Public Health Laboratory Professional Burnout and Effect on Safety

Transcript

Date of session: 02/01/2023

Facilitator

Aufra C. Araujo, PhD

Centers for Disease Control and Prevention

DLSbiosafety@cdc.gov

Didactic Speaker

Anthony (Tony) Tran, DrPH, MPH, D(ABMM), MT(ASCP)

California Department of Public Health

Anthony.Tran@cdph.ca.gov

Aufra Araujo: Good morning, good afternoon, good evening, everyone, depending on where you are. My name is Aufra Araujo, and I want to extend a warm welcome from the Centers for Disease Control and Prevention in Atlanta, Georgia. I am a Health Scientist in CDC's Division of Laboratory Systems and the facilitator for this Extension for Community Healthcare Outcomes, or ECHO, Biosafety session. Thank you for joining our first session.

The topic for this interactive discussion today is Public Health Laboratory Professional Burnout and Effect on Safety. Our subject matter expert today is Dr. Anthony Tran, the Director of the California State Public Health Laboratory. I'd like us to kick off with a little bit of introductions. We also want to know you. So if you could just put a hi, hello in the chat, and just let us know how you're feeling today. Are you excited? Are you caffeinated? Are you energized? I know I'm caffeinated today. So this is just a way of welcoming you and getting to know you.

Before we go any further, I want to briefly mention some technical details related to our ECHO sessions. Please use the video capabilities of whatever device you are using for our ECHO sessions. All audience microphones are now muted. During the discussion, please unmute yourself to speak.

If you are experiencing technical difficulties during the session, please send a private chat message to George Xiang, who is labeled as DLS ECHO Tech. He will do his best to respond to your issue. And he's waving to you now. Yes. OK. If you are connecting to Zoom by phone only, at the time of discussion, please announce yourself by name and institution when beginning to speak. All right. So this is– huh. I'm having a delay on moving these slides.

Here is a brief overview of today's session. For this first session, I will start with a brief introduction to the ECHO Model® and the ECHO Biosafety project. Afterward, I will introduce our subject matter expert, Dr. Anthony Tran, who will provide a didactic presentation, followed by a case presentation. Then, we will open the floor for discussion. And then, CDR Sabrina DeBose will summarize the recommendations. Closing comments and reminders will follow this, and we will adjourn this session.

Today's session is being recorded. If you do not wish to be recorded, please disconnect now. Closed captioning will be provided for this session. Please find the link in the chat box. The transcript, audio recording, and slide deck will be posted on the DLS ECHO website.

So for those of you that are joining us who are not familiar with the ECHO Model®, ECHO, it stands for Extension for Community Healthcare Outcomes. It is an interactive and collaborative problem-solving approach, initially designed to discuss the management of case resulting peer-to-peer learning experience.

How does the ECHO methodology work? Originally, the ECHO Model® was designed to improve treatment of patients by empowering primary care providers to treat certain types of disease usually treated only by specialists. The ECHO Model® uses telecommunication technology and case-based learning to cultivate collaborative mentoring partnerships between specialists and primary care providers. It's also led by a multidisciplinary team of academic medical centers.

In this way, primary care providers present active de-identified cases during tele ECHO clinics and review treatment options. These discussions, along with didactic presentations, web-based disease management tools, among other resources, allow primary care providers to manage complex patient care with the support of a team of multidisciplinary specialists. This improves patient outcomes and reduce costs.

Our goal with the ECHO Biosafety project is to use the ECHO approach to improve safety practices in clinical and public health laboratories and build a biosafety community of practice. The ECHO sessions are conducted in Zoom, which can reach many learners and provide access to knowledge and best practices. Through Zoom, all can teach, all can learn, and knowledge is democratized.

The ECHO Biosafety project relies on evidence-based approach, best practices to help improve the quality of service, a fast and efficient way to disseminate the most current information. Learning from a lecture is not the only focus during these ECHO sessions. Real-world situations are shared among the network, while evidence-based best practices help guide the case discussion. For this project, the situation is discussion of best biosafety practices. This helps create a learning loop where extensive knowledge is shared, skills are taught, and self-efficacy is simulated in several ways. Excuse me. Oh, my throat is– [CLEARING THROAT]

Learning from other laboratory professionals' experiences and knowledge creates a community of practice. We all occasionally ask you to complete short surveys and Zoom polling to help us evaluate your satisfaction. In this way, the ECHO Model® uses data to create a feedback loop for improvement in future ECHO sessions and outcomes. This helps improve the practice because participation can immediately apply– participants can immediately apply knowledge and newly learned skills. The idea of the ECHO Model® is to move knowledge, not people.

We have ECHO Biosafety sessions planned monthly from January to November this year. The sessions will typically be held on the last Tuesday of each month. Upcoming topics for the sessions include risk assessment in clinical laboratories, safely implementing new diagnostics, platforms commonly used in clinical laboratories, and decontamination of laboratory equipment. We hope that everyone will be able to participate in our upcoming sessions, and will be willing to share their own experiences and knowledge, as well.

Now it is my pleasure to introduce Dr. Tony Tran, who will be our didactic speaker and case presenter for today's session. Dr. Tran is the Director of the California Public Health Laboratory, an executive staff-level focused for laboratory science, policy issues and coordination since December 2022. Dr. Tran recently served as director of the FDA's San Francisco Laboratory overseeing microbiological and chemical analysis of human and animal food products to help protect the nation's food supply. He is a board-certified microbiologist and clinical laboratory scientist.

Dr. Tran has nearly 20 years of public health and clinical laboratory experience, including work at the national, federal, state, and local levels. During the seven years prior to pursuing his doctorate, Dr. Tran worked at the Association of Public Health Laboratories. This national non-profit organization represents the state, territorial, and local public health laboratories in the United States.

During his tenure at APHL, he directed the association's efforts on domestic HIV, STD, TB, and viral hepatitis. He had the unique opportunity to blend scientific and technical expertise in HIV, TB, and STD laboratory testing with national guidelines and policy development. He then became a member of the organization's global health team that works closely with ministries of health all over the world to develop core laboratory infrastructure in building capacity for tests of public health significance.

More recently, as the Director of Policy and Operations at the New York City Department of Health and Mental Hygiene Bureau of the Public Health Laboratory, Dr. Tran provided guidance and direction to all areas of the laboratory, and was involved in the city's response to Ebola, NYC's largest Legionnaires' disease outbreak, and Zika.

Dr. Tran also served as Director of the District of Columbia's Public Health Laboratory for nearly four years and a half, where he led the city's testing efforts in response to the COVID-19 pandemic. He also was a member of the APHL Board of Directors and their COVID-19 Task Force. He has expert knowledge in bacteriology, serology, molecular biology, infectious disease diagnostics, and laboratory policy development, particularly in the areas of influenza, HIV, STDs, TB, Zika, and biohazard agents.

Dr. Tran received his BS in Medical Technology from the University of Maryland at Baltimore School of Medicine in 1998, his MPH from the University of Maryland, College Park in 2001, and his DrPH from the University of California, Berkeley in 2013. He completed his clinical and public health microbiology fellowship from UNC Healthcare in 2015.

Now, we'll invite Dr. Tran to describe his experience. Please think about similar situations that you've encountered. We expect this to be a robust discussion, so please offer your questions in the discussion period. At this time, CDC will not make any official comments around this discussion. Dr. Tran, the floor is yours – I'll stop sharing.

Anthony (Tony) Tran: Thanks very much. I appreciate that. And thank you for the warm welcome. I say that warm intentionally, and maybe some pun there, as I'm seeing some of these temperatures out there in the chat. You all are warming me up. I feel bad about feeling cold at being 40 degrees here in the Bay. So thanks for helping me warm up a bit. I'm going to go ahead and start sharing my presentation. I want to make sure that you all can see it. Is that visible now?

Aufra Araujo: Yes, it is, Tony.

Anthony (Tony) Tran: Perfect. Thank you so much. All right. So as Dr. Araujo had mentioned, I want this to be pretty iterative. I mean, we want you to be participating in it. I have some slides here that I'll go through, and we have some time yet to discuss. And this is really what it's about. It's about your participation, as well. So I'm hoping from what I'm seeing in the chat, which is great, that you all are going to be very participatory today, right?

