How Laboratories Should Prepare

for Future Responses

Hello again. I'm going to give you a few notes before we start OneLab Summit for the third and final day. This and all other sessions are being recorded and will be posted to the OneLab Summit page at a later date. If you have any technical issues while attending the Summit, please email the OneLab's inbox for support at onelab@cdc.gov.

We posted the link to live captions in the chat. Please be sure to keep the caption windows open, if you use it, in addition to the Zoom meeting window. If you have questions throughout today's event, please insert those into the Q&A function at the bottom of your Zoom panel. We'll answer questions at the end of each session, and I'll now turn it over to our OneLab Network lead, Alicia Branch, to introduce today's theme. Alicia? 

Thank you, Blanche. Again, welcome to Day 3, the final day of the 2024 CDC OneLab Summit. If this is your first day joining us, welcome. Again, like Blanche said, I'm Alicia Branch, the OneLab Network lead. Today's theme is preparedness. Again, the dynamic speakers in today's lineup are as profound as those from Days 1 and 2.

So first, I will — before we get started, I'll read our external presenters disclaimer. Next slide, please. Slide decks may contain presentation material from panelists not affiliated with the CDC. Presentation content from external panelists may not necessarily reflect CDC's official position on the topics covered. 

Today's speaker, we have the privilege of hearing from the esteemed Ms. Chris Mangal. She's a senior public health professional with over 20 years of experience leading complex emergency preparedness and response programs, managing personnel, and providing scientific guidance to local, state, territorial, and federal agencies.

Currently, she serves as a director of public health preparedness and response at APHL, where she provides leadership for emergency preparedness, biorisk management, and crisis response to natural disasters, including hurricanes and emerging threats such as Ebola, Zika, and coronaviruses. She has expertise in developing and expanding networks such as the Laboratory Response Network, promoting a culture of innovation and accountability, and advocating for policies and resources to strengthen health care and public health systems.

Our first speaker for today is Ms. Chris Mangal. Over to you, Chris.

Thank you, Alicia. And hello, everyone. I'm excited to be with you all today. Happy Medical Laboratory Professionals Week. It's a great time for us to be having the OneLab Summit. Today's discussion will really focus on how laboratories can prepare for future threats. With that, I'll go ahead and share my slides. 

Hey, Alicia, can you just give me a thumbs up if you can see my slides? 

We can see them.

Wonderful. Thank you. I appreciate that. So as Alicia mentioned, I'm with the Association of Public Health Laboratories, or APHL. And on a day-to-day basis, our jobs are really focused on ensuring that public health laboratories across the US are prepared to detect the next threat. And when that threat evolves, we are actually there to help our laboratories respond. Today, I'll share a little bit more about the things that we do at APHL. And then more broadly, how can laboratories prepare to respond to various threats? 

A bit about APHL, our vision focuses on a healthier world through quality laboratory systems. And APHL, ideally, we are sort of centered at that intersection of policy, science, and laboratory practice. Our members and staff work to shape national and global health outcomes by promoting the value and contribution of public health laboratories, and also to continuously improve the public health laboratory system and practice. Of note, when we use the terminology "public health laboratories," we are implying any governmental laboratory that performs testing of public health significance.

About a year and a half ago, we embarked on an initiative to think through our organizational values. And really the purpose of this was to foster a strong sense of community. The membership developed four organizational values that guide APHL. Those values are community, and that's actively fostering meaningful connections and a sense of belonging among members and partners. And that community really promotes collaboration, growth, and diversity of thought. And the idea there is really to make sure that folks have a home. There is a home for these types of folks with similar backgrounds and similar interests. 

In addition to community, APHL's organizational values include innovation, where we are meeting a diverse and ever changing public health landscape through forward thinking and adaptive leadership. We also have two additional goals. One of them is centered on diversity, equity, inclusion, and accessibility. And here it's where we're really embracing a model and a culture of diversity and making sure that everyone has a home within the organization. 

The COVID pandemic showed us where there wasn't — there was a question of science, a question of data, and a question of our public health activities. And one of the things that's important to remember is to make sure that whatever we are putting out there in this world, we have the scientific and professional integrity and we are seen as a trusted leader in public health laboratory science and we continue to strive to ensure that there is the highest level of ethics in the work that we do. And these are the four organizational values that really shape APHL, and it defines our membership, our staff, and also our partners. 

