by Jill Sakai, PhD, writer
Myra Kunas, MS, became the interim director of the Minnesota Public Health Laboratory on May 1, fewer than two months after the first cases of COVID-19 were confirmed in the state. She didn’t expect taking the helm in the early stages of a pandemic would be easy. Fortunately, she had experience stepping into difficult situations: Just a few months after becoming assistant division director of the laboratory in 2015, an internal situation unfolded that initiated a year of investigations, press releases and meetings with the governor’s office.
“There’s never an ideal situation. Mistakes are always going to happen,” Kunas said. “It’s just part of leadership. You make mistakes, and you learn from them, pull yourself up and keep moving forward.”
The COVID-19 pandemic has hit public health laboratories everywhere with an unforgiving combination of intense demands, logistical challenges and heightened scrutiny from officials and the public alike. For laboratory leaders, the fundamental goals have not changed: Oversee the laboratory’s staff and operations, and make sure the needed work gets done in a safe and efficient manner. But the pandemic response has forced a re-examination of the leadership roles, skills and strategies needed to carry public health laboratories through the 21st century.
A New Century
The anthrax attacks in 2001 helped usher in a new era of responsiveness and emergency preparedness for public health laboratories. Suddenly, laboratories were faced with demanding levels of round-the-clock, high-stakes testing.
"Everybody needed to know the answer ASAP,” said Andrew Cannons, PhD, HCLD(ABB), director of the Bureau of Public Health Laboratories in Tampa, Florida. “If that powder contained anthrax, you knew somebody was exposed and had to be treated, so you basically needed a 24/7 operation.”
From this involvement has emerged a new model in which public health laboratories must be prepared to respond to large-scale incidents alongside new partners, such as law enforcement and first responders. For the Louisville Metro Health Department Laboratory in Kentucky, director Leslie Wolf, PhD, HCLD(ABB), said, “that was our foray into learning about incident command structure and the National Incident Management System.” These added responsibilities reinforce the importance of both new and traditional collaborations to be ready for the inevitable next public health crisis. “The job is becoming too big for a public health [laboratory] to carry on its back,” Wolf said. “We keep our core services, but we add on these layers of partnerships and collaborations.”
Parts of the COVID-19 pandemic carry echoes of the anthrax response, Cannons said, especially in some of the early fears and uncertainty and the need to ramp up high-volume testing capacity very quickly. But COVID-19 has reached a scope and duration that today’s public health leaders have never before confronted. “Public health laboratories were not structured well [then] to meet those high throughput testing demands. Twenty years later, we’re facing the same demand with COVID-19,” said Mike Pentella, PhD, MS, D(ABMM), director of the State Hygienic Laboratory at the University of Iowa. “How do you maintain high throughput capacity when you only need it every 20 years?”
That challenge is further complicated by the huge changes in testing technology seen in the past two decades, notably a massive expansion of molecular detection methods and next generation sequencing. The larger menu of potential testing options can enable rapid turnaround and higher throughput workflows, but can also constrain laboratories to chosen testing platforms and supply chains. What’s more, federal and state funding for public health laboratories has not kept pace with increasing demands, even as it becomes more imperative to try to prepare for whatever might be just around the corner.
At the Helm
One key role of the laboratory director is to balance the multitude of external pressures—from federal officials, state government, and state and local health departments, sometimes simultaneously—with getting the job done. Laboratories are facing unusually heavy political pressure right now, making it extra challenging to buffer those outside pressures and meet demand without overwhelming the laboratory staff.
“I feel like my role as lab director is first to make sure my people are okay, because they’ve been asked to do a lot, and make sure they have what they need,” said Wolf. “Then, trying to take care of other things that come along so they can focus on what we’ve asked them to do in the laboratory and aren’t overburdened.”