So I'm going to immediately kick us off with a poll. And we have some polling in here, as well, which I'm really excited to be using. So here's the first poll question that we have for you. A bit about your background, right, and how long you've been in this position.

So go ahead and answer that question right on the screen. You should see a pop-up screen on your Zoom. Go ahead and answer that, and then hit the submit button. And we're going to wait for some responses here, make sure we get a nice number of folks responding. And this will help me understand a bit more about our audience today. And we'll broadcast it for you all to be able to see, too, but how long you all have been in your position there.

OK, so here come the responses. So most of you have been in your position for 6 to 10 years. That's closely followed– so about a third of you on the call today. That's followed by one to five years, which make up the vast majority.

We have some 19% that have been in your position, so relatively new. So about a fifth of you are pretty new to your position, which I would say within the last year. And then we of course we have some vets here, which are great, as well, spanning over a decade, and some over 20 years. So that's fantastic.

OK, so moving on here. So what I am going to be presenting today are some data from a national survey. And this national survey is called the Public Health Workforce Interests and Needs Survey. It was developed by de Beaumont Foundation and the Association of State and Territorial Health Officials– so that's ASTHO– to get a better understanding of public health professionals all across the country.

And this specifically had to do– it was two years into the pandemic. So I just want to have you all understand, this is 2021– 2021, excuse me– this survey was conducted. So there were almost 140,000 workers, public health workers at the state and local level that were requested via web survey to fill out and to answer. This covered 47 state health agencies– so you see the SHA there– of which 34% of those responded, 29 big city health departments, of which we had a bit over a quarter to a third of those responding, and then other local health departments.

And there were 259 local health departments, or workers in local health departments, that were surveyed. So most of the survey, you can probably see, is coming from those local health departments, right? So we're 50% response rate there. All in all, there were almost 45,000 public health workers that respond to this, including laboratorians. And we'll talk about that, specifically your cohort, in a few minutes.

So here's a snapshot that we're going to be going over in the first part of this presentation. So this is the snapshot of the survey, all the different metrics that they tried to capture with regards to mental health status, your intent to leave due to the pandemic, some questions with regards to, again, looking at mental health issues, PTSD, and then overall job satisfaction. So we're going to go ahead and go through and break that down.

So the one thing that I want you to see here in this first part of this survey– I don't know who's been able to see this or not, and I think it's pretty revealing– again, is that this was two years into the COVID-19 pandemic. So kind of put your mindset and time frame into that. And what it revealed overall is our high levels of stress, burnout, and intent to leave. That probably is not that surprising to you.

You never want to be a statistic, and I see– I want to call him out here, but Michael Adjei, who I worked very closely with during the pandemic, he's DC's Biosafety Officer, and he knows. He probably saw this. And you all did in your specific public health laboratories, as well, during the pandemic, just with regards to the amount of pressure, the amount of stress. And I did get burnt out. I had to take a break.

And I'm not ashamed to say that, that I had to take a bit of a hiatus, a bit of a timeout, right, to reset myself. So I did become this statistic. And I actually didn't participate in this, but actually reviewing the survey was pretty eye-opening for me. And so I hope, as we walk through this, you can reflect upon your own experiences, as well, that you've gone through in the past three years now, as we and many health jurisdictions are starting to step out of this pandemic response and what we're kind of normalizing now as COVID-19 has really settled in, right?

So the one thing I want to focus on in this slide here is the post-traumatic stress and mental health– so PTSD, right– and that more than half of the public health workers, more than half of the 45,000 people that were surveyed had some form of PTSD, whether they knew it or they didn't. Whether they knew it or they didn't. And many are struggling with mental health.

So we're going to kind of drill down into that in this next slide here, where– and I want you to kind of– if you didn't take the survey, take it with us right now. If you did, thanks for your response, because you really helped for folks to be able to understand better the toll that this pandemic has taken on this unique workforce that was frontline in fighting it.

So has the coronavirus or COVID-19 outbreak been so frightening, horrible, or upsetting that you had nightmares about it, thought about it when you did not want to, tried hard not to think about it, went out of your way to avoid situations that reminded you of it, right? Knowing that you worked in a laboratory or worked in public health, how many of your family and friends started asking you about it right at the beginning or the middle of it, and you didn't want to talk about it anymore.

Were constantly on guard, watchful, or easily startled. Felt numb or detached from others, activities, and your surroundings. 56%, so over half of the people, public health professionals surveyed, had one or more of those symptoms. Like I said, again, you probably didn't even know it while you were going through it. That's pretty striking. 25%, or a quarter, reported three or more of those symptoms, which indicates probable PTSD.

May not be clinically diagnosed, or you might not have gone to the doctor about it. That's pretty striking, as well. And one in five, or 22%, of those surveyed reported that their mental health was either fair or poor, so on the middle to bottom part of that scale. Pretty telling, I think, right, again, the toll that this took on all of us.

We move on to more– hopefully, this didn't happen to folks in the laboratory. I'm hoping. I don't know. But this definitely happened to folks in the health department, especially when we're talking about executives. So high-level health officers, deputy health officers, that sort of thing, folks on the executive teams reported bullying, threats, and harassment. 41% felt bullied, threatened, or harassed, and nearly 60% so that their public health expertise was being undermined or challenged.

Think about that for a sec. How about you all– and this could have been, as a biosafety officer, even inside your laboratory, right? Because we're linking all of this to effects on safety within the laboratory. That's the point of today's discussion.

Think about whether or not your expertise or your opinions with regards to safeguarding the employees within the laboratory during COVID-19, and even after, has that ever been undermined or challenged? If it has, you're not alone. So we're going to go to poll question number two now. Pop that up for me, please.

We're going to have two polls questions together, so. So here it's asking about, during the pandemic– so this is the last three years– did you ever think about leaving your job?

And if yes, it talks about a time frame. So go ahead and answer that question and hit submit for me.

All right. So here we have 45% of you in the room now said that yes, you, during the pandemic, so during the last three years, you thought about leaving your job within the last– or within the next year. That's a lot. 50%. And overall, 62, so almost a third of you– two thirds, excuse me– two thirds of you are thinking about or have thought about just leaving in general, maybe within a year or over a year. Right? So that's pretty telling.

So those who answered yes, we're going to have another poll question. Thanks very much.

We're going to go right into poll question number three. I really appreciate you all doing this. And I'm hoping this is helpful for you all, as well, to see within your own cohort what you all are going through, what have you all gone through. So this question is for those who answered yes, with the intent to leave during the past three years, what was the reason? Again, select all that apply. And we're going to compare your results here with this national survey.

So was it because of pay? You can pick more than one. Select all that apply. Was it because of pay, workload and burnout, lack of opportunities for advancement, stress, organizational culture and climate? Go ahead and take some time to answer that.

And I do have a question in the chat. I'm trying to monitor this. The polls give me a little bit of time to be able to monitor some questions, as well. And the question is about whether or not we can get these survey results and information for your own individual state. I don't know.

I can find out for you, though. And I can let Dr. Araujo know if we can, and she can get that information to you. This was done in aggregate for the entire nation, obviously, but I can see if we can get the data by state. It's a great question.

So poll question number three. Thank you again for participating. Wow, this is striking. Look at this. For those who answered yes, so almost the two thirds of you in the room that are answering yes, why did you leave, or why did you want to leave or thought about leaving, so over half was because of pay. 90% was because of workload and burnout. Wow. Wow. And 80% because of stress.

Lack of opportunities for advancement is in there at 40%, and organizational climate and culture at 65%. So again, two thirds of you. So I'm going to leave that up there for a second just so you can see that, right? So again, 9 out of every 10 folks that said yes because of burnout and workload, and 8 out of every 10 because of stress. And of course, other factors, as well. Thank you.

Thanks so much for doing that. So how do your results compare? Well, to the rest, right? So a third here of folks in public health during that pandemic– now, this was two years in, we're three years in now, but two years in– said that they were considering leaving the organization.

