A week after the 9/11 terror attacks in 2001 killed thousands, letters containing deadly anthrax spores were mailed to news media offices and to two U.S. senators, killing five people and infecting 17 others.
The nation was on high alert, and workers in clinical labs and hospitals across the country were busy testing packages containing powders and chemicals for signs of danger.
Working in a lab for the state of Michigan was microbiologist and future Central Michigan University doctoral student Barbara Jacobson.
"I experienced 9/11 firsthand — all the samples that we got, all the protocols we had to go through."
Fifteen years later, that part of her life became the basis of her doctoral research in CMU's Doctor of Health Administration program.
The results of her investigation into the benefits of a nationwide post-anthrax laboratory education effort have won praise from her dissertation committee.
"This is the most comprehensive study of overall laboratory preparedness in the United States," said Lana Ivanitskaya, a faculty member in the health administration program and Jacobson's dissertation chair.
The anthrax attacks spurred the College of American Pathologists in 2003 to create a national program to train workers in clinical labs how to detect bioterrorism agents and warn others.
More than a thousand clinical labs in the U.S. public health system began taking part in biannual tests to maintain their alertness through a response pyramid:
- Sentinel labs are the first the line of defense against potentially dangerous biological and chemical agents. Their job is to spot suspicious agents and rule them out or send them to more advanced reference labs.
- Reference labs do in-depth analysis to determine if the agent is dangerous.
- National labs make the ruling on what to do.
In 2016, Jacobson, as a CMU doctoral student, wondered if labs were as prepared for a bioterrorism attack as in 2003. Could they recognize a bioterrorism organism, as well? Is the communication tree still healthy?
"I wanted to know if the discipline of following the testing protocols is not as high the further we get away from 9/11 and what the impact was from the cutback of government funds over the years," she said.
"Even today, the state of Michigan laboratory gets about half a dozen suspicious powders a year."
To find answers to her questions, she looked through 15 years of CAP lab surveys.
She found that the preparedness of sentinel labs has remained high, and communication among them has improved, both to around 90 percent. That percentage is encouraging, but in bioterrorism, a 10 percent failure rate could be disastrous, she noted.
The problem is that new technology has replaced many of the old methods, and many laboratories don't have the CAP tests available, more than 40 percent aren't performing them, and others are not recognizing a dangerous agent, Jacobson said.
The speed and accuracy of communication among hospital labs and the correct authorities also need to improve, including more availability and knowledge of whom to call 24/7, wider lab worker participation, safer procedures for packaging and transporting suspect organisms for testing, and larger numbers of well-trained clinicians, she recommended.
Hopes and dreams
"I hope there are some policy changes and that state laboratories will take the initiative to do additional training in recognizing a bioterrorism agent, to develop better relationships with sentinel labs and that somehow taking part in the tests would become mandatory for all labs.
"My pie-in-the-sky goal would be for all laboratories in the United States to participate in some sort of biannual proficiency testing as a requirement of performing basic biological tests. They would have the tools available in their labs at all times."
Jacobson, currently a technical specialist in the microbiology lab of Henry Ford Allegiance Health in Jackson, plans to remain a key player in the defense against bioterrorism by becoming a laboratory manager.