work in a biosafety cabinet? I'll take my question off the screen.

And this is recognizing that some clinical laboratories are very good about the way they set up all of their cultures. And other ones triage each one as they come in. And whoever's working the bench that day makes their judgment.

And this is definitely a small laboratory in a small community. There's about 5,000 permanent residents in this particular community. They don't have that many hospital beds. And their laboratory is otherwise, I would say, a fairly low-throughput facility.

And I would say for most of the state of Alaska– I'll put the poll results back onto the screen so everybody can see it. For most of the state of Alaska, I would say that a wound culture would not automatically trigger biosafety concerns from the staff. And that is something that I learned when I came to being the biosafety officer for the state of Alaska and I started doing these trainings.

I have always, my entire career, worked in a BSL-3. So for me, it is and was foreign to work up anything on the bench. And it took me a while to realize that that was actually normal for a lot of the facilities that I would be interacting with.

So what did that microbiologist actually see? Let's back up. In 48 hours, they saw small colonies on blood and chocolate plates. They opened the plate on the benchtop because, again, this is a slow grower.

But they weren't thinking it was anything weird at that point. Particularly a cat bite in this region of the state didn't trigger anything in their mind. And they prepped the Gram stain. And they did catalase on the bench. And what they saw was tiny, faintly staining Gram-negative coccobacilli that were catalase-negative.

Do I have a poll question on this one or was it the next one? Yes, right there. And here's the question. If you're a microbiologist who just worked something on the bench, would you immediately go and discuss an exposure? Yes or no?

And as a little bit of backstory, this particular microbiologist had, in fact, been to one of the workshops that we hosted in one of the prior years so. They were familiar with the sentinel lab rule-out algorithms and guidelines but was just unfamiliar or was, I think, caught by surprise by this particular organism in this region. So most people answered yes and a couple, 20% answered no.

And I will show you what they did do because, like any case study that is a biosafety issue, it is not just one error. It is typically a chain of events that leads to a larger issue.

So instead of going and discussing with the department supervisor that they may have had an exposure, they went and asked questions about whether or not the sample looked weird or if their catalase was having issues. So the department supervisor and another lab employee walked over to review the plates shortly after working with cultures on that had been worked on in the open bench. And the catalase had been performed on the open bench. And this is what actually happened.

Ultimately, and not long after the department supervisor took a look at the plates, they started to suspect that it was a biothreat agent. And they moved all of their work into the biosafety cabinet to finish the rollout testing. It ended up being oxidase negative and had a strong beta-lactamase reaction.

And they set up a satellite test, which was going to be read the next day. But before they even read out the satellite test, they had already called the state public health lab, discussed it with me. We agreed that yes, it would be within their best interest to send me that sample as quickly as possible.

And if this is any surprise to you, then maybe we should all go back and look at the rule-outs for Francisella. But the micro supervisor and the tech both agreed that the culture was a suspect Francisella tularensis. They did send it into me. And I was able to complete my testing the same day that specimen arrived. Thankfully that flight arrives early in the morning and allowed me to get all of the confirmatory tests done by the end of the afternoon.

They consulted with the state epidemiologist. And the lab micro, the supervisor and the other employee that walked over there shortly after work had been conducted on the bench, they all agreed that beginning prophylactic antibiotics was going to be the best course of action for everybody. And that kind of kicked off then the response, an exposure to a select agent.

What did they do about it? Well, they used this experience to request a new six-foot-wide biosafety cabinet to be installed in their lab. At the time they had a much smaller cabinet. And it made it very difficult in the room and in the space they had been working in to do a lot of setup and culture reading.

So they would do some high-risk things in the biosafety cabinet. But then if they weren't just– if they didn't really see anything that made them particularly worried, they would do reading and other diagnostic assays out on the bench. So after they got their new six-foot-wide hood, they made a change so that all setups, all readings, and all biochemicals would be done inside of that biosafety cabinet because space was really the limiting factor for them.