Our current membership continues to evolve and continues to increase. What we're looking at today, it's a little over 1,600 members at APHL. Those members include folks from state and local public health laboratories. They also include representatives from agricultural institutions. Additionally, we have corporate members. So there are companies that have shared public health values, and they're also members of APHL. And then there are a number of individual members. 

In addition to those individual members, we have what's called institutional members at APHL. Those institutional members total a little over 130 laboratories, and those are laboratories across the US that perform testing of public health significance. A majority of those laboratories are state and local public health laboratories. But then we also have agricultural laboratories that may be members of APHL as well.

With that, I'll go ahead and transition into discussing what I see as the preparedness and response life cycle. In terms of readiness, we think of it in terms of a four-pronged approach: preparedness, detection, response, and recovery. For the next few minutes, I'll spend some time describing each of those components and how public health as well as private laboratories can better prepare for the next threat. 

So when we think of preparedness, the first thing that comes to my mind, it's this concept of networks, whether that's the Laboratory Response Network, the Food Emergency Response Network, or many of the other networks that are charged with responding to a specific threat. I think of the networks that are in place and how those networks are preparing its membership to respond to whatever the threat may be. A critical component of those networks are the partnerships that we form during what I will say is the sort of ready state or that preparedness state. 

Those partnerships are essential in that we are not scrambling to develop new relationships when a threat evolves. We already have those established partnerships, and we can respond to whatever the threat may be. As part of those partnerships component, it's something that we emphasize at APHL that it must be a combination of public and private partnerships. There is no one laboratory, there is no one governmental agency that will respond to a COVID or a Zika. It's a plethora of organizations that are responding to mitigate that threat. 

Communications, it's critical in ensuring that you have built relationships, not just with individuals, but you've built relationships with those institutions that can outlive positions. When folks move on, those relationships still continue with the institutions. In addition to that, we think through lab-specific policies and procedures, ensuring that notification policies are in place prior to an event. So who are the key partners that must be notified? What's the type of information that must be shared with those partners? 

We also think of safety. What are the personal protective equipment? What is the biosafety practices and biosecurity practices that are in place in specific laboratories? How do you safely contain a specimen? How do you ensure that access to that specimen or access to samples is limited? 

We also think of planning. So one of the things that APHL has developed, it's a model continuity of operations plan. And during a preparedness state, one of the things that we encourage laboratories to do is to review those continuity of operations plans, update those plans, and if possible, look at exercising that COOP.

Similarly, surge capacity planning: you may need to move routine tests out to other laboratories during a response, or you may need to look at how you adjust shifts within your laboratory to ensure that there is ample capacity to respond to whatever the threat may be. So when we think of preparedness and planning, two big plans come to mind. That's your continuity of operations plan, or COOP, and your surge capacity plan. 

Additionally, we think of systems and infrastructure. The first thing that comes to my mind is data reporting and ensuring that you've got a robust infrastructure in place to report critical data, whether that's to public health agencies or whether that's to the Centers for Disease Control and Prevention, but really ensuring that there's a system in place to report data. Also ensuring that your equipment has updated maintenance contracts, that equipment is ready to go.

You also have a diversity of equipment. You may not want to rely on one platform, but may need one or two platforms to ensure that you can meet capacity requirements. As part of preparedness to ensure that you've got a system for inventory, you also have connections for the supply chain to ensure that your laboratory would have a steady supply of critical reagents and other supplies for the laboratory. 

A very important aspect of preparedness, it's workforce. And workforce meaning that you have folks for accessioning, to testing, to reporting. And that investment in workforce can't possibly happen just in a response. It's a sustained investment to ensure that folks are trained, they're competent, and they are prepared to respond and detect threats. 

I also think of during the preparedness phase, your regulatory compliance, ensuring that all of your tests meet the regulatory compliance, and that can be compliant with CLIA requirements. It can also mean that you are meeting the FDA requirements as well, depending on the nature of the tests you have in place. As part of preparedness too, whether it's a public health laboratory or a private laboratory, I think of ongoing test development to stay ahead of the next threat. How do we ensure that we've got the right workforce in place that has that forward thinking skill set to develop that next test, if you will?