This is overall, right, including laboratorians, but non-laboratorians, as well. 45,000 people, a third of them, 15,000 of those surveyed of the 45 said they were going to be considering leaving. Here, we had 65 almost percent, right, so almost– or 62%, I think it was. Almost two thirds of you. Skewed a bit. Very telling, I think.

And then reasons for leaving you all see there, as well. Here was nearly half were saying is pay, but 40% because of working overload, 40% lack of opportunities, 37% stress, 37% organizational culture. You saw how, remember, if you recall, how that was skewed for us in this cohort. 90% workload and burnout. 80% stress. Right?

And then also, probably not surprising, but 40% said that they considered leaving– sorry, 40% of those who said they were leaving or considered leaving, the pandemic made it more likely for them to leave. Not so surprising, I'm sure.

So what about job satisfaction? And I think this is probably, for me, the most impactful part of it, is that despite the stress, despite the burnout, despite wanting to leave and the pandemic making them want to leave more, calling that timeout, right, saying I need to take a break, I need to do something else, I can't do this anymore, so despite all of that, the majority of public health workers remain committed to their jobs and organizations. 80% said they're still satisfied with their job, 68% with their organization.

94% felt that the work that they do is important. 93% determined to give their best effort every day at work. That's striking to me. It still hits me. You know, two years post me leaving, right, it still hits me because you all don't want to leave, but it feels like you're being forced to, right? You feel like you've reached your limit. And I think especially so with this group.

So the next part here, I'm going to move more into the laboratorians. So we're going to tease this out. And unfortunately, I don't have the number of laboratorians that were actually surveyed. I have the percentages. I don't have the actual number of the 45, near 45,000, right?

Here's a bit more about your overarching cohort, I guess, if you will, from this survey. That these were, for laboratory professionals– and again, this is in state and local government, so these are for folks in public health laboratories. We're not talking about the clinical sector.

But a third have some sort of advanced degree. So a third of your contemporaries have some sort of advanced degree, either a master's or doctoral degree, and then 8% has some sort of specialized public health degree. And you can kind of see there the charts, or the bar graphs there that provide more visuals.

And then they were asked, obviously, some of the same thing, and they would be able to drill down into some of this. For laboratorians specifically, intent to stay or leave. More than a quarter of lab professionals considering leaving the organization within the next year. Right? 45% of you all said that. 22% reported that the pandemic impacted their decision. And among those, 38– let's see, among those with intent to leave, 38 said the pandemic directly impacted their decision.

Their reasons for leaving and staying, you all entered this, as well. And some of the top reasons were pay and workload and burnout. Again, you can see the breakdown. This is specifically for public health laboratory professionals, right?

Again, your colleagues, contemporaries in your laboratories that were surveyed. Don't know if you all took the survey or not, but just compare your responses here within your cohort of biosafety officers versus the rest. Pretty stunning to me. Pretty amazing. Thank you for participating. Really, thank you for participating.

So I want to go back now and bring this back to how biosafety and why– and I know I'm preaching to the choir here– why it is so important within the laboratory. This is a case study from my time in DC. This is prior to COVID-19, prior to the pandemic. And I'm calling this the unsuspected specimen, right?

So we had a hospital that sent three specimens– these were isolates– to us for identification of unknown bacteria. They couldn't identify it. And that's not unusual. Probably in your laboratory, as well, in your state or local jurisdiction, this probably happens, as well, I'm sure, that your local hospital, you may have a relationship with your local hospital and hospital systems where they could send out to you for identification of an unknown bacteria isolate.

When the isolates arrived into our accessioning unit, all the paperwork was appropriate. We have them fill out a test request form and send it to us properly filled out with all of the demographic information, as well as the test request information. That was all fine. So accessioners took a look at it, didn't have any issues with it. That was then delivered to our microbiology unit for further follow-up.

However, when it arrived in micro, the microbiologist there noticed the words "Bacillus r/o"– that stands for rule-out– on the submitted blood agar plate, right, where they had the isolates. And so they said, wait a minute, Bacillus. Are you talking about just routine Bacillus or are they talking about [B.] anthracis? Right? We never received any calls. There were no calls made, because that was part of our protocol, there were no calls made to the public health laboratory for what we would consider a select agent rule-out, a clinical select agent rule-out.

So we had no idea. The accessioners obviously missed it and didn't see the Bacillus rule-out component of it, or if they did, it didn't click, right? But thanks to our astute microbiologist, that person raised their hands. And one of the things that I don't know if you all do within your laboratory, and whether or not it's possible– I think that the size of the laboratory where I am now, I'm still trying to figure out how to be able to do it, but in DC, it was right-sized for us to be able to do this, and what we did was laboratory rounds.

So I walked, along with my kind of senior staff, our chiefs walked with us. Generally, we'd have our quality person walk with us, as well. And this was brought up. And so we talked about it and we said, I don't think. You know, let's hold off. Let's not open any plates. Let's not do any work until we figure out exactly what this hospital wanted.

So we made a call to the hospital, talked to the MD pathologist who's head of the lab about what exactly they were looking for. And they indeed said, oh yeah, we're following the LRN protocols and we're doing a rule-out. Well, there comes an education piece there, right, because they were supposed to alert us ahead of time. But as you know, sometimes that doesn't happen.

So the specimens' isolates were immediately rerouted to BSL-3 for the anthrax rule-out. And thank goodness, it was negative, right? But that just goes to show, for this case study, that biosafety permeates into everything that we do, right? Everything. And it permeates– and I'm hoping that you all do this in your jurisdictions, but we very much always had a lot of outreach to the clinical labs, even– especially after this, obviously, but even before this, as well. But we really did ramp up our initiatives to do outreach to them.

Fortunately, and geographically speaking, in the District of Columbia, it's a very small jurisdiction. So we actually, on a quarterly basis, have our state training coordinator– or had, I don't know if they still do it– and the lab epi coordinator, which was EOC funded, actually went out and did outreach on a various array of discussion points. But obviously, we included this, with regards to protocols and what to do. And we haven't seen any since. Michael, correct me if I'm wrong. Chime in if you've seen any of those sorts of situations since then.

OK, so moving on to poll question four. How do you rate your mental health? Poor, fair, good, very good, excellent? How would you rate it today? Basically almost, right, three years almost, for many of you, or some over three years, post-pandemic. Answer that and hit submit. We'll wait for some folks here.

All right, here you go. So three years in, and many folks or many places looking for an exit, right, many jurisdictions looking for a way out from the pandemic, it looks like you're also doing pretty well. And I'm really happy to see that. So almost half of you, 43%, said good. Almost three quarters are good to very good, that's great, or even excellent, if you add that in. And some, of course, are there at the poor or fair, for your own reasons, right? For your own reasons.

But how did that compare to public health professionals, laboratory professionals a year ago? Pretty much the same, I'd say. Pretty much the same. Thanks for bringing that back up. Pretty much the same. So you can see the kind of results there, right?

So for laboratorians, two years in, 60%, 70%, about three quarters were good or above, good, very good, and excellent. So pretty similar to what we're looking at here, with about 25%– what do we have there? About 23%, and we had here 23%, it's almost the same here being fair or poor, right?

So three years in versus two years in, of course your cohort, our cohort here on the call versus all laboratorians. Pretty similar. All right, and then this is the last poll question I have for you. And again, thank you all for participating. Really appreciate it.

This is specifically about risk assessments. And how you all are doing. So if we can have that poll question up, that would be great. Is it up? I can't see it if it is.

Aufra Araujo: Just wait two seconds, Tony.

Anthony (Tony) Tran: Perfect. Thank you.

Aufra Araujo: We're having some technical—

Anthony (Tony) Tran: No worries. Thank you.

Aufra Araujo: Yeah. It's coming.

Anthony (Tony) Tran: Thank you all. Thank you. And thank you for your patience.

While we wait, Michael, thank you for chiming in for everybody, saying we haven't seen a similar incident again. That's great. And so part of that is outreach, good communications, some education for our folks. Again, I know larger states, that's much more difficult. You have a lot more. I think I'm dealing with some of that now, just the breadth of handling and what we can do for the state of California and how large it is.

