Navigating the SARS-CoV-2 Pandemic in North Dakota

Christie Massen PhD, MS, MLS(ASCP)CM

The North Dakota Public Health Laboratory staff before the SARS-CoV-2 pandemic. The laboratory capacity expanded during the pandemic through many critical partnerships.

Being the laboratory director at the North Dakota Department of Health during the SARS-CoV-2 has been rewarding, and the lab has seen plenty of successes and challenges. The laboratory looks very different today than it did at the end of March.

Pre-COVID-19, the North Dakota Public Health Laboratory (NDPHL) would perform an average of 200 tests per day. In mid-May, the laboratory was reporting an average of 2,000 tests per day for SARS-CoV-2 PCR alone, and we are aiming to run over 5,000 tests per day in June. The only way this is possible is through the partnerships that have been created along the way.

In the beginning, like most public health laboratories, we struggled to obtain reagents and consumables to perform SARS-CoV-2 PCR tests. Supply shortages are common in public health laboratories. This was different. For the first time in my laboratory career, I felt the magnitude of a global supply need. During the first few weeks after the virus was identified in the United States, we only had enough reagents to test about 200 people total. We were forced to be very strategic in our criteria for physicians. It quickly became clear that increasing test capacity and reducing turnaround time was critical to effectively respond to the virus.

It was a challenge; we were drowning. We didn’t have adequate resources. Our people worked themselves into exhaustion in an infinite cycle of long days with no rest in sight. We needed help. But, so did everybody else. We did not know how to send out the SOS signal. Even if we did send the request, could it be answered? Then, the tides turned.

Send in the Reinforcements

We received a call from Major Waylon Tomac with the North Dakota National Guard’s 81st Civil Support Team (CST) offering assistance. He reached out to us during one of the most difficult times, and we were relieved to get help. Our previous relationship with the CST, through the Bioterrorism program, allowed us to work quickly and efficiently together. We did not have to waste valuable time getting to know one another; we were able to jump in headfirst and hit the ground running.

The first CST member to show up was Major Aaron Noragaard. Within hours he was here entering demographics. We quickly realized we needed significant reinforcements if we were to mount a sizable defense against the COVID-19 pandemic for our citizens. The formal request was sent up.

First Sergeant Robert Ferderer and other members of the ND National Guard, Army, and Air Force came and helped us immediately. They assisted with processing specimens, identifying resources such as additional laboratory space, facilitating supply orders, building sample collection kits, and solving a multitude of old and new problems. It was this initial partnership and immediate support that allowed us to come up for air and start focusing on the future.

“In mid-May, the laboratory was reporting an average of 2,000 tests per day for SARS-CoV-2 PCR alone, and we are aiming to run over 5,000 tests per day in June. The only way this is possible is through the partnerships that have been created along the way.”

Public Health Lab Coordination

While the National Guard was a pivotal partner, they, like everyone, did not have a secret stash of extraction reagents and consumables tucked away at their warehouse. So, we needed to reach out to another resource—the Northern Plains Consortium (NPC). The NPC is a group of public health laboratory directors and leaders in the upper Midwest. This amazing support system includes North Dakota, South Dakota, Montana, Wyoming, and Idaho. We meet regularly to discuss issues that are affecting our states. Since our state public health laboratories tend to deal with laboratory tests of low volume but of important public health significance, we also share time, resources, and services. For example, the ND Public Health Laboratory offers HIV confirmatory tests to the other states. Other NPC laboratories have assisted North Dakota with sequencing particularly difficult bacterial isolates to help us when our biothreat laboratory needed decontamination. These relationships with other laboratory personnel gave a solid support of resources in times of need.

During one period of time, our operation was coming to a standstill because of a lack of nasopharyngeal swabs. One of our laboratorians reached out to the South Dakota Public Health Laboratory (SDPHL) and discovered that they had extra swabs but didn’t have any extraction kits, so we swapped supplies. This transaction helped move both the NDPHL and the SDPHL forward. We were able to keep collecting samples, and they were able to continue to perform laboratory tests.

Not too long after that, our largest throughput extractor failed, and we needed a replacement immediately. Working with our state’s government leaders, Dr. Tim Southern at the SDPHL was gracious and allowed us to borrow one of their extractors. That night, the CST drove through the night to Pierre, South Dakota, and picked up the extractor. Again, SDPHL and the CST saved the day for us! Unfortunately, that was not the last time we would need an extractor to maintain test capacity.

Sharing Local Resources

As technologies shifted rapidly and new platforms became available, we decided to validate a new assay with higher and more efficient throughput. We had the right analyzer; however, we did not have the correct extractor. Dr. Brett Webb at the North Dakota State University (NDSU) Veterinary Diagnostic Laboratory (VDL) agreed to lend us one of its extractors without hesitation; even going as far as delivering the instruments to us
with consumables. In true professionalism, he trained our team on how to use it onsite! This partnership was critical to ensure our advancement of technologies. In addition, they agreed to perform all rabies tests in North Dakota to help reduce our workload.

With new instruments and increased capacity at our disposal, we turned our sights to increasing laboratory personnel to match our newfound instrument capacity. This is when the next great partnership was formed. Northern Plains Laboratory, a local hospital laboratory, was experiencing decreased test volumes while our test demand was climbing. A contract was established, and the local laboratory started to schedule laboratorians to work shifts within our facility. In addition, laboratorians from all over the state have started working with us to help respond to the crisis. This influx of staff moved the lab to a 24/7 operation.These individuals provided much needed relief for the original laboratory team and continue to aid us in sustaining our test capacity.

With capacity increasing and time running short to complete non-COVID-19 tests, we reached out to the University of North Dakota’s (UND) Medical Laboratory Science (MLS) program to brainstorm some options. Dr. Brooke Solberg agreed to bring equipment into their student laboratory and transform it into a high-complexity CLIA laboratory to help us perform Chlamydia and Gonorrhea Nucleic Acid Amplification tests along with Hepatitis C RNA tests. But, as with everything in this pandemic, we had to shift focus again. They graciously agreed to start performing SARS-CoV-2 PCR for overflow capacity. At this time, we are working to establish this assay in their laboratory and look forward to their continued support in the future.

Future Plans

As we settle into our new normal, we are continually reassessing our operations. The ND National Guard, Army, and Air Force federal emergency orders are expiring soon, and we are working to establish long-term plans. We reached out to Bismarck State College’s Medical Laboratory Technician (MLT) program director, Mari Volk for help. Their students are interested in helping with the pandemic and will assist us with creating collection kits and specimen processing. It is a unique experience to be part of a public health laboratory during a pandemic. We are extremely grateful for the willingness of these future laboratory professionals to step up and engage during a time of crisis. It is a rare opportunity for these students to get to experience the laboratory during a pandemic before they have even entered the workforce!

The vision of our future is expansive. We hope to place North Dakota in a position to better prepare and monitor for novel respiratory viruses. We intend to bring on even more advanced technologies, better laboratory facilities, increased Biosafety level 3 space, and ultimately Biosafety level 4 capabilities. As we look to our future and set our sights high, we are excited to foster even more partnerships and great relationships!

I am incredibly proud of and grateful to all the laboratory professionals I have worked with. They stepped up, worked extensive overtime, and united to provide critical laboratory data for physicians to better diagnose and treat their patients. Their passion for science and herculean efforts have moved North Dakota to second in the nation for tests per capita. We are forever grateful to the individuals who have consistently helped us reach our ever-changing goals again and again.

Christie Massen is Microbiology Director at the North Dakota Department of Health Division of Microbiology in Bismarck.