Lessons From D.C.’s Botched Zika Surveillance Program

Once again, we are reminded that our scientific and public health infrastructure is not some massive edifice, but is usually a handful of people operating with very limited budgets. Which can lead to some real problems (boldface mine):

When Anthony Tran took over the District’s public health lab late last year, he had a feeling something was wrong with its testing for the Zika virus. He had just come from the public health lab in New York City, where technicians had been finding markers for Zika in the blood of arriving travelers almost every day. In the smaller, but still international, city of Washington, the same test was negative — every time.

Soon, U.S. health officials joined in Tran’s concern: Samples supplied by the federal government of the frightening, mosquito-borne virus that were tested in the lab as a control were appearing as if they contained no virus….

There were two types of solution the District could have purchased to conduct a phase of the test. One bottle came marked with a “D,” for diluted, and the other with a “U”, for undiluted. D.C. lab workers had purchased the diluted version, Tran said, and then mistakenly watered it down as if it was the more concentrated one, weakening the ability to detect for Zika.

For a public health lab to commit such an error once would be an embarrassment in the high-stakes testing of Zika, which has potentially devastating consequences for pregnant women, scientists and federal health officials say. That the District lab — which is also a first line of defense in screening bioterrorism threats — repeated the mistake daily, and without anyone catching it for more than six months, amounts to a more systemic and worrisome failure, experts said.

Interviews and public documents show that the debacle unfolded over a period of months last year in which the District lab was in a state of turmoil — understaffed, lacking permanent leadership, spread thin on competing projects, and relying on new employees to test for the emerging public health threat in Zika.

“A relatively inexperienced staff and a lack of leadership — that’s a bad combination,” said Kelly Wroblewski, director of infectious diseases for the Association of Public Health Laboratories, which works to safeguard the integrity of public health labs nationwide. “The positive here is that the lab does have new leadership and he caught the error quickly, even though the situation is already really, very unfortunate.”

In the year before it confronted Zika, the public health lab was shedding its most experienced staff — for a variety of reasons.

Former director Alpha Diallo, a native of Guinea, left to fight Ebola in Africa. The lab’s head of virology, Anicet Dahourou, and its head of microbiology, Morris Blaylock, also resigned and took jobs with the CDC in Atlanta.

In March 2016, with Zika as a looming threat, three of the lab’s six quality assurance jobs were vacant

Blaylock said the loss of the lab’s virology director was a major gap, and any sustained campaign of virus testing would have exposed weaknesses in the team’s staffing.

We could deal with an emergency response, we could manage it for a short time, but anything long-term, it was going to wear down that team because it was so short-staffed,” he said. “I know they were trying to get personnel on board, I do know that was the primary challenge.”

When a team is understaffed and overworked, stupid mistakes that ordinarily would be caught are far more likely to be missed. Moreover, when there are a lot of really inexperienced people, they are often reluctant to call bullshit when that’s exactly what needs to happen–experience gives you the confidence to not ignore things that ‘seem weird.’

But I’m sure the early proposals of the Trump administration to cut the CDC’s budget by over twelve percent will fix this. Or something.

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