Other systems for preparedness include having a robust specimen collection and transport system. So that if you need to move specimens to another laboratory, you've got a system in place to do so. Similarly, as I mentioned, in terms of COOP, continuing to train staff, and also implementing drills and exercises. So during that preparedness phase, it's where we want to test our system and ensure that our system is robust. 

An example of preparedness that I wanted to highlight, and I mentioned this at the beginning of my discussion on preparedness. It's the importance of partnerships. At APHL, we invest heavily in our partnerships with clinical laboratories and clinical laboratory organizations, such as the American Society for Microbiology, or ASM, and the College of American Pathologists, or CAP.

Since 2005, we've maintained a memorandum of understanding with CAP, and the purpose of that MOU is to strengthen the Laboratory Preparedness Exercise. So we work closely with CAP and CDC to develop and issue two exercises each year. And those exercises test the ability of laboratories to rule out and/or refer biological threat agents to public health laboratories.

A critical partner for these clinical lab guidelines, it's the American Society for Microbiology. And we work really closely with ASM to review and improve, if needed, what's called a Laboratory Response Network Sentinel Level Clinical Lab Guidelines. And those guidelines help laboratories to recognize, rule out, and refer threats. And it's been a really successful partnership, and it's both with ASM and CAP, to ensure that there is a readiness within the clinical laboratory community. And there's that connectivity between the clinical laboratories and public health laboratories, especially when it comes to ruling out and referring threats of public health significance. 

We also have an MOU with CDC and many other partners for diagnostic surge testing capacity for public health emergencies. And again, this emphasizes the importance of meeting before an event and having those routine relationships in place so that we know who to go to if there's a surge event and additional testing is needed where commercial laboratories may be engaged. It's important that those relationships are in place well in advance of that response. And we have utilized those MOUs and those relationships for many responses beyond COVID. 

The next phase in that response or readiness cycle is the detection and response phase. And when we get into this phase, I see this phase as important from a perspective of providing timely testing and accurate results. And it's also an important phase of where we really need to have the capacity to respond to that threat. And that capacity may come from a clinical laboratory, an academic medical center, a public health laboratory, a large commercial laboratory, or another independent laboratory. But it's a system of laboratories working together to ensure we have the capacity for timely detection as well as accurate testing.

A critical component here, especially within the public health world, it's the use of an incident command or incident management system. And when I think of this system, I think of it as really an opportunity for enhanced organizational coordination. It just means that within your organization, you are coordinating that response. And here, I would encourage laboratories, whether it's public or private laboratories, to be part of that system and be part of that system — it may be at your institution level. It may be at an agency level. But it's really important that there are laboratory representatives engaged in this incident management system because you are providing that critical data for responses. 

In terms of detection and response, we also think of notification. And what we mean by notification, again, it's understanding who will be notified during this particular response, what information are you sharing with those different groups? So take, for example, public health laboratories. Those laboratories may need to notify the FBI, their weapons of mass destruction coordinator if there's a specific threat in place that requires a law enforcement component. 

When we start to think of clinical laboratories, you may need to notify your public health agencies so that there can be ongoing surveillance, there can be case tracking. There is an engagement with epidemiology there as well. So understanding in that preparedness phase who to notify and then in the detection and response phase, really ensuring that you are notifying those key partners, it's critical to this lifecycle of readiness.

When we also think of the ongoing communications for response, we don't just notify and we stop. There's an ongoing communications to track cases, understand the evolution of the disease, and understand what steps need to be taken to mitigate the spread of disease. So the ongoing communications aspect is very critical as well. And throughout our response phase, we never lose sight of quality testing and regulatory compliance. The regulatory space may evolve.

So if we take, for instance, select agents during a particular response, we may have some different requirements for select agents. So instead of transferring out a particular pathogen or destroying it within that seven-day window, there may be other flexibilities from the federal select agent program that allows us to keep those agents for a longer time period or transfer those agents to another institution. So I think keeping track of regulatory requirements and ensure that we're compliant with those regulatory requirements, it's an ongoing aspect of any response.

