How to Prepare for a Pandemic: Invest in Public Health Labs
The ongoing COVID-19 crisis serves as a stark reminder that microbes are unpredictable, and pandemic responses rarely unfold according to plan. Even countries with the most advanced infrastructure struggle with tracking cases and supply chain shortages, especially when confronted with novel pathogens and rapidly evolving variants. In the face of much uncertainty, forward-looking measures that improve the ability and capacity to prepare for future pandemics are critical.
ASM's Global Public Health Programs (GPHP) design and implement lab capacity-building programs around the globe, particularly in countries with limited resources. These programs enable local laboratory professionals to effectively respond to a wide array of diseases of public health significance amid rapidly changing circumstances. "Lab capacity" refers to the ability to effectively and reliably operate microbiology-related programs, which is directly dependent upon the lab's access to basic resources and technology as well as properly trained and uniquely skilled personnel. Therefore, GPHP prioritizes training technologists and leadership to perform proper diagnostic techniques and identify supply, equipment and resource gaps that may impede performance. This is key to implementing quality management systems, external quality assessment systems and biosafety and biosecurity protocols to ensure standard laboratory practices.
Traditionally, when it comes to infectious disease, governments and donors have invested more heavily in treatment and prevention at point-of-care facilities than in laboratory capacity. Yet, successful GPHP lab capacity-building programs have demonstrated throughout the COVID-19 pandemic that the impacts of strengthening lab capacity are far-reaching. Prior ASM investments in Mozambique and Ethiopia enabled both countries to rapidly pivot to commence their respective COVID-19 responses. By having biosafety and reporting measures already in place, these countries are poised to collect and share data to shape national protocols and the global response to the pandemic.
"Obviously, there are a lot of challenges, especially in resource-limited countries, but we must keep going. We must be part of the solution," said Amete Mihret Teshale, a microbiologist at the Ethiopian Public Health Institute (EPHI) who participated in ASM's hands-on training. "Once we are equipped with the required knowledge and skills in our professions, we will have a lifelong benefit that no one can take from us."
Empowering Ethiopian Experts
Since 2016, ASM has collaborated with CDC-Ethiopia and EPHI to control the spread of antimicrobial resistance (AMR) through developing and implementing Ethiopia's first AMR Surveillance Plan. ASM consultants and partners mentored staff at 4 sentinel sites and 16 pilot surveillance laboratories, and through the virtual Extension for Community Healthcare Outcomes (ECHO) training program. Though originally managed by ASM, the ECHO program "empowered Ethiopian experts to lead the program as facilitators, subject matter experts and coordinators," said Estifanos Tsige, team lead at EPHI's Clinical Bacteriology and Mycology Reference Laboratory. "This is one of the biggest changes we noticed in our laboratory."
ASM also worked with the National Reference Laboratory (NRL) and 2 regional reference laboratories in Adama and Bahir-Dar to improve quality management. ASM's stepwise quality implementation helped EPHI's NRL to achieve and maintain accreditation by the country's International Laboratory Accreditation Cooperation (ILAC)-affiliated accrediting body. "This helps us to be recognized as a good national reference laboratory by local and international collaborators," Tsige explained. Moreover, the NRL strengthened its ability to detect and report outbreaks as part of emergency management. Ethiopia's NRL has gone on to train additional labs, which are now serving as COVID-19 testing centers.
"A Culture of Quality" in Mozambique
"ASM is the backbone of microbiology in Ethiopia." - Amete Mihret Teshale, ASM Young Ambassador to Ethiopia
ASM and partners began work with the Mozambique's regional tuberculosis reference laboratories (RTRLs) to adopt new diagnostic standards after TB was declared a national emergency in 2015. At the time, only 3 RTRLs located in the cities of Maputo, Beira and Nampula were capable of growing TB cultures. Working with these designated "champion" laboratories between 2014-2020, ASM helped establish best practices for important procedures like drug susceptibility testing on first-line TB drugs and line probe assay.
The ASM TB mentoring program yielded rapid and positive results at the Nampula RTRL, moving from 1 star to 4 stars in the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) system in only 9 months. ASM mentoring also included support in the implementation of a diagnostic algorithm for TB testing; standardization of management and technical standard operating procedures (SOPs); development of technical assistance manuals addressing quality and safety; and publication of a client handbook. Now, each of these 3 RTRLs has helped to train over 10 provincial, central and district hospital laboratories, to increase diagnostic accuracy and accessibility.
ASM's training and support created "a culture of quality" that is observed in all routine lab activities and implemented in public health emergencies, said Dr. Sofia Viegas, Director of Public Health Laboratories at the National Institute of Health (INS) of Mozambique. Both the National TB Reference Lab and TB Reference Lab in Nampula have achieved ISO15189 accreditation. During the pandemic, Mozambique's TB molecular equipment was used for COVID-19 testing, and the lab has built an information technology (IT) staff to support the implementation of the COVID-19 Laboratory Information System country-wide.
Why Invest in Labs
Public health laboratories are critical for disease surveillance, control and prevention. Furthermore, local, accurate and timely diagnoses translate to measurable improvement in patient care, and ultimately decrease morbidity and mortality. Historically speaking, public health labs have been largely overlooked and underfunded. However, global public health crises, including AIDS and COVID-19, have starkly highlighted the need for increased advocacy and resources to improve lab capacity worldwide. The end goal is self-sustaining capacity where local, regional and national labs have robust laboratory systems to detect and characterize both current and emerging infectious diseases. Our GPHP programs design and implement the foundation to achieve this end goal.
"The existence of our laboratory, the reference materials, documents, formats and checklists are all from ASM," said Mihret Teshale, who now uses the knowledge and skills obtained from her ASM experience to mentor fellow Ethiopian lab professionals. "With the help of ASM, Ethiopia is now supported by good microbiology mentors," Mihret Teshale explained, adding that ASM's support extends beyond investments of time and technical support to ongoing mentorship, collaboration and professional development. "Time will not be enough to thank ASM for all their contributions and support they have given to our profession, and I shall stop here by saying that "ASM is the backbone of microbiology in Ethiopia."