Diagnostics Off the Grid: Providing Laboratory Testing...

Diagnostics Off the Grid:

Providing Laboratory Testing

Without Municipal Power

Marcia A. Kilsby, PhD, MLS (ASCP) cmSBB

Chair, Department of Medical Laboratory Sciences

Andrews University

Berrien Springs, MI 49104

2011 ASCP Annual Meeting/

WASPAlm XXVI World Congress

Objectives

� Predict potential factors that must be

addressed when preparing for laboratory

outreach in developing countries.

� Propose practical solutions in performing � Propose practical solutions in performing

testing without municipal power.

� Design options to dealing with resource

and environmental challenges to providing

quality laboratory services in remote

settings.

Globalization and

Impact on Healthcare

� Infectious diseases recognize no borders� Increased travel

� Manufacturing and transportation of goods

� Importing of foods� Importing of foods

� Health care system changes� Outsourcing

� Digital transmission of images

� Marketing surgical options

� More knowledgeable patients

� Renewed sense that we live in “one shared world”

Laboratories in

Developing Countries

� Many countries do have progressive

clinical laboratories in capitals and, in

some instances, other large cities.some instances, other large cities.

� Rural situations maybe vastly

different.

Clinical Laboratories

Highly automated with quality systems in

place comparable to those in the United

States.

Rudimentary that lack any type of up-to-

date instrumentation, reagents and

supplies, and often function under

“make-do” conditions.

Laboratory Services

Delivery

Significant difference from those in the

developed world is inconsistency in quality and

sophistication of the laboratories services sophistication of the laboratories services

within each country.

Laboratory Personnel

� Key differences:

� Education

� In many countries training is based on diploma programs, two or three years in length.length.

� Universities are now initiating baccalaureate degree programs.

� Often there are no national standards or accrediting bodies.

� Quality of the education is based on the institution.

Laboratory Personnel Continued

� Staffing

� Large facilities – personnel better educated

� Rural – may have only basic on-the-job training with no formal education for the position. Note: there are exceptions.

� Resources

CASE STUDY

Case Study Scenario

� A team is setting up a new clinic in a remote

area of equatorial Africa

� The closest medical facility is five hours away

in a four-wheel drive vehicle in the non-rainy in a four-wheel drive vehicle in the non-rainy

season (inaccessible during the rainy season)

from the sight selected

� Malaria, bacterial meningitis, and intestinal

parasites are endemic

Case Study Scenario

� Identify the key diagnostic tests that need to

be performed.

� List the equipment required to perform those

tests.tests.

� If the equipment requires electricity,

determine how the equipment will be

powered.

� List all reagents and supplies necessary to

perform those tests.

Case Study Scenario

Continued

� If the testing requires standards and controls,

determine where they will be procured,

transported, and maintained.transported, and maintained.

� Determine how suitable water for testing will

be obtained.

� Establish a biohazardous waste disposal plan.

Challenges To Consider

In Outreach Ventures

� Length of Stay – short term, long term

� Facility or “lack thereof”

� Equipment – What is available on site and is � Equipment – What is available on site and is

it functional?

� Reagents, Standards, Controls

� Resupply potential in country

� Supplies /Disposables

� Transportation/Airline regulations

Additional Challenges

� Water

� Biohazard & Chemical Waste Disposal

� Cost of Testing

� Climate� Climate

� Permanent documentation of patient testing

results

Personal Challenges

� Our own passion for “laboratory testing

perfection”

� Tolerance for dealing with the unexpected

and the absence of the “comforts of and the absence of the “comforts of

home”

� Tolerance for the presence of “critters”

� Ability to be flexible and non-judgmental

Personal Challenges

Continued

� Understanding the cultural dynamics that

involve clinical diagnostics:involve clinical diagnostics:

� from patients’ perspectives

� from that of other healthcare practitioners

One of the GREATEST

Challenges

ELECTRICITY!!!!� Available?� Available?

� Voltage ?

� Stability?

� Reliability and Predictability?