As I mentioned earlier, the goal of this particular phase, it's timely reporting so that the appropriate treatment can be provided to patients, or the appropriate containment from a public health aspect can be implemented. As always, inventory and supply chain is critical. And monitoring your inventory and ensuring that you've got appropriate supplies on hand for the response, it's critical throughout this phase as well.

In terms of workforce, one of the things that sometimes is overlooked, it's that support for workforce. It's ensuring that the staff are not burned out. How do you rotate staff to avoid burnout, and how do you also maintain a positive work environment and ensure that leadership is always accessible to staff? One of the things that I was really impressed with, whether that was during Zika response, whether it was during the COVID response, it was a manner in which some laboratory directors supported their staff.

One laboratory director in particular ensured that there was a game room. So during break time, staff could go into that game room and unwind and have some downtime. So they were recharged, if you will, to continue to provide quality testing. But they had enough downtime, and they had that critical support of laboratory leadership. We can't forget about those things and the support for workforce during that detection and response phase as well.

I've listed here some of the major events, and I've certainly not captured all of them. But these are the major events that have occurred over the last two decades. And as you can see, we really haven't had a significant break, whether that was 2001 anthrax or 2009 H1N1 pandemic, to present day where we are still dealing with Mpox and also still dealing with the remnants of COVID and other emerging threats. Across all of these responses, one of the things our organization did was really look at how we can coordinate internally during that response phase. 

Back in 2009, we implemented the use of an incident management system, which I briefly described earlier. And that incident management system has been in place at APHL since 2009. It has really helped us to coordinate internally in terms of how we respond to a particular threat and how we support our members in responding to a threat. 

And we bring together every aspect of the organization, whether that's finance, to ensure that we have the resources to do the work, or whether that's a logistics group to procure things for our laboratories, for our members. So again, and I'm happy to share more information on APHL's use of incident management system, but I really believe that this has been pivotal in our ability to have a coordinated response to support our members. 

Following the detection and response phase, it's the recovery phase. And during that recovery phase, I think of it as a return to normalcy, if there's ever such a thing as normalcy in the laboratories. But it's your transition to routine testing. And here again, I emphasize the importance of acknowledging staff and whether that's taking a look at what your budgets are. Do you have an opportunity to formally and financially recognize the staff, then do so. 

If there are no budgets or there are no financial incentives, think of other things that can be done to acknowledge the staff. Is that a certificate? Is that a mention at an all-staff meeting? Is that a publication in a newsletter? How do you acknowledge and recognize the response staff for all of the work that they did? And again, this is beyond the testing personnel. I think of all the medical laboratory professionals who contributed to that response and ensure that they're being acknowledged.

Also, have an ongoing plan for surveillance, especially when we think of public health. Do we move specimens to public health for active and passive surveillance? But what does ongoing surveillance look like? Post-COVID, we see that wastewater surveillance is continued. What do we do for other types of threats? I think we also want to use this recovery phase to review and manage your specimen and your sample inventory. 

And then another aspect of the recovery phase is conducting an after-action review. I think in many instances we essentially negate this after-action review. But the after-action review is really important because it gives us an opportunity to recognize our successes. It also gives us an opportunity to identify areas for improvement. What were some of the challenges that we encountered? How do we improve those challenges, and how do we mitigate it for future threats? 

Some of the things that we have done at APHL, and this is most recently, it was take a look at COVID in general. And we do have a pending report that will be published by APHL and the Rand Corporation. That pending report will be a more comprehensive after-action review of the COVID response. But some of the things that we have done is that we've really taken a look at what were some of the operational challenges and some of the potential solutions during the COVID response? That has been published, and it is linked here for your reference. 

We also took a look at the Lab Response Network, and in general, other networks and how those networks were utilized to respond to COVID. What were some of the challenges? What are still some of the ongoing needs? And then what are some of our ideas or our solutions of how these networks can better evolve to be utilized for broader threat response? 

We've also talked a lot about lessons learned from public health laboratories, and some of our laboratories have shared this in this publication called Creating a Blueprint for the Future. Here they describe, what were some of the lessons learned from the public health labs in that response, and how can we use those lessons for future responses? So I encourage all of you, if you have not — for the laboratories on this line, if you've not yet done an after-action review, this is something that you may want to strongly consider. 