All right, so here we are. So the question asks about risk assessments. How many do you all have in your laboratory? Do you have risk assessments, biosafety or safety risk assessments for all methods conducted in the lab, more than half, about half, less than half? And what's a risk assessment? Which I'm hoping, even if you are new in your position, you all know what risk assessments are.

So I'll give you a little bit of time to answer those questions.

Here we are. So really, kudos to the 17% of you that said all of your methods conducted in the lab have risk assessments. That is fantastic. And moving on to, again, kudos to the more than half, to the folks who said more than half of them have risk assessments. That's great.

That's 38%. 17%, about half. And a quarter have less than half. So some work left to do, right? Some work left to do for you all.

Bobby here is saying we have risk assessment all BSL-3 procedures, which is fantastic, and some BSL-2, which is also great. I think my opinion on it is to strive to get all of them, all of those methods within the lab to have a risk assessment conducted. It is for the safety of the employees. It's for the safety of the laboratory. Sometimes these issues come up and you don't even realize it, right? You don't even realize that you have an issue.

So this is for the 3% that said, well, what's a risk assessment, right? So I did notice that here, all right? So we'll work on that. But of course, I'm hoping that I'm preaching to the choir here, right? So this is off the CDC's website. And it walks you through this whole risk management process and why this is so important.

So it's looking at and identifying the risks. And what we've done and what we did in DC that I've tried to incorporate into all the places that I've been is looking at pre-analytical, analytical, and post-analytical procedures, because each of those have its own risks. A lot of us, being laboratorians, we kind of think about, OK, well, as I'm conducting it, where are my issues? No, but a lot of the issues actually can occur prior to the analyst or technologist actually even having that specimen sample in their hand.

And then what happens to it afterwards, as well, with regards to appropriate cleanup and disposal, right? But it walks you through identifying the risks and hazards, evaluating those, determining controls, controls or mitigation, implementing them, and then reviewing the effectiveness of that, right? And it goes back around again. So these should be living documents, right? They should be living documents.

Here, they talk about some different types of hazards. They could be chemical hazards. They could be sharps hazards. Of course, they can be biological hazards. What are the risks, right, for sharps? Needle sticks, potential infection from exposure, chemicals splashings, contact to the skin, and therefore causing chemical burns.

And this is a bit of what I talked about before, right? So talked about a pre-incident and post-incident, right? So the likelihood of it happening, what can you do to mitigate that, and then what are the potential consequences.

So here's an example of what we can consider a Frankenstein model, if you will. So we kind of took– and APHL has samples of this, examples of this up on their website, as well. But my recommendation is talk to your colleagues. That's what I did, right? So when I got to DC, I kind of took from my experiences at New York City, I kind of took from what I saw from APHL, which really, this process kind of started around the time of the West African Ebola outbreak from '14, '15.

And that really is when– it's almost a decade now when APHL and CDC have really been pushing the importance of these safety risk assessments. And having this matrix, as you kind of see there on the right-hand side of that screen– and these are page one and page two of our risk assessment– is– and George, thank you, George, he's posting the website up there for you– is this risk matrix. And everybody, I think, should be filling this out. And I think it's a great matrix to be able to go through and take a look at the relative risks for each individual potential issue.

And one of the things I kind of want to focus your attention on here, if you can look and see my mouse here, is who's signing off on this, right? So it should be a really iterative process, where the biosafety officer is the person that's facilitating and guiding and walking them through. I mean, this template should be produced by you all, but you all should not be the persons doing it.

I hear so many times, oh, that's the responsibility of the biosafety officer. No, it's not. It's the responsibility of the laboratorian conducting it and the team of folks that are conducting it, so whoever's actually running that method, as well as their supervisor should be involved, all the way up on through.

And you can see here the signatories are the unit manager, so that's, I would say, the supervisor or the chief of that group, the biosafety officer as they're looking through to make sure that things make sense, that they're not missing anything, and then the laboratory director or section head should be signing off on that to make sure, as well. And reviewing it. Not just signing off, but actually reviewing it. And I think that's really, really important. Again, like I said, it's a top down, bottom-up type discussion because, again, it's for everybody's safety, right?

And so I'm going to summarize here real quick, and then I'm actually going to walk you all through one of our risk assessments that was done recently in DC that was shared with me. And Michael is on the line, too, so I know he was involved in that. And that stress and overload of work can really lead to burnout, which in turn can lead to bad decisions regarding safety and biosafety, right?

So when you're stressed, you saw from the survey that many folks felt pressured to do something that they didn't feel was appropriate. And we can talk about that, right? And I'd like to kind of hear your stories, as well, about your situations in the past few years and beyond, before and after the pandemic. It doesn't have to be about the pandemic, but in situations where it could be politically inspired.

It could be because of the director or section head or whatever the case may be saying, no, we've got to get this test out, what's wrong, why are we going through this process. Right? Safety can never be bypassed because of any other process. I mean, this is part of bringing on– in DC, is part of bringing on an assay, a method.

The risk assessment process was done just like you do a verification or validation, just like you do training, just like you do competency assessments. Right? All of that– SOPs, developing the SOPs, or constructions or job aids, this is part of that process. So you can't let the stress and work overload of a situation substitute for good decision-making with regard to safety.

Mitigation– excuse me– of these stressors are key to a safe work environment. When you're stressed out, in a stressful situation– and hoping, you know, if many of you have been on the bench previously prior to becoming a biosafety officer, you'll know that, in highly stressful situations, especially somebody had mentioned work in the BSL-3, that's a highly stressful situation.

You have PPE on. You could be hot or you could be tired because you may have worked extra-long shifts and these samples or specimens are coming in, that they're high priority, eyes are on them, the media attention is on it. It's a lot of stress, right? But so what can we do to mitigate that?

Risk assessments can help to set the stage for success. It's not going to ensure success, but it can help set the stage for folks to really think about, well, if I have an issue with a leaky specimen or sample coming in, what do I do? Right? You don't just kind of say, OK, well, that's not my problem in a session, I'm going to give it to the people who know what they're doing. And that's just you're passing the buck along, right?

Same thing with understanding if I have a spill inside a biological safety cabinet, how do I clean that up, or skill– spill, excuse me– within the lab, how do I clean that up. Do they know where their chemical and biological spill kits are? Have they been trained on that?

And this is what I kind of just mentioned, right? Your role here as a biosafety officer is to advise and consult. It's not to do the risk assessment. Right? If you do the risk assessment for somebody, then they haven't iteratively gone through that process. They haven't learned through that process. They haven't thought through that process.

And more than likely, that's going to lead to them not doing it and not understanding those risks and being able to understand those mitigations, right? So it's really important that you guide and advise and consult, but your role is not to actually do them. And again here, never compromise safety, even in political pressure and stress.

So I'm going to pause right here for a sec. And then what I'm going to do here is to share our risk assessment. And this is a risk assessment, you'll see Michael's name on here. So Michael, feel free to jump in anytime, as well.

I'm going to make this just hopefully a little bit smaller for you, just so that I'm not scrolling so much, right? So can you all see that OK, I hope? Thumbs up or chime in in the chat. Let me know that you all can see that. And this was for monkeypox, right? So done relatively recently. And you can see the title page here.

So Dr. Hauser here is the unit chief or manager over that group that conducted it. We had our biosafety officer. We have our bioterrorism coordinator. There's Michael Adjei, who's on the call here. And then, of course, at that point in time, Dr. Hauser was playing both roles, right? So she had both hats on. And it's really important for those folks to be able to sign on– oops, sorry– sign off on it. I don't know what happened here. There we go. All right. OK.

All right, so there's a bit of an introduction that talks about it so folks who are reading it can understand what some of these dangers potentially are, what some of the agents, what some of the hazards they're working on. Here's that risk matrix, the risk assessment matrix. The hazard likelihood is how likely that this hazard could potentially happen. Unlikely, possible, likely, highly likely. And then the hazard consequence here, insignificant, minor, moderate, major or critical. You kind of try to stay away from, obviously, the red. You want to be in the green and the low as best as possible.