Once they changed their protocols so that they would be working up all of their cases inside of the BSC, they also instituted a biothreat checklist for all cultures. So they go through Gram stain and all the biochemicals. They go through the checklist. So rather than looking at different flow charts, they kind of check things out on their list.

And then they use that as a quick reference to rule out biothreat organisms. It is not that they have a high burden of biothreat organisms in the area. It was more they had low enough throughput in their laboratory that the cost to them in terms of time or inconvenience was incredibly minimal.

And as they put it, once you go through prophylactic antibiotics in the middle or towards the end of prime fishing season, in the beginning of hunting season, you're just not interested in ever doing that again. So it was it was a practical change for them in terms of not just personnel safety but also just quality of life, right? They just did not want to have that experience again.

And subsequently have shared that checklist with all of our sentinel labs. Some of them are using it to some degree. And others keep it as a reference. But I feel like that has been a really valuable lesson that I've shared across the state when I go and visit sentinel laboratories.

I tell that story with their permission. And I think everybody has learned a little bit. And, honestly, we haven't had an exposure to a select agent since 2017. That was our our last potential laboratory exposure.

So at this point, I think we're doing OK in that you know one bad case does not necessarily pre-empt others from happening. Sometimes we all have to learn hard lessons. But I feel like the training that we've set up and the outreach that we're doing and sharing these lessons between laboratories in the state has definitely helped further biosafety discussions in the state of Alaska.

So that was all I had for you today. And I really appreciate you guys coming and sitting down and listening this morning. I would definitely appreciate any discussion or comments that you might have. I can go back to slides if there's a request to see anything or to have me further explain something in particular as well.

Sabrina DeBose: Well, thank you, John. I don't see anything in the chat right now. As I said earlier, there was a chat that popped up. And it says, "Could you share and elaborate on the practices of setting up cultures and readings in the BSC?"

John Laurance: Yes, I could. Hopefully I'm answering your questions specifically or giving you enough detail.

As the clinical samples come in, particularly for this hospital, as clinical samples come in, they take those, all samples now, into the biosafety cabinets, have their plates ready to go in there. So they will streak out any specimens that they're getting. Or they'll set up blood culture bottles in their hoods.

And once all that's incubating, when we do that kind of biosafety cabinet training, we discuss how we look at plates in there. And so, I mean, I don't know if that's any different than what you would imagine it to be. But after 24 hours of growth, we're taking sealed plates into the biosafety cabinet, opening them up in there, looking at colony morphology.

Optimally we're trying to read it through the plastic. But sometimes that gets fogged up. And you've got to take the lid off.

And then when you set up any biochemical tests– and, really, catalase is the one we focus on the most because it has the potential to create aerosols– we're making sure we do that in a tube in some sort of secondary containment as well. So we teach a method that utilizes both an empty plate. So just whatever the standard size media agar plate that would be empty of agars, so we'll do it in that. Or we'll do it in a tube that we can put a lid on. So both of those methods help capture any of the bubbles or potential aerosols.

But we're still doing that in a biosafety cabinet. And that, again, minimizes potential exposure, but it also keeps your environment cleaner. Right, if anything happens out on the bench that is open and accessible to everybody, and just doing it in a biosafety cabinet is a lot more contained and keeps that– keeps your area lot cleaner.

And if you need more elaboration, I can. And if didn't quite answer your question, please let me know.

Sabrina DeBose: All right, John, thank you. We did have another comment in the chat. It says, "Can you share the biothreat checklist with all of us?"

John Laurance: Yes. Absolutely. Yeah, after the presentation, I can go ahead and– just let me know who the best person to email that to.

It is a relatively simple checklist. It was made in PowerPoint– or not PowerPoint, but Word and Excel. And it just has a set of the set of relevant biochemicals. And but yeah, I'd be happy to share that checklist. We've definitely gotten permission to share it around the state of Alaska.

