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From the Spring 2021 issue of "Microcosm."

The Pandemic Has Exposed Vulnerabilities in the Public Health System. Can We Learn Those Lessons in Time to Prepare for the Next One?

Last March, as the COVID-19 pandemic began to spread like wildfire across the country, clinical laboratory scientist Brandy Gunsolus, D.C.L.S., M.L.S. (A.S.C.P.)CM, saw an unexpected problem fast approaching. Her diagnostic testing lab at Augusta University Health in Georgia was quickly running out of nasal swabs. Ordinarily, she'd just order more, but her supplier had also run out. This was a huge problem: Without swabs, Gunsolus and her staff couldn't collect patient samples to test, and without tests, new cases of the disease couldn't be confirmed.

So she turned to an unlikely source: The school's dental college. Her colleagues there were already using 3-D printers to create customized, transparent teeth aligners for patients. She asked whether they could use the same material to print swabs. Within days, she had prototypes to test, and once they had settled on a design, the printers started printing.

"We validated that printed swab against the few other swabs that we had left, and we went for it," Gunsolus said. The printed swabs proved to be a lifeline. "We lived on 3D swabs for several months. Not until October were we able get supplies of our regular swabs again."

The swabs were the first of many shortages that emerged as the pandemic — and the need for testing — ballooned. After swabs, Gunsolus had to scramble to find a viral transport medium. Then she had to look for the plastic tips used in the lab's automated liquid-handling system. That manufacturer had run low on raw material, Gunsolus said, and couldn't keep up with the surge in demand. In desperation, she began searching the internet — and found a solution.

"We found them on eBay," she said, "and that's how we were able to keep COVID-testing."

Gunsolus' Situation Wasn't Unique

The pandemic plunged diagnostic labs around the country — and the world — into a tailspin, with lab workers forging creative solutions on the fly. "If I had to sum it up in two words, they would be 'roller coaster,' " said medical laboratory scientist Ian Wallace, M.L.S. (A.S.C.P.)CM, of Saint Joseph Hospital in Denver.

Since the start of the pandemic, labs in the U.S. have conducted more than 360 million COVID-19 tests. Just over 31 million have tested positive, and more than 600,000 people have died of the disease. Virtually no aspect of 21st century life has been unaffected. But many people saw it coming: Virologists and epidemiologists have been warning at least since the late 1980s that a pathogen as contagious and dangerous as SArS-CoV-2 could wreak havoc on the world. Researchers also warned that the U.S. would not be prepared because of a paucity of public health funding and a workplace shortage. According to a 2020 report from the National Association of County and City Health Officials, government spending on local health departments fell by 18% between 2010 and 2019. In 2008, the Association of Schools of Public Health predicted a shortage of 250,000 public health workers by 2020. Tens of thousands of public health jobs that disappeared between 2007 and 2009, during the Great Recession, were never replaced.

Nevertheless, those warnings and signs went largely unheeded. As a result, underfunded and understaffed public health systems were underprepared to respond to an emergency of COVID-19's magnitude.

Clinical microbiologists, public health personnel and medical laboratory professionals in labs at hospitals, clinics and other facilities were caught in the middle. Almost overnight, starting in February 2020, scientists like Gunsolus found themselves scrambling to test, as quickly as possible, an unprecedented number of incoming samples, using a variety of platforms, for a potentially lethal pathogen that had only recently been sequenced and about which, in the early weeks of the pandemic, experts knew very little.

Swabs and tips weren't the only materials in short supply. Personal protective equipment, or PPE, became a scarce commodity. Labs ran out of pipettes, pipette tips and tests. "Almost immediately there were not enough tests available," says Gunsolus. "We ended up using five different platforms to keep up with the testing demand and the reagents that were available."

Microbiologist J. Michael Miller, Ph.D., who runs a company in Dunwoody, Ga., that consults with government and private labs across the country, said that the pandemic disrupted other tests as well. "The supply shortages started with COVID supplies but then extended into all other areas of the lab," he said. Many labs that he worked with managed to keep functioning through local cooperation — often connecting through the CLIN MICRONET and DIV C listserves hosted by the ASM.

"We reached out to sister laboratories nearby and shared what we could," he said. "We all shared the same problems and same roadblocks."