And here are some examples. Here are the pre-analytical components of it. You're retrieving a specimen from the courier. The CEU is the Central Evidence Unit. So basically, it's just whoever is bringing in the specimen into the laboratory and then transferring it over to the public health laboratory. Worries, concerns about a leaky specimen from the primary, secondary container.

The specimen primary container could be open or exposed, could be broken. So how possible is that? It's possible, right? The couriers, the delivery folks could have dropped it. It could have gotten kicked around inside the truck. Who knows. What's the hazard consequence? Moderate.

And so therefore, the initial ranking is high. Now, what do you do to mitigate that? There's PPE involved here. There are gloves worn during the transfer process. There's education, outreach to the couriers about appropriately packaging. The leaky specimen is placed into a secondary container and sent into the BSL-3 for disposal, if required or if needed.

Again, this is for monkeypox, right? So depends on what your agent is and what your hazard is. Transfer it to the public health laboratory. Specimen is placed inside a biological safety cabinet. DC, their biological safety cabinet is within the accessioning area.

So again, that is kind of almost over an overarching assessment of your facility. That's really what I recommend. You really need to have biological safety cabinets, as well as a chemical fume hood, if you can have one in the accessioning area. If it's centralized to accessioning, if it's decentralized, those are the things you have to think about, where are you accessioning.

Respiratory protection may be worn. And it looks like here they're talking about fit testing, right, if needed. So then you go from medium– excuse me, from high down to medium, right, which is great, which is kind of what you're looking at. This is specifically, I believe, if I'm looking at this correctly– I apologize here for scrolling– accessioning unit procedures, right? So this is for the accessioners.

And again, you're looking at how likely it is to what is that consequence. Initially, it may be somewhere here. You're trying to, through those mitigation, be able to lower that, right? So I think that the matrix, if you don't have that initiated into your risk assessments, it's a really good one to have. It's a really, really good one to have. And then here are some comments, right?

So I'm going to scroll through this because you have it for the analytical component, with pre-analytical, and then post-analytical. Again, this is for a accessioning, so they don't have anything analytical, but looking through what you do with packaging these things to be able to send the specimens out if you need to, and/or archiving for longer storage, right? So in DC, they– they being the accessioners– also helped with storing or freezing of specimens.

So something else here that I highly recommend if you all have it– if you don't have it, excuse me– is looking at some of the biosafety components, as well as the chemical safety components. And this is basically a survey, right, of looking at these established questions and then seeing about whether or not, again, having the analysts and the supervisors, the folks that are conducting the survey– excuse me, the method– thinking about these potential situations, right?

Is there a potential for aerosol generation? Is there a need for vaccinations? Are there going to be sharps? Is there use of a biosafety cabinet? Should there be then, at that point, right?

Now you go into the chemical safety component of it. Is there proper labeling? Where's the fire department permit posted for the laboratory? Updated chemical inventory. Are the SDSs accessible. If so, where are they, right?

Thinking about chemicals and not mixing them together, flammables, all this sort of thing, it kind of walks you through all of that. And now, some of these may be not applicable, and that's fine. But it's kind of a standardized form for folks to always think about all of that.

Here's a chemical spill kit. Has it been maintained? It forces folks to go through and take a look, right? And then PPE. What type of PPE are you using? Is it going to be required? Is it not? And then where are they stored? So it kind of gets you all and the laboratorians to really think about this sort of a thing.

Waste management streams, again, you get into the post-analytical. And then you have the documentation and training, right? And then emergency preparedness. And then you have folks signing off. So all these folks here at the end, those are all of the accessioners. So they all sign off on it. Once it's done, they all read it and make sure that they completely understand it. OK? All right. So now, I'm going back here.

Here we go. All right. So going back here, now we're into the discussion period. So happy to have you share here. So I have a couple of questions here for you. Stress, overload of work, burnout, has that led to, in your opinion, a compromise of biosafety in your laboratory?

Have you all seen that in your lab? And I'm going to pull up here– how do I pull up the chat? I'm going to pull up the chat here, too, just in case. So if anybody wants to come off of mute and talk about your situation, how you're all doing there, I'd be really interested to see.

Aufra Araujo: I'll just say a word, Tony. Thank you for your presentation. Now, we will open, as Tony mentioned. And this slide, we'll stay there so we can see the topics for discussion. Open for ideas and questions from the audience, and so Tony can respond. We value the discussion amongst all of you, and want to encourage you to share your own experience and challenge on this topic.

Please raise your hand, and I will call your name. We recommend turning on your camera and using your microphone to introduce yourself when you initially speak. So floor is open for discussion. Or you can post your question in chat, if you prefer, but we really would encourage folks to come on camera, so we get to know each other.

Anthony (Tony) Tran: So we have somebody here that's in chat I'm seeing, right? So Marcia Pindling says that it has been busy keeping up with new tests, instruments, and changes in SOPs in response to COVID-19. And can definitely understand that with everything that's been happening.

Can you expand on that a little bit, Marcia? Don't want to put you on the spot here, but thank you for speaking up, really appreciate that, and being the first to chime in on this. So what kind of difficulties and have you been facing, with regards to the pandemic and beyond, with regards to keeping things safe within your laboratory?

Marcia Pindling: Tony, hi. Can you hear me?

Anthony (Tony) Tran: You're very soft.

Marcia Pindling: OK. Hold on. Let me turn it up.

OK, I'm going to put my headphones on. But basically, the changes were so rapid. And as a biosafety officer, I'm working it alone. So there were kind of people who started the projects, the head of biosafety risk assessment, and they were a little disgruntled because I was not turning over the risk assessments as rapid as they were demanding.

Anthony (Tony) Tran: Yeah, thanks for that. I'm not sure if– I had to turn up the volume really, really high, Marcia, to be able to hear, so if I missed something, go ahead and you can plop it into chat. I'm not sure if others heard it.

But Marcia was saying that– at least the part that I heard was basically there was a lot of– or there were some folks that were requesting the process to be expedient or to be accelerated because they felt that the approval process for these risks assessments were not moving at a pace that was quick enough for them to be able to implement the test. Is that correct?

Marcia Pindling: Exactly.

Anthony (Tony) Tran: Yeah.

Marcia Pindling: Can you hear me clearly now? I have my headpiece on.

Anthony (Tony) Tran: Yeah, Marcia, I can hear you when I turn up the volume, yeah.

Marcia Pindling: OK.

Anthony (Tony) Tran: So no, I appreciate that. Yeah, so have others felt that? I can understand where you're coming from. And it's one of those things where I feel that Rome wasn't built in a day, right? And unfortunately, that's, I think, the pressures that you all probably do feel.

And that's why I think having the lab director or folks that are in high-level positions– and I'm hoping that's not where it's coming from, right? And if it is, then I think that's a larger discussion in all of this, is with regards to there's that kind of sweet spot, I guess, if you will, right, where I think the understanding of you should have a process in place to be able to go through these reviews in a timely manner, right?

And I know the more people that you have with the reviews, then yes, there is potential for stoppages and delays because of how busy peoples' schedules are. But when you have the biosafety officer, when you have the lab director or the section chief or whatever the case may be involved in that, they should be supportive of that. Nobody wants an incident within the laboratory, right?

Nobody wants an employee to be impacted by the work that we're doing, especially on one of these new emerging infectious diseases that keep popping up, right? We want to be cautious at first. So yeah, so that's a really important point. And I guess, Marcia, as you're typing in, or if you want to chime in on the conclusions of that, I mean, did you feel that your process for safety was compromised because of this?

Marcia Pindling: Yes, it was.

Anthony (Tony) Tran: OK. And did you have– sorry, go ahead.

Marcia Pindling: It was because I didn't get a chance to do a deep dive sometimes into some of the activities that were being conducted. And there were a lot of also new staff and fellows and residents that were on board that were recent graduate in a master's program or fellows program. And it was just difficult with the demands. And it's not really a position that has a backup, or perhaps even assistance.

Anthony (Tony) Tran: Yeah.

Marcia Pindling: Maybe that's the stress, yeah.

Anthony (Tony) Tran: Yeah, so I think that kind of goes to John's question or– yeah, well, his question in the chat here about how many people have multiple roles in the lab or are primarily biosafety officers, right? And Marcia, you just said this here that you don't have any assistance in other roles, and you do have other roles and responsibilities.