Sabrina DeBose: Perfect. You can send that to myself and George. And we'll be more than happy to put that on our resources once the recording is released on our site.

We did have another one that says, "That was amazing. I appreciate you providing an overview of the challenges in remote laboratories. Are there language issues? And how do you advise and hire temporary laboratory employees?"

John Laurance: The language issues I'll address first. Sometimes that is a situation where we have had some struggles. I cannot tell you exactly how many Indigenous languages there are in Alaska. There are several.

And our remote laboratories, particularly in Western Alaska, are operated not exactly through the Indian Health Service but in coordination with them. We actually have a slightly different situation in Alaska, where we have a Tribal Health Consortium, which has more or less taken care of or taken over control of administering Tribal and Indian Health Services in the state.

Those hospitals that they operate have preference for Alaska Native hire. And all the employees that I have interacted with speak English, but that does not necessarily mean that English was their primary language growing up. Sometimes it's Inupiaq. Sometimes it's the regional languages for the Inuit or the Athabascans or the Aleuts.

And there have been language difficulties in communicating certain aspects. And a lot of that has to do with sample collection or understanding what tests have been performed by staff within a laboratory. We do run into that.

And, again, that's where in-person communication has benefited us over the years. Those people, those individuals in those communities that are typically from the community and speak the regional language and dialect, they're actually far less likely to be a transient employee in those laboratories. So oftentimes I go, and I see the same people year after year after year. And I develop a relationship with them.

And once we start that relationship, that makes it easier, that communication in subsequent visits but also in phone calls, which is the really important part because a lot ends up getting missed when we just call and we speak with the laboratory personnel. So once you establish that relationship with them, that does help clarify some of those language barriers and communication issues. And then the– oh my gosh, I've talked long enough. I kind of forgot what the second question was.

Sabrina DeBose: Let's see, the second question. Oh, how do you advertise and hire temporary laboratory employees?

John Laurance: This was a special case during COVID. So usually, we have a fairly regimented system of interviewing and grading employees and bringing on new staff. And we don't have very many temporary hires.

So this was something that we were given the opportunity to do specifically to spool up for the large number of staff we needed for COVID. I don't know if there's a trick to it. There are things that I focused on specifically that I felt very important– that I felt were very important. And having been a key part in building up the team for COVID testing for our laboratory, I was on the interview and hiring panels for all of– yeah, pretty much every single one of our– we call them long-term non-perm employees.

I came from, I would say, not a nontraditional background. But for what I do as an LRN microbiologist, I'm not a medical laboratory scientist. And I do not have a history of working in hospital clinical laboratories. I did immunology research for tuberculosis and other things that were worked on in the BSL-3 prior to coming to the state laboratory.

So my background has been in largely research and preclinical vaccine development. So I was not necessarily looking for somebody with a hospital clinical background. And the State of Alaska doesn't require that to work in the state public health lab. So that opened up the door to a people with a little bit more of a diverse background.

And so the things that I were looking for specifically, because we were hiring at essentially all levels, people to be lab techs and do very simple just accessioning procedures. We had people doing very basic microbiology to people doing more higher-level microbiology and running complex assays, PCR, and actually reporting out results. So we did look at all levels.

The things that I looked for was, honestly, somebody with a reasonable and positive attitude. COVID was immensely difficult emotionally and in terms of just managing yourself as a person and as an employee. We split our lab into two teams. Our teams worked four days a week. And we worked anywhere from 10 to 18 hours a day.

So I, honestly, looked for somebody who I felt like would have the emotional will and kind of a personal ability to regulate themselves, to be able to do that. And that was not a requirement, right? We didn't force anybody to work 18-hour days. We just did because that felt like we had to do. And so that personal relatability aspect was one of the key things that I was looking for.

And second to that was trainability. I wanted people with a demonstrated ability to learn, even if they were coming from a background which was not classic clinical laboratory sciences. And so if we found somebody who was an MLS and who had done time working in a hospital and they kind of had that relatability aspect, then they were definitely top candidates.

