Module 5: Laboratory Infrastructure

Maputo Declaration

Laboratories are the backbone of the entire public health surveillance system. Correct laboratory diagnosis is essential for treatment and data collection of many diseases. A large barrier to laboratory access in developing countries is the distance between the patient and the laboratory. Many patients cannot afford to make one trip to a clinic for tests, and then make another return trip weeks later (after their specimens have been shipped long distances to be scrutinized) to view their results. To solve this problem, POC tests would be ideal in developing countries. However, POC tests are often unreliable or non-existent for many diseases with high health burdens.(1) For these diseases, traditional laboratory diagnostic procedures are necessary, and lab turn-around time is crucial in determining the patient’s outcome.(2)

In 2008, representatives from many areas of the WHO met together in Maputo, Mozambique to discuss the importance of clinical laboratory enhancement worldwide. They put forth the Maputo Declaration on Strengthening of Laboratory Systems, which called for a more united laboratory system that was integrated in its approach to controlling the burden of priority diseases—HIV, malaria, and tuberculosis.(3)

Objectives of the Maputo meeting included:(4)

In developing countries, there is an increasing need for the improvement of individual labs, as well as a building and reshaping of entire lab networks. This need is increasingly apparent with regard to the AIDS epidemic, as a majority of people with HIV are unaware that they are infected.(5)

Individual Lab Enhancement

The quality of individual laboratories is often assessed using the following criteria:(6)

Laboratories in developing countries often fall short on many of these criteria, compared to laboratories in the developed world. Of particular importance is improved training of laboratory staff. Studies show that in developing countries, the quality of trained staff personnel and their distance from a capital city are positively correlated.(7) This is especially problematic when many citizens live in rural areas. Developing countries also tend to lack mechanisms for assessing laboratory quality.(8) This is problematic because without surveillance of laboratory work, there is no way to ensure the usefulness of the lab’s existence.

Planning a National Laboratory Network

The Association of Public Health Laboratories collaborated with the WHO-Geneva, WHO-Regional Office for Africa, and the CDC to develop the Guidance for Development of National Laboratory Strategic Plans. This document serves as a “guidance tool for country leaders for the development of NLSP and provides information on organizations available to support countries with technical expertise and funding”.(9) The publication helps countries organize themselves as they create an interconnected system of quality laboratories.

Description: http://ajcp.ascpjournals.org/content/134/3/368/F2.large.jpg

http://ajcp.ascpjournals.org/content/134/3/368/F2.expansion.html

The laboratory network that developing countries create should be a tiered referral system (see chart above) that serves patients with its interconnectivity and ability to rapidly disseminate diagnoses.(10) There should be a primary federal reference laboratory linked to multiple regional district laboratories.(11) Standardization across laboratories is critical for easy and fluid communication within the system.

According to an article by experts in the field, important parts of a national plan to develop a network of laboratories in developing countries include:(12)

The establishment of functioning, tiered, quality laboratory systems in developing countries depends on public-private partnerships, political will from the country’s government, and extensive planning.(13) Stakeholders should work together to pool resources and ensure that there are no wasted materials in new lab-building initiatives. The training of lab technicians is also very important in ensuring that labs function properly.(14) Major global health organizations (including the WHO and CDC) continue to create standardized sets of manuals and materials that can be used in training to assure the quality of human resources.(15) It is also important for those involved in building laboratory capacity to advocate for more resources from public and private sources. Without a functioning laboratory system for diagnostic and statistical reporting, public health initiatives in developing countries are blindly attacking health problems with no facts to support their programs.

Case Study: Building Laboratory Infrastructure in Tanzania

Insufficient disease surveillance in many countries in Africa has contributed to a breakdown in the medical system. In Tanzania, the main laboratory network required extensive updating. The slow generation of results was hampering the success of HIV/AIDS interventions and other infectious disease programs. As the AIDS epidemic progressed, Abbot, a global health company, decided to intervene in Tanzania by strengthening the laboratory surveillance system. Abbott has a philanthropic foundation called the Abbott Fund, which financed this project (http://www.abbottfund.org/). Abbott started by renovating the Central Pathology Laboratory in Muhimbili. This renovation included updating equipment, stocking the laboratory with reagents, and supplying the lab with experts to ensure that it ran smoothly. With the help and input of the Tanzanian government, Abbott then started to renovate the 23 other labs across the country.