Chelsea's saying she's the biosafety officer, as well as the BSL-3 program advisor. Bobby's saying yes, multiple roles. State training coordinator, as well as bio– wow– as well as biosafety, as well as responsive official, as well as quality assurance. Wow, Bobby. And Michael is here saying he's the BT coordinator and is also acting biosafety officer. So yeah, Michael over in DC.

So it sounds like this is an issue, right, because you all seem to be balancing a lot of different responsibilities that are obviously all very, very important. And so kind of balancing that with the– and again, the risk assessments are not the be all and end all. I think you all understand that, and as the administrators of that, right? But the laboratory safety side is something that really needs to be key.

You know, I have a question for you, as well, kind of building off of that, is do you all have direct access– I guess this is more of a question about where you all sit within the organizational structure with regards to the biosafety program, but do you all have direct access to, let's say, the lab director or the executive management team within the lab, or are you kind of buried down within other programs? I'm curious about that. Does anybody want to talk about that and their situation?

Marcia Pindling: This is Marcia. I have many roles of biosafety officer, safety officer, responsible official, quality. However, the laboratory director is part-time, and I do not have direct access per se. I sort of have to go to the program manager, who is microbiology, and who is not really fully invested in the risk assessment process. So I'm sort of pulled into other areas at will.

Anthony (Tony) Tran: Yeah. So I'm a firm believer in the safety component kind of being in this– being in kind of the operational side of the house, which means that they would have somewhat of a direct linkage. And again, it really, I think, depends on how large your public health lab is, as well.

I think it's really important for the laboratory director, as well as whoever are the heads of– it depends on how you set up your systems there or your lab, but the heads of your individual departments to be really in tune with that. I think it makes more sense, because the biosafety officer actually touches all the different programs, not just one program, right? So it makes more sense for them to have direct access into that.

And I'm seeing some in the chat, again, as well, here, that some folks are saying that, yes, they do have some direct access, which is great because that's, I think, really, really important, to have that direct line to the lab director so that they know exactly what's happening, right? And making sure that they're hearing that directly from you all.

Let's see. Just going through some things in chat here. Dan is saying he's the lab safety officer, meaning they cover biosafety, chemical safety, general OSHA safety, help with facilities, projects, have three or four construct– wow– three or four construction projects going on right now. And I can imagine that's a lot, yes, absolutely, with facilities, especially if you don't have– even if you do have, I should say, a brand-new spanking facility, there are always facilities issues in the lab, right?

Marcia's chiming back in again, saying all new and existing SOPs have been risk-assessed. That's great. And created an online module that keeps track of risks. Oh, that's fantastic, yeah. Marcia, I'm wondering if you could share that, this online module to keep track of the process. That's fantastic. That's, I think, pretty innovative. If you can share that, that would be great.

Marcia Pindling: Yes, I can. I've already shared it with the group for the APHL. I think Michael may have been aware of it, as well, Michael. Is he on the line?

Anthony (Tony) Tran: Great.

Marcia Pindling: Is he on the line?

Anthony (Tony) Tran: Um.

Marcia Pindling: With APHL, the biosafety.

Anthony (Tony) Tran: Oh, is it through the– APHL is like a list, the biosafety, yeah.

Marcia Pindling: Michael [INAUDIBLE]. Oh dear, I'm looking at the participants to see if he's online. I'm sorry. Yeah, the group, as well. So it was well received.

Anthony (Tony) Tran: Oh, perfect. That'd be great. OK. Thank you.

Daryl here is saying biosafety, safety, security officer, supervisor, specimen receiving logistics. Yeah, lots of folks are playing multiple roles here. Nick is saying safety officer, and similar to Dan, but also acting COOP coordinator. And then Bobby's answering the question about access here. So director is accessible, which is great, involved in safety, which is fantastic. John's saying direct access to lab director, but not as a biosafety officer, more because of RO and running the bio threat lab.

But John, I would say use that to your advantage, right, and bringing up any other potential safety issues that you're seeing, right, and some pinch points direct access. But scheduling time is difficult. I can understand that. Nick, scheduling can be difficult.

Chelsea is agreeing with that. Direct access. Daryl's saying that, as well. And Leah's saying good access in Florida. The only issue is that there are three state labs and can't teleport everywhere. Yeah, so exactly. So depending on your structure of your system, as well, within your jurisdiction, it can be difficult, right?

So maybe this is a question for Leah, sorry– is do you have an opportunity to travel in Florida? I'm assuming you're out of Jacksonville, right? But do you have opportunity to travel to Tampa and to Miami, then?

Oh, you're in Tampa. Thanks. So to Jacksonville and to Miami to be able to visit the labs and see how things are?

Yeah. So Leah saying that she gets around semi-regularly, but not always the same as always being there. I completely agree with you. And another follow-up in Florida, then. So does Jacksonville– like, do you have counterparts in Jacksonville and Miami? Do they have their own safety, whether it be a biosafety person, biosafety officer or their own safety person that handles the kind of day-to-day?

And I'd say feel free to come off, as well, if you want to come off of mute. And you can– if that's easier. You can always chat here, too, or in the chat.

OK, so it looks like– that's good. So it looks like at least the other labs have at least safety leads or somebody handling safety on a day-to-day basis. That's great. So. And for something like that, I mean, I think it's good that that system, you all have your own individual safety persons. And then hopefully you all have an opportunity to converse on a routine basis to discuss some of the issues independently within Tampa, Jacksonville, and Miami, because I think that there can be a lot there, too, to be learned from each other.

Daryl's saying here they have a branch lab in Mobile, Alabama. And let's see, a local safety officer there, too. That's great. And you get there once a quarter as needed. That's fantastic. Yeah, that's good. That's good.

Does APHL have any sort of formalized kind of biosafety call, I guess, that's either led by one of you all or has an opportunity for you all, much like this, to come together and just have discussions about biosafety topics or safety topics within your laboratory?

Michael's saying they hold a national call that they try to convene quarterly. That's great. Thanks. OK. And yes, yes, of course, there's a biosafety and biosecurity committee, as well. Thanks, Peter. That's good.

Well, I appreciate the discussion. We've talked a lot about the first question here. And I went ahead and I shared a kind of a case study from DC. Do any of you have a case study that you might like to share? Or anything at all, really, some of your experiences that you might like to share with regards to something that happened in the lab that could help shed some light on some issues that I'm sure we all have had and some of those solutions that you were able to come through and figure out there locally that you might want to share with the group.

Well, folks are thinking about that. Michael Adjei is saying yes, there's an APHL Biosafety and Biosecurity forum network, as well. That's great. So it looks like APHL is doing a good job, hopefully, of providing you with some of these resources to be able to communicate with each other and share experiences with each other, which is really, really important. But yet, here we have another opportunity, right? So yeah, does anybody want to share anything? Would love to hear from you.

Aufra Araujo: So Tony, while we wait, folks are thinking about questions or comments they'd like to share, I have a question for you. Based on the– you showed some of the data, and it seems like some of the participants in the survey were discontent with their salaries. So how do you think that can be addressed nationally? What are your thoughts? I know that's a very deep question, but any thoughts you would be able to share?

Anthony (Tony) Tran: I have been playing Powerball and Mega Millions, so if I win it, everybody across the country gets a raise, OK? Maybe just a minuscule one. No, I'm kidding. But yeah, that has been an issue for quite some time, as I'm sure you all are very much aware, right? And I know CDC is aware of this.

It's a national workforce issue, right? So not only are we talking about salaries, but we're also talking about positions. I mean, you all have talked about how many different roles you all are playing, as well, right? So how do you kind of concentrate on specific issues when you're being pulled in multiple different directions? So there's a workforce shortage issue. And the salary compensation situation is also quite serious.

So I can tell you that one of the large initiatives for myself in coming in here with the state of California is trying to address that. So my boss and I know that this is a big issue. And how do we, as public health laboratories, be able to compete against– not only on the recruitment side of the house, but also the retention side of the house– you saw with regards to how many folks are intending to leave, as well– with private partners, with clinical hospital laboratories, with private industry. I mean, biosafety is an issue everywhere, right, not just public health laboratories.