If they came from other backgrounds– we had people coming from micro degrees, who had just graduated from university. I had a general biology degree, a person who came and worked for us. We had two staff that got masters, one in environmental chemistry and another in environmental geology with a lot of chemistry and laboratory background.

And then we had a lot of people who we did bring over from hospitals, some people who were actually working as micros in hospitals around town or had left positions in hospitals around town. So we had a really diverse, but I think the thing that made it most successful for us was people who could be trained to perform the various tasks. And if they didn't have the capacity, or they didn't meet the CLIA requirements to do more complex testing or to do more complex stuff in the lab, there was always plenty of other work to do. I mean, most of our work was definitely accessioning.

And then positive outlook and pleasant to work with– I think our team was successful because we had good people who, despite the incredible challenges, actually kind of liked being there every day. And even if they hated the work and they hated the hours, they felt a connection to how important the work was and could make the best of it.

And that, I think, is really important with just working in Alaska in general. It is always making the best out of what you have because we're always, what, a day late and a dollar short, right? We're always struggling to get the necessary supplies, get things out there. Planes are stuck. Weather has us stranded.

We would run out of you know critical things and were constantly having to pivot to what else do we have in our pocket? How else can we make this work? And having a group of people who were similar in that mindset, who wanted to work together to see all of that happen, was really important.

Going forward, we do have to narrow it back down. And our hiring practices has been much more regimented and regulated by the state rules for our positions. And so some of that has gone away.

But I also feel like that there is now a bit of a culture of looking at and being more accepting of nontraditional backgrounds for some of our positions within the laboratory. And we don't have positions that open up frequently. So this is not a common thing that we have to worry about. But there is certainly more acceptance of nontraditional backgrounds as having a role in a public health laboratory doing diagnostic testing.

Sabrina DeBose: All right, well, thank you for that response. We do have some– there's some conversation in the chat. But there's one I'd like to read to you before we close out. It says, "Thank you for the presentation. Would it be possible to seek additional guidance from you in the future? If so, please provide an email for that."

John Laurance: Yeah. I'll see if I can get my own chat up.

Sabrina DeBose: And we can also include your email address, your contact information in our references with our slides.

John Laurance: Yeah, that would be excellent.

Sabrina DeBose: And George can drop it in the chat if you don't mind. And done. There you go.

John Laurance: Yeah. State emails, thankfully, are fairly simple.

Sabrina DeBose: OK. All right, well, we are– I want to say thank you for that. Like I said, there is some discussion in the chat and amongst the participants. But I wanted to take this time to say thank you for the presentation. That was an excellent discussion. And we want to thank everyone for participating.

So now I will invite my colleague Dr. Mary Casey-Moore to provide a summary of the discussion from today's session. Mary, I will turn it over to you.

Mary Casey-Moore: Thank you, Sabrina. I wanted to start by saying a big thank you to the participants for engaging in today's discussion. The presentation highlighted the unique biosafety challenges that arise due to Alaska's immense size and diverse geographical features. So as we learned about the unique circumstances and approaches required for this region, I took note of some key points that encapsulate the biosafety challenges and topics we discussed.

The first items I want to go over is a brief reminder of the poll question results. The preferred method of delivering training was in person, traveling to sentinel laboratories, with 59% of the poll, which was the most convenient for laboratorians' schedules and allows that face-to-face interaction and further understanding of their training needs.

And the least preferred method was, unfortunately, the remote training, which is what we had to do a lot of during COVID. The most commonly requested training was the DOT and IATA shipping, with 60%. And bioterrorism agents rule-out tests with 47%.

However, there were responses showing a need for pretty much all the options, including the risk assessments and the diagnostic assays and equipment. In the chat, it was also noted that technology updates and new equipment testing was a topic of requested training. And this just highlights that many labs are behind the curve in terms of technological aspect and the challenges with expanding past the set tests that we're used to usually performing.

