Diagnostics Off the Grid: Providing Laboratory Testing...
Transcript of Diagnostics Off the Grid: Providing Laboratory Testing...
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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
Copyright ©2011 Marcia A. Kilsby
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2011 ASCP Annual Meeting/
WASPAlm XXVI World Congress
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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.
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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”
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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.
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Clinical Laboratories
from:
Highly automated with quality systems in
place comparable to those in the United
States.
to:
Rudimentary that lack any type of up-to-
date instrumentation, reagents and
supplies, and often function under
“make-do” conditions.
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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.
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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.
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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
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CASE STUDY
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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
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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.
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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.
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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
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Additional Challenges
� Water
� Biohazard & Chemical Waste Disposal
� Cost of Testing
� Climate� Climate
� Permanent documentation of patient testing
results
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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
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Personal Challenges
Continued
� Understanding the cultural dynamics that
involve clinical diagnostics:involve clinical diagnostics:
� from patients’ perspectives
� from that of other healthcare practitioners
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One of the GREATEST
Challenges
ELECTRICITY!!!!� Available?� Available?
� Voltage ?
� Stability?
� Reliability and Predictability?
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Sharing Glimpses of My
Recent Personal Journey into
Healthcare OutreachHealthcare Outreach
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OPTIONS AND
PRACTICAL SOLUTIONS
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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
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Regular Laboratory Equipment
No municipal power -
Use a generatorUse a generator
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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
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Portable Equipment
� Runs off both electricity or battery pack
� Battery pack must be rechargeable from
� 110v110v
� 220v
� car battery
� solar panel
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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
� Solar PanelCopyright ©2011 Marcia A. Kilsby
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Hemocytometer Use Without
Mouth Pipetting ☺
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LUMIN
(Epi-flourescence Light Source)
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Chemistry
� Albumin
� Calcium
� Creatinine� Creatinine
� Glucose
� Total Bilirubin
� Total Protein
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Hematology
� Hematocrit
� Hemoglobin
� Cell Counts by Hemocytometer � White Blood Cells� White Blood Cells
� Red Blood Cells
� Reticulocytes
� Eosinophils
� Differentials
� Sickle cell screening
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Microbiology
� Gram stains
� Direct Examination of Throat specimens
� Direct Examination of Urethral Pus� Direct Examination of Urethral Pus
� Acid-Fast staining
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Parasitology
� Malaria smears
� Fecal concentrates
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Urinalysis
� Urine chemistries
� Microscopic examinations
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LUMIN®
� Sputums for Tuberculosis
� Acridine orange for malaria
� Any procedure that needs a fluorescent � Any procedure that needs a fluorescent
microscope
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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
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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
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Reagents Continued
� Transport premeasured aliquots:
� Pellet form
� Blister-type packetsBlister-type packets
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Homemade
Pelletized
Reagent
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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)
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Strip Tests
� Should be endorsed:
� In addition to urine chemistries, are
available for:available for:
� Malaria
� HIV
� HBV
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Supplies
� No kimwipes – try locally produced facial
tissues or TP
� Need parafilim – use locally available
plastic wrapplastic wrap
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Insects
� Natural insecticides
� Create moats
� Water� Water
� Oil
� Make “teepees”
� Build insect traps
� Cornmeal for ants
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Water Mote with Fly Deterrent
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Protecting
supplies
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Insect Trap
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Mold
� Use sealed containers
� Make silica gel pouches
Recharge in:Recharge in:
� Microwaves if available
� Sunshine
� Dry heat oven
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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
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Water
� 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
Copyright ©2011 Marcia A. Kilsby
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Solar Still
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Hand
washing
Station
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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In-Country SolutionsIn-Country Solutions
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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Copyright ©2011 Marcia A. Kilsby
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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!!!! ☺
Copyright ©2011 Marcia A. Kilsby
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“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
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SHARE YOUR EXPERTISE
AND
PASSION FOR SERVICE!PASSION FOR SERVICE!
Copyright ©2011 Marcia A. Kilsby
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Thank You for Attending.
I hope YOU were
blessed!blessed!
Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
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www.andrews.edu
www.andrews.edu/cas/mls/research/index.html
www.globalcarepartners.org
Copyright ©2011 Marcia A. Kilsby