October 04, 2011
Gunturu Revathi, Professor of Microbiology and Consultant Microbiologist in the Pathology Department at the Aga Khan University Hospital, Nairobi, is also a collaborating Scientist at the Kenya Medical Research Institute and visiting faculty of University of Nairobi and Jomo Kenyatta University of Technology, Nairobi. She spoke at the Global Forum during Microbiology Laboratories (hospital and other) and during the hands-on session, Analyzing and Understanding Hospital-level Resistance Data. She is a member of the GARP-Kenya Working Group.
Providing health care services in resource-poor settings is certainly a complex challenge for governments in developing countries. Quality clinical laboratory testing is the key to confirm clinical diagnoses, conduct accurate infectious disease surveillance, and inform and direct public health care policy. Unfortunately, during the current HIV/AIDS crisis in several African countries, the existing laboratory and health care infrastructures are inadequate to meet these needs and have been under benign neglect. Chronic neglect of clinical laboratories has led to a common perception among clinicians in these regions that lab diagnosis is expensive and time consuming.
Usually in primary care clinics or hospitals with minimal-to-no laboratory support, diagnoses of infectious diseases are often made based on the clinical picture. However, managements based purely on such diagnoses can be at times unreliable, ineffective and associated with increased death and chronic disease burden. To mention one example, a lot of patients diagnosed with malaria in such settings have other serious conditions like meningitis, bacteremia or pneumonia, which are not cured by antimalarial treatment. Misdiagnosis results in preventable deaths due to failure to institute the right therapy in time. Similarly, in children with HIV /AIDS, there are at least 4 different lung infections that produce illnesses similar to tuberculosis. In the absence of lab support, doctors tend to treat a lot of them as tuberculosis. Mortality is very high in such children due to delay or mismanagement. The majority of the estimated 12 million annual deaths in sub-Saharan Africa remain uninvestigated.
There are many challenges to quality clinical laboratory testing in Kenya. First, microbiology is perceived as purely a technologist s job that deals with strange materials like culture plates. Pathologists pay scant attention to the subject as it is considered the least glamorous. The most glamorous pathology lies in cancer diagnosis and Medico-legal post mortems. Pathology trainees tend to spend the least possible time in microbiology.
Additionally, until recently major hospitals never cared to employ microbiologist who might be engaged only for a couple of hours on a sessional basis. As such, infectious disease consults are not available even in major hospitals.
Qualified clinical microbiologists are also not available in the country, and the availability of well-trained and skilled staff is a major problem for microbiology lab services in Kenya. Donor funded NGOs and research projects attract the skilled technologists. The migration of skilled personnel from the public sector to higher-paying positions within the private and research sectors further weakens the public sector infrastructure.
In this scenario, interpretation of bacterial cultures and other tests is done purely by technologists with scant clinical knowledge without any supervision by pathologists. Normal body flora growing from cultures of swabs, urine and other specimens, is regularly reported with susceptibility results. Usually microbiology sections are unaware of QC & QA issues, especially the technique and reporting of antibiotic susceptibility tests. Ability to isolate and identify various common bacterial pathogens both in terms of technical competency and availability of tools to work with (antisera, reagents, biochemicals, antibiotic disks etc) is a major problem.
Inadequate numbers of staff overwhelmed by huge numbers of patients are unable to collect and transport suitable patient samples for lab testing. Medical staff often have no training to collect certain important specimens like urine sample by supra-pubic aspiration or Cerebrospinal fluid. Lack of availability or accessibility of microbiology services, and lack of facilities to transport specimens to the lab for rapid processing, are quite daunting challenges in rural areas.
It has been realized recently that limited laboratory capacity is the greatest barrier to effective health care provision in African countries. In response, leading global health care funders decided to finance provision of accurate frontline diagnostic services, even in the poorest countries. The World Bank sponsored East African Public Health Laboratory Network (EAPHLN) Project covering Kenya, Tanzania, Uganda and Rwanda is a bright example of such an initiative heralding a bright future for these countries. The ASM and CDC supported LabCap program is another such ventures. Universities have also realized the importance of a clinical specialty with in internal medicine called clinical infectious diseases. This decade is sure to witness a drastic improvement in capacity of microbiology services and training in sub-Saharan Africa.