So in regard to our cat bite case study, we had a couple of poll questions. And based on the patient history, it was decided that majority of the poll deemed it necessary to perform all the work in a BSC. But, unfortunately, it did not happen in this particular case. And once receiving the Gram stain and catalase results, the poll also deemed that it was necessary to initiate that discussion with the safety lab officer or lab manager for a possible exposure. So the results of that last question really mirrored the conclusion of that case study, resulting in notifying a safety representative to start the antibiotics for anyone involved, changing protocols, requiring all culture setups and plates to be read in the BSCs and the institution of a biothreat checklist.

So then moving into topics that were discussed throughout the presentation or after, we did say that it was important to make sure our shipping boxes were labeled correctly, including refurbished fish boxes. In our example, the UN arrows and sticker placements need to be adjusted for more accurate and legible labeling of what agents are within the box.

We also discussed how John and his lab set up cultures in BSCs. He mentioned the streak-out and the blood cultures are done within the hood. After 24 hours of growth, sealed plates are going back into the hood and also that the catalase test are performed in tubes with secondary containers to try to help capture those potential aerosols. And, again, this is all done in a BSC.

In terms of challenges with working with communities of diverse languages, John also mentioned that in-person communication is key or working with other entities that can more easily communicate with those where English isn't their first language. Another point is what he looked for in temporary hiring of employees. And the two main things that were focused on was somebody with a reasonable and positive attitude and the trainability, so people who have demonstrated that they can learn, even though they are coming from more nontraditional backgrounds.

The last note is just the resources. We did have someone in the chat that included a link for templates to create bench cards, in addition ask for that biothreat checklist. And as we mentioned that would be available with our other session materials following the session.

So I just want to conclude this by noting that while this focus today was on Alaska, the lessons learned from this discussion hold relevance beyond this region. And that's something that John mentioned earlier in the presentation. The insights gained can be applied to laboratories facing similar challenges or different challenges with similar aspects. So it's just really wonderful to see that engaging in such discussions supports the well-being of not only our laboratory professionals, but also the diverse communities they serve. And that is all I have. So thank you.

Sabrina DeBose: Thank you, Mary. We appreciate your summary. John, is there anything else you would like to add to the summary? Please feel free to share your thoughts with us.

John Laurance: No, I think I'm all good. Thank you very much.

Sabrina DeBose: All right. Well, we want to take this opportunity to say thank you, thank everyone for participating in the discussion today. John, thank you for the terrific presentation. And we look forward to your participation in future sessions as we dive into specific laboratory biosafety topics.

So thank you all for filling out the post-session survey. We appreciate your feedback, which has been invaluable in improving the ECHO sessions. So in addition to the post-survey session, you will receive for this session– if you have attended additional ECHO sessions in the past, you will receive an additional survey asking you to provide feedback on the ECHO sessions that you have attended collectively. Your responses are vital in shaping the content of these sessions to meet your needs and inform the development of future ECHO sessions. We genuinely appreciate your time and information in completing the post-session surveys.

So I will share my screen. Share. There we go. All right. And we're excited to have our next session in August. It will be on Tuesday, August 29 at 12:00 PM Eastern. The topic will be Safety Challenges with Specimen Collection, Transport, Accessioning, and Storage. And that presentation will be given by Joey Stringer from Dallas County Health and Human Services. Please visit the ECHO Biosafety website to view all upcoming sessions.

If you have any questions, remember, you can reach out to us at dlsbiosafety@cdc.gov. Now we will adjourn. We thank you all for attending. And I hope you are intentional about having a fantastic day. Thank you.

Additional resources and related publications

• Association of Public Health Laboratories. (2017). Biothreat Agent Bench Cards for the Sentinel Laboratory.
• Centers for Disease Control and Prevention. (2021, October 21). Biological Risk Assessment: General Considerations for Laboratories.
• Alaska State Public Health Laboratories. Select Agent Rule Out Work Card.