by DRWG members Andrew Ramsay and Emma Back
The work of the CGD Drug Resistance Working Group has been focused on some of the major diseases of poverty – such as TB, malaria, pneumonia and cholera – that impact so disastrously upon the human and economic development of poorer countries. In its analysis of what drives drug resistance across the world, the Working Group has also looked at some of the most neglected aspects of developing country health services.
Laboratories are perhaps the most neglected of all health system components in developing countries, and have been termed the "Achilles Heel" of global efforts to combat infectious diseases.1 Investment in developing country health infrastructure is more often focused on hospitals and clinics than on laboratories; while investment in human resources for health is frequently targeted at expanding cadres of doctors, nurses and midwives. Data from the WHO Global Atlas of the Health Workforce suggests that, in many developing countries – particularly across Africa – the numbers of laboratory health workers are critically low. Rwanda, for example, had 39 laboratory health workers nationwide in 2004, while Senegal had 66. Many laboratories – particularly those at district hospital level or below – lack not only skilled staff but even the most basic equipment. As a result, in most district hospitals across Africa, there is very little capacity even to isolate and identify bacterial pathogens let alone conduct quality-assured drug susceptibility testing.
Nevertheless, laboratories are central to effective patient care – and to the management of drug resistance. Where clinical diagnoses are not backed by laboratory tests, patients may receive unnecessary or inappropriate medicines. Where patients do not respond to treatment, drug susceptibility testing (for example, using basic microbiological techniques, as supported by WHONET – see guest column in the May edition of this e-newsletter) can determine which drug to use next. Laboratories can also monitor trends in such testing over time, which aids drug resistance surveillance. Without such routine monitoring, drug resistance data in many countries are patchy, being derived from discrete field studies or generated by reference laboratories that test limited and potentially biased selections of samples. The lack of monitoring also increases the threat to patient safety presented by drug resistance in clinical settings, as recognized by WHO’s 3rd Global Patient Safety Challenge, to be launched in 2010.
Thankfully, the poor state of medical laboratory services, particularly in Sub-Saharan Africa, is becoming more widely recognized – as is the need to find innovative ways to end the neglect.2-5 Most efforts have been disease-specific. Indeed WHO has accredited specific laboratories for the detection of many diseases, including polio, measles, influenza, and drug-resistant TB.
There are promising signs of increasing collaboration across disease communities. In January 2008, representatives of African governments, professional associations, multilateral agencies and others agreed in The Maputo Declaration on the need to strengthen laboratory systems. This declaration emphasized the need to integrate laboratory support for HIV, TB and malaria programs. The African Regional HIV/AIDS Network for Public Health Laboratories decided at their meeting in September 2008 to broaden its scope beyond HIV/AIDS and associated diseases, to become a cross-disease network of laboratories to be incorporated through WHO/AFRO’s accreditation scheme. This e-newsletter recently described (link to December 2008 guest column) a World Bank multi-disease laboratory strengthening project for diagnosis, management, and surveillance of TB and other communicable diseases. Activities are expected to begin in Kenya, Tanzania and Uganda in early 2010.
For those concerned with drug resistance, these steps are encouraging. But more is required. A system is needed that will develop and network laboratories capable of detecting a variety of drug susceptible and drug resistant strains of pathogens. This will need to be sustained over the longer term, as advanced technologies come on stream or are translated to lower levels in the system – i.e. closer to the point of care, where they can inform the management of drug resistant disease as well as simply detecting it. It will be important to ensure that both public and private laboratories are undertaking coherent and consistent approaches to drug susceptibility testing and related data collection.
As a first step, the global health community and their partners in developing countries must correct previous eras of neglect and invest in strengthening public health laboratory capacity. Second, existing and planned laboratory strengthening initiatives – such as the Global Laboratory Initiative (GLI) for TB, infectious disease laboratory fellowships such as those supported by CDC and Eli Lilly, and the World Bank’s planned laboratory strengthening program – should aim to work across diseases and address issues of drug resistance. Third, efforts should be made to incorporate national public health laboratory systems into cross-border information sharing and surveillance initiatives, including those specific to drug resistance. This will help ensure that developing country laboratories are better positioned to contribute to the effective care of patients with drug resistant disease and to the collection of better data on drug resistance – locally, regionally and globally.
- Berkelman R, Cassell G, Specter S, Hamburg M, Klugman K. The "Achilles Heel" of Global efforts to Combat Infectious Diseases. Clinical Infectious Diseases 2006; 42: 1503.
- Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA. Laboratory Medicine in Africa: A Barrier to Effective Care. Clinical Infectious Diseases 2006; 42: 377-82.
- Bates I, Maitland K. Are Laboratory Services Coming of Age in Sub-Saharan Africa? Clinical Infectious Diseases 2006; 42: 383-4.
- Okeke IN. Diagnostic Insufficiency in Africa. Clinical Infectious Diseases 2006; 42: 1501-2
- Muula AS, Maseko FC. Medical Laboratory Services in Africa Deserve More. Clinical Infectious Diseases 2006; 42: 1503.