Sharing Glimpses of My

Recent Personal Journey into

Healthcare OutreachHealthcare Outreach

OPTIONS AND

PRACTICAL SOLUTIONS

Point of Care Equipment

� Advantages� Easy to use

� Small and portable

� Uses reagent cartridges or stripsUses reagent cartridges or strips

� Concerns� Availability of cartridges/strips in country

� Cost per test

� Stability in conditions of extreme temperature and humidity

� Management of who is performing the testing

Regular Laboratory Equipment

No municipal power -

Use a generatorUse a generator

Generators

� Determine size of generator necessary to

yield the power required

� Check for availability and COST of the

fuelfuel

� Establish whether a power conditioner is

needed

� Do NOT get the biggest generator

available – right size it

Portable Equipment

� Runs off both electricity or battery pack

� Battery pack must be rechargeable from

� 110v110v

� 220v

� car battery

� solar panel

Portable Laboratory

Instrumentation Assemblage

� Microscope with Lumin®

� Hematocrit Centrifuge

� Large Centrifuge – 8 well, 15ml capacity

� Hand-Cranked Centrifuge� Hand-Cranked Centrifuge

� Hemocytometer

� Cell (Talley) Counter

� Colorimeter

� Glucometer

� Rechargeable Battery

Hemocytometer Use Without

Mouth Pipetting ☺

(Epi-flourescence Light Source)

Chemistry

� Albumin

� Calcium

� Creatinine� Creatinine

� Glucose

� Total Bilirubin

� Total Protein

Hematology

� Hematocrit

� Hemoglobin

� Cell Counts by Hemocytometer � White Blood Cells� White Blood Cells

� Red Blood Cells

� Reticulocytes

� Eosinophils

� Differentials

� Sickle cell screening

Microbiology

� Gram stains

� Direct Examination of Throat specimens

� Direct Examination of Urethral Pus� Direct Examination of Urethral Pus

� Acid-Fast staining

Parasitology

� Malaria smears

� Fecal concentrates

Urinalysis

� Urine chemistries

� Microscopic examinations

LUMIN®

� Sputums for Tuberculosis

� Acridine orange for malaria

� Any procedure that needs a fluorescent � Any procedure that needs a fluorescent

microscope

Reagents

� Determine if equipment can handle

open source reagents if proprietary

reagents are unavailable

� Use Reagent Packs/Kits� Use Reagent Packs/Kits

� Find in country

� Transport from the U.S.

� Often bulky

� Subject to luggage weight restrictions

Reagents Continued

� Make from scratch on site

� Requires in country availability of basic chemicals if regulations prevent transportation of some chemicals in transportation of some chemicals in passenger luggage

� Involves time to find the sources

� May require electronic balance for measuring ingredients

� Might be able to use “Dash, pinch, smidgeon” pre-determined formula

Reagents Continued

� Transport premeasured aliquots:

� Pellet form

� Blister-type packetsBlister-type packets

Homemade

Pelletized

Reagent

Reagent Controls and

Standards

� Transport from the U.S.� Problem with transporting blood products� Problem with transporting blood products

� Make own standards

� (for some analytes this is virtually impossible)

Strip Tests

� Should be endorsed:

� In addition to urine chemistries, are

available for:available for:

� Malaria

� HIV

� HBV

Supplies

� No kimwipes – try locally produced facial

tissues or TP

� Need parafilim – use locally available

plastic wrapplastic wrap

Insects

� Natural insecticides

� Create moats

� Water� Water

� Oil

� Make “teepees”

� Build insect traps

� Cornmeal for ants

Water Mote with Fly Deterrent

Protecting

supplies

Insect Trap

� Use sealed containers

� Make silica gel pouches

Recharge in:Recharge in:

� Microwaves if available

� Sunshine

� Dry heat oven

Biohazard Waste

� Use available rigid plastic containers –

soft drink or water bottles

� Fill with bleach water before disposableFill with bleach water before disposable

� Build an incinerator

� For reagents and controls:

� Deionized water

� frequently not available economically

� If available, volumes insufficient� If available, volumes insufficient

� Reverse osmosis water

� Solar still water

� Local bottled filtered water

� Works for most basic testing reagents

� Not acceptable for calcium testing

Solar Still

washing

Station

In-Country SolutionsIn-Country Solutions

Outreach Opportunities

� Mission trips sponsored by:

� Churches

� Humanitarian groups

� Physicians

� Educational activities:� Educational activities:

� Workshops

� Train-the-trainer sessions

� Academic Institutions in developing countries

� Consultation work

� International outreach initiatives with American professional organizations, such as ASCP!!!! ☺

“Sometimes we never know when or how

our work will ultimately affect the lives of

others.”

Kathy BrysonKathy Bryson

Director

Servants in Faith and Technology

Lineville, AL

SHARE YOUR EXPERTISE

PASSION FOR SERVICE!PASSION FOR SERVICE!

Thank You for Attending.

I hope YOU were

blessed!blessed!

Marcia A. Kilsby

www.andrews.edu

www.andrews.edu/cas/mls/research/index.html

www.globalcarepartners.org

Diagnostics Off the Grid: Providing Laboratory Testing...

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