The current COVID-shaped spotlight on public health means that it is more important than ever for directors to advocate for the importance of public health laboratories and showcase their value and expertise, Pentella argues. “We are now recognized for what we’re doing to support our states. And we have to use that platform well, to make others in our state recognize the importance of a public health laboratory. We can’t squander this opportunity,” he said.
Much of that work is done through building relationships and strengthening collaborations. When reflecting on the challenges of managing current and past outbreaks, many laboratory directors cite the importance of strong local and regional networks. When the Minnesota Public Health Laboratory was forced to evacuate in May on extremely short notice due to civil unrest, the staff were able to redirect all their incoming samples to the Mayo Clinic in Rochester, a few hours away. In Louisville, where prior to COVID-19 the laboratory did not perform routine respiratory testing, Wolf arranged to get samples from nearby laboratories to complete COVID-19 test validation for an emergency use authorization. The Fairfax County Public Health Laboratory was able to obtain point-of-care molecular testing equipment from the Virginia Division of Consolidated Laboratory Services (DCLS) and a mobile laboratory unit from the county fire and rescue department to host community events and conduct point prevalence surveys.
Just knowing there is someone else to call on can be a huge mental boon, says Deborah Severson, BSMT(ASCP), director of the Fairfax County Public Health Laboratory. The collaborative spirit between the county laboratory and DCLS is “just phenomenal,” she said. “If they need help, we’re here. If we need help, they’re there.”
Within the laboratory, the director must keep a finger on the pulse of the people and processes that keep everything running. It is critical to know the ins and outs of the laboratory workflow to make smart decisions.
Kunas noted the value of being able to step back for perspective on where—and how—to improve. “The space that we normally use to accession samples is tight, and social distancing was hard to achieve. Our staff talked for a long time about moving on really high surge days into our training lab, a larger space where everything’s on wheels so we can flex it a lot better. There was conversation and conversation for weeks, and nothing was changing,” she said. Kunas brought in a facilitator to talk through the workflow and create a project plan. At first, she said, people were upset by the outside intervention, but she ensured that the members of the team that would be using the space were part of the conversations. In two weeks, they had a plan in place, and by week three the changes were made.
Especially during stressful times, transparency, honesty and open lines of communication are essential for directors, said Denise Toney, PhD, HCLD, laboratory director of DCLS. “We don’t have all the answers. I think as long as you let people know what you’re doing, why you’re doing things, and that you’re making the best decisions you can based on the information that you have, they will trust you,” she said. “And if you make wrong decisions, fix them quickly.”
That trust from staff and partners needs to be earned, Cannons said, and it goes both ways. “I think a leader has to know their limitations,” he said. “I don’t profess to know everything about public health or in the lab, but I know who to turn to.”
Often, the best advice comes from within the laboratory. “You have something to learn from everyone on your staff,” Pentella said. Prior to the pandemic, he held quarterly listening lunches with randomly selected staff from across all areas of the laboratory. Too often, he says, the director can be one of the last people to hear about a problem. “A director has to realize that when somebody is telling you about something that you may not want to hear, it’s really important information to you. It’s not personal,” he said. “To do your job well, listen, and try to make improvements where you can. You can’t solve every problem. Solve the ones you can. But most importantly, listen to people.”
Of course, any laboratory is only as good as the people who work there. Wolf views looking out for her staff’s safety and wellbeing as one of her most important roles. “One of my concerns during this response has been watching for people burning out. We feel like we’ve been running a race for a really long time,” she said. It is critical to acknowledge that everyone is coping with many burdens, both in and out of the laboratory.
Severson agreed. “My staff is so dedicated and committed. They come in early and stay late to ensure that all testing is completed and results issued the same day. I worry that it’s going to take a toll on them and they’re not going to know it,” she said. She has been juggling responsibilities to be able to reduce workloads in the past few months and give her staff weekends mostly off.
“I think the hardest thing as a lab director is finding that balance where you don’t burn out your staff, but yet you meet all the expectations coming from above you. It’s such a fine line. Sometimes we do it really right, and sometimes we don’t. And when we don’t, I think you have to take a pause, rethink it, back down and go at it again,” Toney said. “You just have to realize that your people are more important than the deadlines.”