Material Shortages Were Matched — and Worsened — by the Lack of Trained Personnel

Many labs run on a skeletal staff. The pandemic highlighted the severe shortfall of workers needed to run the tests and keep the system functioning, said clinical microbiologist Amy Leber, Ph.D., at Nationwide Children's Hospital in Columbus, Ohio.

"We already had holes in our staffing," Dr. Leber said. "When we pile on top of this a pandemic, it exaggerates and exacerbates our need for extra personnel. And it's not like we can hire more people because we can't even fill the positions we had open to begin with."

Dr. Leber called the shortage of scientists in medical laboratories a "hidden crisis." Part of the problem, she said, is a lack of training programs. Between 1983 and 1999, enrollment in medical laboratory scientist (MLS) certification programs dropped from over 8,000 to nearly 5,000, and the number of programs fell from 638 to 273, according to the National Agency for Clinical Laboratory Sciences. As of 2017, the U.S. had 234 MLS programs and 244 MLT (medical laboratory technician) programs.

"Our programs have fallen way off," said Dr. Rohde, who used to work for the Texas Department of Health and now runs the Clinical Laboratory Science Program at Texas State University in San Marcos. Many labs are staffed by scientists who are nearing retirement, he said, and he worries that their expertise will be lost without a younger generation to train.

Dr. Leber responded to her lab's shortage by appealing to the research institute affiliated with the hospital. "We had to find people who might be able to come in and work in the lab, and had to reposition people from other areas," she said. "People brought in nontraditional workers during this period of all flavors and types, including students and doctoral candidates."

Before COVID-19, Gunsolus said, her lab had been trying to hire a new recruit for one open position. "We were already short-staffed, and we have a large number who are at or past retirement age across all our labs, including microbiology," she said. But when case numbers rose, the lab faced a mass exodus of older scientists who interpreted the pandemic as a sign that it was time to retire. Now, she says, the lab has six open positions and remains understaffed.

As vaccinations have become available and case numbers have steadied or declined in many parts of the country, clinical microbiologists and other experts are considering how labs and other public health services can prepare for the next catastrophe.

To assess the state of workplace shortages in clinical microbiology, for example, the ASM invites its members to take part in the 2021 Clinical °®¶¹´«Ã½ Workforce Survey that launched this month. Dr. Rohde, in Texas, believes that public health and medical laboratory training programs should be considered for line-item (eternal) funding, similar to how the Department of Defense is treated. "Shouldn't we treat pathogens, which are stealthy and always mutating, [as being] at least as dangerous as our worst terrorist event?," he asked, pointing out that pathogens have killed more people than many wars combined.

In a New York Times editorial published in April 2020, ASM chief executive Stefano Bertuzzi, Ph.D., and ASM president Robin Patel, Ph.D., called for a "microbiologist National Guard" to address the workforce shortage. During a pandemic, trained graduate students, postdoctoral scientists and research scientists whose labs have closed would be able to fill in the gaps in non-critical roles in clinical microbiology labs and help with testing. (Unless they'd completed an accredited program, Dr. Rohde notes, they wouldn't be qualified to swap in for every job.)

Dr. Leber says an increased investment in MLT and MLS training programs — as well as outreach programs that raise awareness among high school students — could bolster the workforce; she encourages ASM members who run labs to consider becoming a training site.

Dr. Miller, in Georgia, said he thinks labs should address pandemics in their in-house emergency-preparedness training. "We used to think of emergency preparedness for bioterrorism," he said. "This wasn't a bioterrorism event, but the pandemic did give us a good, sobering view of how fast something like this can occur."

Preparation should also include addressing the supply shortage, said Gunsolus. "As a health system, we've identified that we do need a reserve stock of things like gloves, lab coats, and basic PPE," she said, "but we don't want to horde. We don't want it to be like toilet paper."

"Also, we need stockpiles of swabs," Dr. Leber said. For other materials, knowing how much to keep on hand will be trickier. Lab reagents, for example, often expire after a year, and "it's hard to keep stockpiles of stuff that expires," said Dr. Leber.

By bolstering the workforce, funding and supply shortages, the public health system may be better prepared for the emergence of the next virus that wreaks havoc on the world.

"I'm hoping that we never have to experience this thing again," said Gunsolus, "but as Rodney Rohde said at the beginning of this pandemic, ‘viruses are going to virus.' There will be another respiratory pathogen, and we've just got to be ready for it."