So it is a very serious issue. We're taking it very seriously here. One of the things, I think, is having a better understanding of folks' salaries, like what the baseline is, and how far apart are we, right? So even some of those simple questions– I mean, I've asked around, as I've gotten in here, when's the last time we did a salary survey?

Have we done a salary survey, right? Where do we rank versus everybody else, right, and our competitors? And depending on what field, like what area, the microbiologists might have competitors in the hospitals, right, or private industry. The chemists that we have here might have competitors in academia and private industry, right? Maybe not so much the hospitals. Biosafety officers, same thing. They might have industry or academia or hospitals or whatever, right?

So we need to take a look at that better in order to be able to answer those questions. I'm not sure if we really know. And I know that there are some overarching organizations that have done these types of surveys. APHL is looking at that, I know, as well as ASM, which represents microbiologists, more so on the clinical and academic side. But so they've done salary surveys, as well, right?

So yeah, Rebecca, I think they have, as well. But I'm wondering how far down they've actually drilled down into the specific categories, right? Because I think an overarching one is great, but I really do think we need to have a very, very, very specific one. And it's got to be jurisdictional, as well. I think somebody else had asked about the survey data that was shared here. It's national data. But having jurisdictional data is really important. How do you all compare in your jurisdiction, right, with others.

So I think we have a lot more work to do drilling that down. But yeah, no, it's very, very important. It's very, very important. So I think it's something that we need to have done and should be addressed. It's a topic that keeps getting brought up over and over and over again, so it's a great question. Unfortunately, there is no easy answer, right, except that we have to fight. We have to be vocal. So one of the things I've said, as laboratorians, we can't be quiet, right? So APHL I do think has been a leader in this arena for us of being a voice.

That's kind of their role, right, is to be our voice. And I think they've done a good job, specifically over the pandemic. So I think that we also have an opportunity here because of the pandemic and because of the role that public health laboratories and public health played in the response that was so covered by national media, right? And then a lot of funds and money were provided by the federal government.

So I think a lot of things that we should have and needed to think about was how do we now make this sustainable, right, as now the federal funding is starting to dry up. So build an infrastructure, but part of that infrastructure a lot of people think about is equipment, instrumentation, IT systems, whatever the case may be, which is true, but building that infrastructure, as well, with regards to personnel, right? So I'm hoping in your jurisdictions that has started to happen. And it happens at the laboratory director level and beyond, right, of where do we go with this. So.

Aufra Araujo: And that's a good segue way to another question, which is, how can we use pandemic and outbreaks lessons learned to prevent laboratory professionals' burnout in the future? What are your thoughts?

Anthony (Tony) Tran: Yeah, I mean, it's a tough one. During any sort of– I mean, remove COVID. I mean, that was such an extreme, right? And my hope is that we don't ever see any of this type of a response ever again, right?

But we know history. This is not the first time. It's the first time, really, in our lifetime that we've seen such a dramatic pandemic response, but outbreak response happens all the time, right? In your jurisdictions, you all know that. They happen all the time.

And that's kind of the beauty and, I guess– I don't want to say the curse, but the downside of public health. I mean, people come into public health because it is exciting. You don't know what's going to be next, and you don't know how we're all going to have to respond to something to be able to use our experiences and our brain and come up with something that's innovative to be able to stop this outbreak, right, to stem it.

But during an outbreak, the curtain is pulled back, right? You get to see everything. And if you're not organized, if things are not in place, if they are not well functioning and well oiled, including the safety side of the house, you really are going to start seeing that bubble up to the top, right? And you're going to see potential issues. And you have your fingers crossed that you don't actually have an issue, a workplace exposure issue or a safety issue that actually happens, right? So it's many times, and I think that– I just saw this in the chat. I apologize here. Let's see.

Oh yeah, Marcia's commenting with regards to the biosafety risk assessment process. It's not considered mandatory. Is there respect for the position? I think you're spot on. I mean, there needs to be, right? There needs to be. That position needs to be discussed. It needs to be flaunted, if you will, almost, by laboratory leadership and beyond.

It really does need to be, because that's where it comes about, because you play such an important role in not only keeping– and I think biosafety officers are being asked to do this, as well. I know Michael can chime in on this in DC, but we're asking folks not only internally, but you're actually asked to be a bit of a– play an ex-officio role, too, like going out and being advocates out in the community, as well, right? Because what happens out there can very easily be brought into the laboratory where you all work in the public health lab, right, with regards to these pre-analytical issues, right? So where do you mitigate all of this?

Yeah, no, that's a tough question. It really is, because– and I don't think there's, quite frankly, a great answer for it, except use from your experiences here. I'm hoping you all did a lot of hot washes and after actions. And those are great, I know, but you have to actually have some action that actually happens from that, right? You actually have to have some improvement plans that actually occur from that.

So yeah, let's see. Going back to the chat– demands such experience and education, but no respect to authority. It's a very difficult position. It is an advisory, consulting type position, right? So being able to play that role, Marcia, is really key, and understanding where you all fit into that. But again, having leadership support, I think, is also very key. So hopefully you all have that within your laboratories. And if you don't, I think that's what needs to happen, slowly yet surely.

So OK, so Leah has here a case study. One issue that really increased workload there in pandemic was constant rotation of new staff, most of them who had little or no lab experience and often stayed only a few months. We were training new staff constantly. And of course, inexperience is a safety risk. Absolutely. 100%.

So Leah, was this kind of like contracting? I know a lot of folks ended up hiring contractors. That was really the only way to be able to meet the demands of all this testing. We did that in DC, as well. And kudos to them, because they really helped us keep afloat. And Michael, chime in, please.

We always integrated the safety components into the fabric of every sort of onboarding, right, and procedure and everything like that. It was really important. And it was a struggle, obviously, yes. It was a struggle. In DC, as well, I'll share that with the federal purchases of these Abbott ID NOW instruments, we were asked as a laboratory to actually place them into a lot of nontraditional laboratory settings.

These were prisons, jails, behavioral health centers, clinics that didn't have a laboratorian on hand. What else am I thinking, Michael? You were part of that assessment team. So what we ended up doing was formulating a team that included the biosafety officer, included our safety– excuse me, our quality person, included a technologist. And they would actually go out and assess.

And we had this very large, intricate process for assessment of these placements. And they had to make sure they showed us the floor plan. We had to do a tour. We had to make sure that they had an appropriate place to be mindful of cross-contamination and contamination into their own employees, because again, even though it was, quote unquote, waived, which I don't think it should have been waived, but that's a topic for another day, they were.

And so we wanted to make sure that the folks that were non-laboratorians could indeed handle the testing. And we trained a core group of people. We actually provided proficiency testing for them, as well, which is not required for a waived test, but kind of going above and beyond. So I know your role is huge, right?

Let's see. Rebecca, OK, saying here this one is Before COVID, BC. Yes, exactly. Kind of how I refer to that, as well. Useful and show a jurisdictional breakdown in different job titles might help someone that wants to look into further. And she put the link in there. Thank you.

And Marcia's chiming in again here. Sudden influx of COVID-19 funding created simultaneous and, yes, nontraditional laboratory. Traditional, excuse me, test sites increasing existing workload. Over 683 non-traditional COVID-19 test sites plus one clinical lab to train on bio, yes, risk assessments. Yes. And we did that in DC, as well. They had to have a biosafety risk assessment.

And the biosafety officer really– they submitted it. The biosafety officer helped to administer that, helped to guide them, but they had to actually have something on paper before we would actually hand over that Abbott ID NOW. So yes, it is a situation of scales. I get that. It is a lot. It is a lot. What I learned here in California coming in is they had set up over 4,000 school sites for antigen testing, right? So yeah.

So Michael's saying he's from DC and they need to perform the risk assessment themselves and to own the process. Yep. Exactly. So yeah, it's just depending on what your jurisdiction is asking you all to do. I know, sometimes it seems hopeless. It seems like, oh my gosh, how am I going to be able to do this?

But at the end of the day, the work's got to get done. I mean, that's how we are in public health, right? We just lower our heads and say, OK, let's do it. But I think the intersection here is to be sure that we don't intersect too much between this compromise of safety with what the mission that needs to get accomplished.