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Laboratory in Tanzania before Abbott project

Description: http://www.abbottfund.org/images/thumbnails/08b_AF_TanzaniaRegional/08b_AF_TanzaniaRegional_04_1000x800.jpg

 

 

 

 

 

 

 

Laboratory after upgrade (http://www.abbottfund.org/project/17/67/Modernizing-Regional-Level-Labs-in-Tanzania)

Standardization was the focus of laboratory upgrades. Abbott believed that the standardization of the labs would facilitate collaboration and communication between them. Each lab reconstruction cost approximately $500,000. The new labs show great improvements in many areas including a rise in the number of tests performed per year (15,000 to 134,000) and a decrease in the turnaround time (previous average was 3 to 14 days, while the new average is less than 24 hours). The new laboratories must report their activity to the Abbott Fund on a weekly basis so that Abbott can monitor the effectiveness of the program. The most frequent logistical problems that the new laboratories encountered were shortages of trained personnel and reagents needed to conduct tests. The program is constantly being changed and improved to solve these problems in the system—another demonstration of the importance of surveillance in public health programming. One way that Abbott is working to solve the problem of a shortage of health care workers is by funding more than 100 scholarships to the Bugando University College of Health Sciences for medical technologists every year. Not only are these scholarships improving the laboratory staff in the region, but they are also demonstrating to the Tanzanian public that laboratories and public health surveillance is a key part of the health care system.

Information from this case study was adapted from the following article:(16)http://casestudiesforglobalhealth.org/case_study_PDFs/GHCS_30_LabSvcsTanzania.pdf.

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Footnotes

(1) Peeling, R. W., & Mabey, D. (2010). Point-of-care tests for diagnosing infections in the developing world. Retrieved May 29, 2012, from European Society of Clinical Microbiology and Infectious Diseases.

(2) Nkengasong, John N.; Birx, Deborah; Sankalé, Jean-Louis. Challenges in Developing Laboratory Capacity and Infrastructure to Support HIV/AIDS Care Programs. In: Marlink RG, Teitelman ST, eds. From the Ground Up: Building Comprehensive HIV/AIDS Care Programs in Resource-Limited Settings. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation; 2009.

(3)The Maputo Declaration on Strengthening of Laboratory Systems. (2008, January 24). Retrieved May 29, 2012, from World Health Organization.

(4) Ibid.

(5)HIV/AIDS Policy Fact Sheet. (2006, November). Retrieved May 29, 2012, from The Henry J. Kaiser Family Foundation.

(6) Otrompke, J., J.D. (2009, October). Standardizing Solutions to Change the Face of Laboratory Services in Tanzania. Retrieved May 21, 2012, from Alliance for Case Studies for Global Health.

(7) Nkengasong, John N.; Birx, Deborah; Sankalé, Jean-Louis. Challenges in Developing Laboratory Capacity and Infrastructure to Support HIV/AIDS Care Programs. In: Marlink RG, Teitelman ST, eds. From the Ground Up: Building Comprehensive HIV/AIDS Care Programs in Resource-Limited Settings. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation; 2009.

(8) Ibid.

(9) World Health Organization, Centers for Disease Control and Prevention, & Association of Public Health Laboratories. (2008). Guidance for the Development of National Laboratory Strategic Plans. Retrieved May 29, 2012, from Association of Public Health Laboratories.

(10) Nkengasong, John N.; Birx, Deborah; Sankalé, Jean-Louis. Challenges in Developing Laboratory Capacity and Infrastructure to Support HIV/AIDS Care Programs. In: Marlink RG, Teitelman ST, eds. From the Ground Up: Building Comprehensive HIV/AIDS Care Programs in Resource-Limited Settings. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation; 2009.

(11) Ibid.

(12) Ibid.

(13) Ibid.

(14) Ibid.

(15) Ibid.

(16) Otrompke, J., J.D. (2009, October). Standardizing Solutions to Change the Face of Laboratory Services in Tanzania. Retrieved May 21, 2012, from Alliance for Case Studies for Global Health.