Many laboratorians have found small ways to give day-to-day life at work a sense of normalcy and fun. Socially distanced outdoor group lunches and break rooms stocked with snacks and drinks can help provide camaraderie in the midst of a stressful schedule. Severson even brought in her golden retriever puppy for some pet therapy. “We dressed him up in a lab coat, and I put a mask on him,” she said. “My staff could come outside and sit in the grass with him and play with him as a little break.”
It is also important to take the time and effort to recognize successes, Kunas said. “It’s much more difficult now when you can’t have a cake in your lobby or something. But being creative about celebrating successes is so important, especially when everything is going a mile a minute.”
Some laboratories have been able to hire new staff to ease workloads. Virginia has added both scientific and support staff across many areas, including testing, sample accessioning, data entry and reporting. They also extended the workday and workweek to handle higher volumes.
But finding, hiring and training staff all take time, which was precious in the early days of the pandemic response. To accelerate the process, the Virginia team started by reaching out to former employees, recent retirees and others who would be familiar with the laboratory and its work environment, Toney said. In addition to typical job posting venues, they used word of mouth, current employees’ personal networks and social media to find candidates. For non-technical roles, they tapped people who suddenly found themselves under- or unemployed in other fields due to the pandemic. DCLS also adjusted the usual onboarding structure, designating staff for training and focusing on very specific tasks to streamline the process once new hires were in the door.
A common challenge when hiring in the public sector is salary competitiveness. “Oftentimes, the private sector has the ability to offer sign-on bonuses and other kinds of incentives that the public sector doesn’t have the ability to do,” Toney said. That challenge has been exacerbated during the pandemic, when other laboratories and biotechnology companies are recruiting heavily as well. However, the best candidates can recognize that there is more to public health than compensation packages.
“We’ve had great public visibility for the work that the state lab is doing, which has definitely helped show the importance of our contributions to COVID testing for the Commonwealth,” she said.
Looking back through the history of science, Pentella said, there are pivot points where a single event or advance redefined the trajectory of a field. He believes we are living through one of those moments now. The need for more and faster testing is driving advances in PCR assays and antigen tests. Public health laboratories have adopted new strategies to increase capacity and adapt to changing science, demands and policies. And many of those adaptations are likely to color future responses.
Several laboratories have refined their workflows, increased automation and upgraded laboratory information management systems to improve throughput and efficiency and reduce errors. “I think when you’re not being pushed to do more with less, sometimes it’s easy to just continue what you’re doing,” Toney said. “We have brought in automation that will allow us to continue to do COVID testing in a very high throughput, efficient manner now, and later apply it to testing for other infectious diseases.” She also expects to see more virtual meetings, briefer communications and perhaps even remote workers after the pandemic eases.
Pentella hopes that laboratories will maintain the local and regional networks they have built during the COVID-19 response. “The duration and scope of the pandemic have exposed the ongoing shortcomings in public health laboratories’ reliance on contract laboratories to provide testing capacity in a surge. Regionalization could provide scalable capacity that would improve both responsiveness and efficiency.”
But for laboratory directors, some of the most lasting lessons from the pandemic may be the ability to embrace the unknown. “We’re asked to do things that we’ve never been asked to do before. And we’re asked to do it faster with less,” Severson said. Planning is critical, of course, but it is imperative to recognize the limits of planning. “When something as huge as this coronavirus comes, we don’t have the resources to plan for that,” Kunas said. “But as a leader in public health, you need to recognize those limits and what you can do within the boundaries of your resources. Just take it day by day.”
For Toney, one of the strongest lessons from the pandemic is to remember the power of gratitude. “COVID has created a situation where we’re more mindful of those around us. We’re all tired and we’re all stressed,” she said. “Sometimes just a simple ‘thank you’ goes a long way.”