And again, it does not necessarily need to involve every single partner that you worked with during a response. It can be an internal after-action review. So taking a look at your specific laboratory, what were some of the things that went well? What are the areas that you see for improvement? And then what are some of the things that you've identified that needs to move up the chain, if you will? Here is an important opportunity to advocate for your facility and the needs of your facility.

When we think of — so one of the things in terms of conducting that after-action review, I think of, well, what do we do with that information, right? We don't want to just do something for the sake of, let's check a box. We've done it. I think of, what were the lessons that we learned from that response? And once we've got that sort of well understood within our institutions, then let's look at a pathway to implement those lessons learned.

And that pathway can be where you're having to sign new agreements. You may need more — you may need to identify a specific process for recruiting additional workforce. You may need to look at opportunities for retaining your existing workforce. But again, it's really thinking through, what were the key lessons learned from a particular response, and how do we implement those lessons so we're not repeating the same mistakes or we're not faced with the same challenges for the future responses? 

I also think of us recognizing the diversity in testing options in that not everything may come into our laboratories for testing. There's a lot of technology now for at-home testing, recognizing that at home testing may play a role in testing patients or sort of reducing the specimen volume coming into your laboratories. And yes, there may be times when we are missing things within our laboratories, but we have to recognize that testing is evolving. It's not necessarily always the traditional testing when we think of what's going on within a laboratory. But recognize the diversity in testing options and plan for that. Plan for that in terms of, should technologies evolve within your laboratories? Should we look at batch testing and so forth? 

And then another important aspect of that future state is reviewing and updating policies. Are there regulations that need to be improved? Do we need to comment on different types of regulation? Do we need to look at what types of new policies should be placed in the laboratories? And one of the things we circle back to and it comes full cycle, if you think of that readiness cycle, it's the partnerships element as well. It's important that we continue to maintain those partnerships in peacetime or normal laboratory times and not, again, wait for a response to reinvent those same partnerships.

One of the other aspects of that recovery phase, it's informing and educating leadership. And that leadership, again, could be governmental, where you utilize your national laboratory organizations. So whatever you're a member of, how do you engage with that organization and utilize those organizations to be an advocate for you, an advocate for workforce, an advocate for critical equipment, an advocate for a more robust supply chain? So I think we really utilize those after-action reviews to think through, what are the next steps that we can take to be better advocates for our laboratories? 

I emphasize here, again, the investment in workforce. I've been doing this work now for 20-plus years, and I can't emphasize the importance of being able to recruit highly-qualified individuals, but then also being able to retain that qualified workforce. We invest a lot in training and development, but look at other opportunities. How do we expand and broaden the skill set of our existing workforce?

What are some unique programs that we can put in place to ensure that we are putting our best foot forward to retain that qualified workforce? So recruitment is one component, but the retention aspect, it's something that our leaders should be invested in and should actively be engaging the workforce to seek their feedback and input. What can we do to really retain your skill set and continue to make sure that you see that we are invested in your success as well?

At APHL, we received funding from the Centers for Disease Control and Prevention, from CDC for — it's a fellowship and internship program. It's essentially looking at how we strengthen the laboratory workforce. And this link here will take you to our fellowships page, which describes more information on this website about APHL's efforts. It also identifies specific opportunities for fellows and internships. I encourage you to share this with your colleagues across the laboratories, with academic institutions, and other avenues where we can recruit a robust workforce from.

Another item or activity that APHL engaged in, and this is in a post-COVID world — it's the development of what we're calling a Testing Playbook for Biological Emergencies. Our lead authors for this playbook are Mr. Scott Becker, Dr. Jill Taylor, and Dr. Eva King. And they partnered with a number of folks, we think, through Brown University, The Pandemic Center, and they developed what's called this better testing or a Testing Playbook for Biological Emergencies.

The goal of this playbook is to provide US decision makers at the federal level with a clear and evidence-based guide for making effective decisions. And those effective decisions are around the development, implementation, and scale-up of diagnostic testing in an emergent infectious disease. This was really sort of — it came from us being involved in so many responses and thinking through, what are some of the critical questions that should be addressed to help ensure that we've got a robust system in place to respond to the next threat?

