Readers of Mountains Beyond Mountains, by Tracy Kidder, know that Partners In Health in Peru has been fighting drug-resistant tuberculosis for years.
Since developing a successful program to cure a disease once deemed untreatable, staff at Socios En Salud have continued to fight tuberculosis in Peru. The country sees more than 25,000 cases of TB annually, of which more than 50 percent occur in the capital city of Lima. Of the total TB cases in Peru, about 2,000 are multidrug-resistant, and about 75 percent of those occur in Lima.
To support treatment efforts, PIH/SES opened a state-of-the-art laboratory in Carabayllo late last year to run tests for TB. The lab provides immediate, high-quality information to guide TB treatment—ensuring patients receive the medications that are most effective against the disease. And the scientists behind the lab hope it will prove to the world that a higher standard of TB services is feasible and necessary.
“The mantra for treatment and lab services over the last 25 years has essentially been, ‘keep it simple, stupid,’ said Carole Mitnick, a tuberculosis expert at Harvard Medical School and long-time PIH collaborator. “By opening this lab in Peru, we’re showing that we can bring new technologies close to the people in need and use them to help cure TB patients.”
Tuberculosis is a contagious disease caused by bacteria that infects people’s lungs. It spreads easily when people live in close quarters and have weakened immune systems—conditions that often affect poor people. When people fall sick with tuberculosis, it’s critical to diagnose the disease quickly and start them on treatment with antibiotics, which lessens the risk of them infecting others and expedites their recovery.
It’s also important to provide them the right medicines—those that will be effective against the strain of TB that’s infecting them. That includes multidrug-resistant tuberculosis, which does not respond to the main TB drugs.
In addition to supporting treatment, the facility also serves as a platform for training and research. There, laboratory workers learn to use new technologies to diagnose TB and monitor its treatment. The lab also supports research that aims to make treatment shorter and more effective and that enhances our understanding of how TB spreads.
With a Level 3 Biosafety classification, indicating it’s equipped to perform a range of tests on very dangerous bugs, the lab has some interesting attributes.
1. The lab is made from a recycled shipping container.
To conduct sophisticated TB tests, lab technicians must work with live tuberculosis bacteria. It’s a hazardous and sensitive process. If handled improperly, the bacteria could infect staff at the lab and people living in surrounding areas. And the tests are no good if other organisms have contaminated the bacteria samples. So the lab must be tightly sealed to prevent microorganisms from coming in and going out.
It turns out that one of the most easily sealed structures is recycled shipping containers, the big steel boxes used to carry goods from continent to continent on cargo ships. Socios En Salud bought a repurposed shipping container from a company in South Africa to form the core of the lab—the area where the riskiest tests are done.
Opening a lab in a shipping container is also quicker and cheaper than housing the TB lab in a building. Instead of constructing an entire facility and sealing a room within it, PIH/SES imported the container and began work almost immediately.
2. It’s the first in Peru to offer same-day turnaround on tests.
The lab is Peru’s first ever to offer molecular diagnostic and resistance testing with a same-day turnaround. Peru’s national referral lab offers the same test, but it’s on many samples at once, about once a week. Same-day results allow doctors and nurses to enroll patients more quickly on the treatment that will work best for them.
3. It’s breezy in there.
Negative air pressure pulls filtered air from clean areas toward more contaminated areas, helping prevent airborne bacteria from making contact with staff. The air is filtered before it enters and exits the lab, and the entire air supply changes more than 20 times an hour, almost twice as often as the 12 times per hour required for this safety level.
4. Lab technicians use chicken eggs for some tuberculosis tests.
Tuberculosis bacteria grow with the help of a protein called albumin, which is found in eggs. To test a patient’s TB infection for drug resistance, lab technicians grow bacterial cultures using egg whites and apply various antibiotics to see which drugs kill the bacteria. The drugs that wipe out the bacteria are then prescribed for the patients.
5. It serves as a TB bank.
In addition to conducting tests, the lab also needs storage of bacterial samples, functioning as a “’bank” for samples. With patients’ permission, these samples can be used to test new drugs, or to further refine our understanding of resistance. To store the tuberculosis samples, the lab is equipped with three freezers the size of a large household refrigerator. Each freezer is kept at –112 degrees Fahrenheit. This allows lab technicians to freeze samples, making them non-contagious, but still able to be thawed and grown for further testing.
6. It’s located in the heart of the epidemic.
Most referral labs are established near the center of a nation’s capital, but that’s not always where the most patients live. In Lima, tuberculosis is a big problem in the shantytowns on the capital’s outskirts, where poor people settled after leaving rural areas in search of work. This lab is located in Carabayllo, where PIH first discovered an epidemic of multidrug-resistant tuberculosis in 1995, as chronicled in Mountains Beyond Mountains. Locating this specialty lab in Carabayllo helps speed up the testing process for patients whose health depends on it.
7. It’s one of 14 labs in the world that allow for “gold standard” research to develop new TB drugs.
Only 14 labs in the world have the capacity to do quantitative cultures—to count the number of bacteria in a sample. This technique is known as the “gold standard” for measuring drugs’ effectiveness against tuberculosis bacteria. It’s used to develop new drug regimens to provide shorter, more effective treatment and cure more people.
8. Only highly trained personnel perform lab procedures.
Peruvian laboratories have begun requiring highly trained personnel to perform tests and other lab procedures. The lab’s staff received training in both the national reference laboratory and various regional reference laboratories in Lima, many of them training and working in other labs for several years. Now they are employing this training in service to poor communities.
9. It could be the first TB lab in Peru to receive international certification.
To protect the safety of staff and surrounding communities, the lab follows rigorous procedures for the proper handling and testing of bacteria. And the test results must be reliable for clinicians to use to make clinical decisions. The lab has established procedures according to international standards, and is seeking certification from the International Organization for Standardization to recognize the high quality of lab activities. No lab in Lima is currently certified for tuberculosis, and the PIH/SES lab may be the first. This certification will help the lab attract large-scale TB research studies, which are critical to the development of better diagnostics and treatment.
10. The mission of the PIH/SES lab is to improve public health.
Establishing new labs in Lima helps decrease the incidence of TB by allowing the decentralization of diagnostic tests and especially by improving the quality of lab services. PIH/SES has developed a systematic and sustainable plan to expand lab capacity and improve public health in Lima and all of Peru.