I mean, it needs to be folded in just like everything else, folded in with having a verification and/or validation on file, right, because that's it's a regulatory issue, right? And having training because that's a regulatory issue, right? And having a competency assessment, excuse me, because that's a regulatory issue. But beyond it being a regulatory issue is what does it actually mean, right?

It actually means that we have assurance that the test and the result that's actually being conducted and reported are accurate and reliable, right, using– to the best of our ability that it's accurate and reliable. Well, the same thing on the safety side. Everything that rolls out, every procedure that is completed, we've got to make sure that our folks are safe, right? And so that can't really be compromised. It shouldn't be compromised, I should say.

All right. Thanks for sharing. Anybody else?

Aufra Araujo: I think this was a great discussion. And thank you so much, everyone, for participating. This is a really important discussion. Now, let me share the slide. And thank you so much, Tony—

Anthony (Tony) Tran: Let me stop sharing.

Aufra Araujo: –for your experience and case study and answering all the questions. This has been really good. Let me get the presentation here. Share. OK. So– hm. What's happening with the sound? I hear an echo. Do you?

Now, my colleague Sabrina DeBose, Safety Team Lead in CDC's Division of Laboratory Systems, will provide a summary of the recommendations discussed during this session. Sabrina.

Sabrina DeBose: Yes. Thank you, Aufra, and thank you, Tony. We appreciate you all for that robust discussion regarding professional burnout and the effects on safety. So based on the discussion, I will provide a summary of recommendations that we heard you all mention or type in during the presentation.

Just a few– and this is a brief summary– we looked at the discussion on risk assessment as an area that we need to focus on, since it is for the safety of the lab as well as the safety of the laboratory professional working in the laboratory.

One of the other discussions consists of an individual noted that, during the COVID outbreak, when it was high during the response, laboratories experienced individuals requesting that the approval process for the risk assessments be escalated, which contributed to the safety and could have affected compromise in the safety of the laboratory workers being compromised. Sorry about that.

We also heard you all say that biosafety officers are serving in multiple roles without sufficient support. You all are balancing multiple positions when laboratory safety should be a main priority. And also, as a biosafety officer, you should have a dedicated line to the laboratory director and/or management.

Biosafety officers are responsible for different locations that may not be in close proximity to one another. Some of the solutions that we saw you all offer in the chat were to assign a local safety lead or have someone that was assigned as a local safety– or a general safety or a training lead, since you cannot physically be there. We also saw you all make a suggestion to say visit that location as often as possible, even though you're not physically there all the time. But visiting as often as possible does help with your presence in that area.

We also heard you all discuss building an infrastructure around personnel to ensure salaries are comparable and competitive. We also saw that there were several resources listed in the chat for later use. One of the ones was APHL does have a biosafety and biosecurity forum network for you to use as an additional resource.

Once again, we want to thank you all for contributing to this discussion. And we're looking forward to continue to build this community of practice. Aufra, back to you.

Aufra Araujo: Thank you, Sabrina. Wait. Can you hear me? OK, sorry about that. Thank you so much, Sabrina. And at this point, I'd like to ask Tony if there is anything else he would like to add as a summary of the discussion that Sabrina didn't cover.

Anthony (Tony) Tran: Thank you. And Sabrina, thank you for doing that. That was a great summary, and hopefully that kind of hit home for folks here. No, I just really want to say thank you for the opportunity to share with you some of the data, which I don't think get enough publicity.

I think it's quite– I'm sure, to many of you looking at this, it probably resonated, right, especially from your own responses. And I appreciate you all responding to the survey, appreciate you all involving yourself in the discussions today. And I'm hoping that, again, that formulates into some motivation for you all, too, within your own jurisdictions and your own laboratories to think about how your role and how important that is. And I wouldn't say pivoting, right, but how does that help to move that needle forward a little bit on the safety side, right?

So I'm hoping that our discussions today, I'm hoping that you are able to formulate some thoughts and ideas of how to be able to bring that back to the important safety issues, to bring them back to your laboratory and have that direct line with management and talk to them about that. I think that's really, really key, to be in this all together. And if you all have certain situations where you're feeling the way that you are, this is the other thing that I would also recommend, is to be open to that with your supervisor, right, and talk to them about that, because as a supervisor and as a manager, I would never want my folks to be overwhelmed.

And understanding the situations with the pandemic and what it caused, I mean, this has really hit home for me, as well, as one of my own process improvement activities is to make sure to check in with folks more often, and check in and make sure that they're doing OK, and being more aware of not only internal stressors, but obviously also external stressors that we see on the news every day. And the news, unfortunately, it's just turned into this broad net of just despair and violence and horror and all of that. And that takes a toll on you, too, right?

So all of that is, unfortunately, I think, potentially leading to the burnout and the stress. And sometimes an outbreak or a pandemic or whatever the case may be helps to exacerbate that, right? It just shaves you down to razor-thin levels, you know?

So just always be mindful of that. I think the key here is taking care of yourself. Be putting yourself also up there, taking care of yourself. Practice self-care, that sort of a thing. As laboratorians, I don't think we do a lot of that enough, to be honest with you. Our new– well, he hasn't been new now, he's been here almost three years now, but head of our Department of Public Health is very big on that, very big on taking mindful minutes at beginning of meetings and just taking a breath or meditating and all of that.

And it's just to kind of set yourself, even on a daily basis, right? Take a break. Take a walk. Take a break. Just remove yourself from situations I think is really, really key. And hoping from that, that'll help you with your job, as well. So I appreciate, really, the opportunity to speak to you all and connect with some of you. And thanks to CDC for allowing me this opportunity.

Aufra Araujo: Thank you so much, Tony. And these are so really great suggestions. And that work/life balance that we talk so much is really important. Thank you all for taking part in our discussion today. We hope, as Tony mentioned, that you find it valuable in the– that what you heard today is valuable in the important work that you engage with in your individual laboratories.

We look forward to your participation in future sessions as we dive into specific laboratory biosafety topics. Soon, you will receive an email message containing a post-session survey link. It will take about two minutes to complete. Please, please, please, please do respond that survey. If you have additional comments, please send an email to dlsbiosafety@cdc.gov.

And now, I just would like to share our next speaker. Let's see.

All right. So we are excited to have our next session in February. It will be on Tuesday, February 28, at noon Eastern time. The topic will be Risk Assessment in Clinical Laboratories, so it's a good segue from Tony's presentation today, which will be presented by Crystal Fortune from the Montana Laboratory Services Bureau.

Please visit the DLS ECHO Biosafety website to view all upcoming sessions. And George will put that link in the chat. Again, if you have any questions, you can reach out to us at dlsbiosafety@cdc.gov. Now, we will adjourn. Thank you and have a great day. Bye.

Additional resources and related publications

• Garcia E, Kundu I, Kelly M, Soles R, Mulder L, Talmon GA. The American Society for Clinical Pathology's Job Satisfaction, Well-Being, and Burnout Survey of Laboratory Professionals. Am J Clin Pathol. 2020 Mar 9;153(4):470-486. doi: 10.1093/ajcp/aqaa008. PMID: 32080719.
• de Beaumont Foundation. What is PH WINS? Retrieved from https://debeaumont.org/phwins/what-is-phwins/
• Association of Public Health Laboratories. (2018, May). Focus on Public Health Laboratories: A Workforce Survey Report. Retrieved from https://www.aphl.org/aboutAPHL/publications/Documents/IR-2018May-2016-Workforce-Survey-Report.pdf
• Centers for Disease Control and Prevention. (2021, October 21). Biological Risk Assessment: General Considerations for Laboratories. https://www.cdc.gov/safe-labs/php/biological-risk-assessment/index.html
• Association of Public Health Laboratories. Template for Public Health Laboratory Risk Assessment for Ebola Virus Disease Testing. Retrieved from https://www.aphl.org/programs/preparedness/documents/aphl-template.pdf
• District of Columbia Department of Forensic Services. PHL Forms and Documents. Retrieved from https://dfs.dc.gov/publication/phl-forms-and-documents