At the moment, this is focused on biological emergencies, but I can certainly see this evolving to be larger and encompassing other threats as well. And for those of you who are not familiar with this testing playbook, I've included the link. And there will also be a link in the chat, too. You can certainly review the playbook. And on the website called Better Testing Now, it's an opportunity for you to also comment and give us your feedback. If you believe there are elements missing from this playbook, please provide your comments, and they will be reviewed and addressed.

Some of the resources that I've included here today for discussion and that we utilize on a regular basis — and I want to walk through these resources. So one of them is CDC's Laboratory Outreach Communication System, or LOCS. And during COVID, many of you may recall we first had — CDC first held weekly calls on COVID. Over time, that morphed into more monthly calls. And it's since continued, where now there's these clinical laboratory calls that happen on a monthly basis.

One of the things that was really important during those calls and during, I want to say, during the response was the sharing of timely information with all types of laboratories. Everyone had a pathway to access CDC, had a pathway to access subject matter experts and get their questions addressed. I found those calls immensely useful during the COVID response, and I continue to find them useful as an opportunity to learn about ongoing needs and ongoing successes within the laboratory system. 

The other link that I've included here is an emergency use authorization link from the Food and Drug Administration, or FDA. One of the things that we have been sort of examining, it's how do public health laboratories and other laboratories utilize EUA pathway during emergencies? And so we're spending some more time to understand that and really sort of better figure out how to use the EUA pathway and have a quality test in place to better support testing needs within the public health system.

As I mentioned earlier, we have a continuity of operations plan template. In addition to that COOP template, we have sample exercises on our website. These are all free resources. I encourage you to take a look at them. And if you have questions, you're welcome to contact me as well. There are a number of different types of COOP guidelines. The COOP template that I've included here, it's the one that's specific to public health laboratories, but can certainly be modified for a private clinical laboratory. 

Additionally, CLSI has a number of guidelines. One of their most recent, it's planning for laboratory operations during a disaster. And I encourage you to take a look at that resource. CLSI also maintains a COOP for hospital laboratories, too.

APHL has a number of biothreat resources. We have a group at APHL that spends time developing or thinking through, what are some of the needs of clinical laboratories? What resources can we put in place for those laboratories? And so we have what's called a sentinel laboratory training toolbox that includes that information. And when we say sentinel laboratory, sentinel can have a specific meaning, or it can simply mean —

Excuse me.

--any laboratory performing testing. 

We also have additional resources for biosafety and biosecurity, as well as personnel resources. With that, I'll stop and turn things back over to Alicia. 

We'll take a few minutes to answer as many questions as possible. If we do not get to answer your question today, we'll do our best to answer it via email. That's if you have not submitted that question anonymously. If you have any questions after today, you can send them to — please email them to the OneLab inbox at onelab@cdc.gov. 

And Chris, if you're ready, we'll take — I'll read the first question for you. Take your time. 

Sure. Thank you. I just lost a little of my voice there, but I can address the questions. 

That's OK. "Regarding preparedness, what are your recommendations for hospital clinical labs to manage PUI specimens while maintaining a continuity of operation. Should they stop testing to focus on the PUI testing?"

Thank you for that question, Alicia. No, I don't believe that you should stop your testing. I think part of this is having a process in place for timely referral of those types of specimens and ensuring that you have staff that are trained in the appropriate packaging and shipping so that those specimens can be referred on to another laboratory for further testing.

And that may be your local or state public health laboratory, or it may be another laboratory. But no, I don't believe that you should stop testing. I believe that you should have the right systems in place for referring those specimens from PUIs, and then you continue on with your testing.

Thank you. I'll read the next one. "Can you mention how APHL is working with clinical labs, if any?" 

Well, certainly. So we typically do not, at this association level, we may not work directly with one clinical laboratory, but we would work with large national partner organizations. So for instance, we may work with the American Society for Microbiology. We may also work with the — if you think of ACLA, it's a laboratory — It's the laboratory organization that represents the large commercial laboratories such as Quest Diagnostics, Labcorp, Mayo and ARUP, and so forth.

So we typically work with these large companies, national organizations that represent the clinical laboratories. But when we think of our members, our public health laboratories, they work on a day-to-day basis with clinical laboratories across their jurisdictions. A great example of how they may be working with those laboratories would include, for instance, providing training, wet lab workshops, providing guidance on biosafety. 

But they also work with those laboratories around the College of American Pathologists, the CAP's LPX, where they would provide — they would take and accept the calls from those clinical laboratories. They may even ask the laboratories to package and ship and send the specimens over to them. So on a daily basis, public health laboratories across the US work very closely with clinical laboratories on things such as rule-out and referral testing and as well as providing guidance on biosafety. 

OK, let's see. Let's see if you can just press practices there. "Can you discuss the best practice regarding budgetary preparedness in relationship to emergency response?" 

Sure. And I think this depends on your laboratories. But in general, I think for emergency response, one of the things for budgets that I would think of, it's making sure that you've got sort of a packing and shipping line and understanding that perhaps during a response some things may need to be shipped as category A. So having that appropriate budget for packaging and shipping or a courier system in place that can move your specimens to other laboratories. So that, I think, is a good best practice.

I also think of professional development funds for your laboratories, so for your laboratorians. And what I mean by that is ensuring that you've got budget set aside to train laboratorians on response, like use of different systems during a response, communications, leadership-in-crisis-type activities for as part of your budgets. But think through professional development budgets for your staff in addition to that packaging and shipping.

I also think of having a supplies line. You may need to have additional funds set aside for supplies. You may have an increased capacity need during responses. So making sure you've got a good budget for supplies. Packaging and shipping...professional development...supplies. And I'm also thinking through systems. You may need to make upgrades to your data reporting systems. So what types of budgets should be set aside for a data reporting system as well?

But so I think your supplies or inventory, your leadership or professional development of your personnel, and then your systems, the specimen transport, the courier, and your data reporting are probably the extra elements that need some additional attention. You may also need to have a line dedicated to equipment in that there's a new instrumentation for a particular response, whether that's an automated extraction platform or a new testing platform, you may want to have an instrument line as well. 

But in general, I think ensuring that you've got maybe a rough estimate, an additional 10% or so in your budget, to accommodate those emergency response would be a good best practice to keep in mind.

OK. We have one other question here. The person, 

she's actually — she's working on getting her MLS certification through the alternative route, and she's looking for internships. And so she was wondering if APHL offers any type of internships or if you know of any internships that she could possibly look into? 

Thank you. I believe we have a number of internships listed on our website. So if we go to that fellowships page, you will see a number of opportunities for fellowships and internships. And those internships can be in a public health laboratory as well. And it may also contribute to the requirements for your MLS. But I would definitely encourage you to take a look at APHL's workforce website, which has more information on fellowships and internships. 

OK, and let's see. We have one additional question. "So during an emergency, do APHL play a role to ensure that enough personnel are provided to cope with the workload?" 

So that has been mixed. And I can give an example of where we did that. So during the response to the number of hurricanes that impacted mainly Puerto Rico and US Virgin Islands, APHL played a significant role in that crisis response. And one of our chief activities included providing workforce. And we partnered with a number of organizations. And in fact, APHL directly hired 60-plus personnel to support Puerto Rico. And via contract mechanism, we hired about 12 or so individuals to support the US Virgin Islands.

So we have done that in the past for the responses to the hurricanes, but we did not do that during COVID. Those were handled individually by the jurisdictions. I think it really depends on the mechanisms of funding. So for instance, if a federal agency offered the resources for us to do something like that, APHL would certainly explore it if it meant being able to support that response. 

But again, I think it really depends on the funding at that time. And in the case of the crisis responses in Puerto Rico and US Virgin islands, those responses and the ability to surge personnel, they were resourced by CDC.

OK, thank you. Well, that's all the questions that I see. Thank you, again, Chris, for sharing your knowledge and passion for preparing public health laboratories for potential public health threats. And we look forward to having you again. 

Thank you very much, Alicia. I really enjoyed being with all of you here today. And we have a number of free resources, as I've mentioned. We did not list every single one of them as a resource here in the presentation. But if you visited aphl.org, you would have access to those resources. My contact information is also included on this slide, and I encourage you to reach out if you have any questions or if APHL could provide any support to your institutions.

Thank you for this opportunity, and Happy Medical Laboratory Professionals Week. Thank you for all the great work that you do out there. I really appreciate all of you, and thank you for joining me today.