Global Lab Leaders Put Successes, Challenges Under the Microscope

Posted on Jun 14, 2019

Angelique Nyiragashikazi at PIH's annual lab workshop
Angelique Nyiragashikazi, lab manager at PIH-supported Kirehe District Hospital in eastern Rwanda, explains a poster showing her lab's accreditation process to Dr. Anatole Manzi, PIH's director of clinical practice and quality improvement, during the third annual PIH Lab Workshop and Training. The weeklong event was held at PIH's Boston offices in May. In the background is Henry Chinkhata, deputy lab manager at Neno District Hospital in Malawi. All photos by Zack DeClerck / PIH

In Mokenyakenya Matoko’s schedule for moving lab samples from remote health centers in the mountains of Lesotho to testing facilities in the capital, Maseru, there’s a quick sentence that might be easy to gloss over.

“Tuesday morning, car picks up specimens at Lebakeng and Nkau.”

If only it was that simple.

Matoko is laboratory manager for Partners In Health in Lesotho, a small, landlocked nation in southern Africa, where PIH is known locally as Bo-mphato Litšebeletsong Tsa Bophelo. His story about what it takes to move clinical lab samples—including multi-hour drives with lifesaving, time-sensitive blood tests; frozen gel packs; and a canoe—was one of many told by PIH laboratory leaders from nine countries, at the third annual PIH Lab Workshop and Training. The weeklong event was held in Boston in May.

PIH directly supports more than 25 laboratories across 10 countries, and works with a larger network of labs—in areas such as public health, tuberculosis and more—in each of those countries. Some PIH labs are home to broad diagnostic capacity, while others are designed to focus on a single disease, such as TB. While PIH teams in some countries, such as Sierra Leone, have had labs for only a few years, others, like Haiti, have had them for decades. Laboratory expertise and technology also vary across sites, depending on whether staff are catering to a small clinic or a large referral hospital.

But all of them—large or small, new or longstanding—are absolutely vital to PIH’s work supporting  health care and improving patients’ lives around the world. Dr. Joia Mukherjee, PIH’s chief medical officer, recalled times in the early years of PIH when lab materials and testing were extremely limited, if available at all.  

“It is so much more complicated to take care of patients when you have no diagnostic ability. You don’t know what you’re treating; you don’t know how long to treat it,” Mukherjee said to an audience of PIHers who gathered to meet and celebrate the lab group.

There’s a lot to celebrate this year. Daniel Orozco, director of laboratory services for PIH, said the “flagship” Dr. Paul E. Farmer BSL-3 Laboratory soon will be operating at University Hospital in Mirebalais, Haiti, after several years of construction and equipment transfers. The lab’s designation as a Biosafety Level 3 facility, or BSL-3, means it’s a high containment lab where technicians can work with infectious agents, including drug-resistant TB.

“People said to me, ‘Good luck opening a BSL-3 lab in rural Haiti,’“ Orozco said. “And not only have we done it, we also will demonstrate that it’s possible for it to run at a high standard of quality, while working closely with the national TB reference lab at Laboratoire National de Santé Publique (Haiti’s National Public Health Laboratory).”

Daniel Orozco leads a discussion at PIH's annual lab workshop
Daniel Orozco, director of laboratory services for PIH, describes PIH's lab-related achievements and growth over the past year, including the new Dr. Paul E. Farmer BSL-3 Laboratory, which soon will be operating at University Hospital in Mirebalais, Haiti.

Microbiology services to test for bacteria and viruses are starting at PIH labs in Haiti and Rwanda, Orozco added, and capacity is expanding in Liberia and Sierra Leone. Participants in this year’s workshop received training on lab procedures and management, supply chain and procurement, and more.

Participants also focused on Strengthening Laboratory Management Toward Accreditation, or SLMTA, in sessions led by Zimbabwean SLMTA master trainer Edwin Shumba and PIH laboratory program officer Nidia Correa. The training covered basics of SLMTA such as lab management, lab process control, quality assessment, and method validation.

Matoko said the SLMTA training was “extensively informative” in several areas, such as methods to verify manufacturers’ claims about equipment and set appropriate quality standards in labs.

“It was beyond my expectations,” Matoko said. “I’m really hoping that this will impact a lot back home, as far as preparation for accreditation.”

The constant, extensive preparations by Matoko’s lab team were featured in the poster presentations, a highlight of the annual lab workshop since it began in 2017. The poster presentations give participants a chance to showcase their work and learn from the experiences, successes, and growth of their PIH lab colleagues around the world.

Matoko used his poster to describe moving clinical lab samples over Lesotho’s rugged roads and mountains.

Two of the most remote health centers PIH supports in Lesotho are at Lebakeng and Nkau, rural communities several hours from Maseru that are so isolated by mountainous terrain that, in both cases, grassy fields often serve as helicopter pads for urgent visits.  

Matoko said his team visits the health centers by truck to pick up lab samples. The overnight trip requires more than 10 hours of driving, in all. At Lebakeng, the driver calls ahead so someone from the health center can take a 45-minute hike down a mountain—samples tucked in a cooler filled with gel ice packs—and then canoe across a river to hand over the samples.

Work is well underway to shorten that “specimen referral,” as getting lab samples to a testing facility is formally known. PIH works closely with Lesotho’s Ministry of Health, which has provided Lebakeng with a GeneXpert machine to enable TB diagnostics in the remote, mountaintop setting. Plans for a modular building at the facility also are in the works, to provide more space for currently cramped lab work.

Orozco said the three themes of this year’s poster presentations—quality improvement, specimen referral, and lab accreditation—“are all parts of a bigger picture in terms of lab strengthening.”

Zhanel Zhantuarova, a lab quality officer for PIH in Kazakhstan, talked about the heavy amount of documentation required for clinical trials of new multidrug-resistant TB treatment in her country. Some of the paperwork is in Russian, and some in English. Unifying the two can be difficult, because minor differences in language can have major impacts in medical interpretation.

Roger Calderon, laboratory director for PIH in Peru, known locally as Socios En Salud, talked about his team’s work to test for first- and second-line TB drug resistance—one of only three labs in Peru to do both—while shortening test turnaround times from six months to one.

PIH lab leaders gather for a group photo with co-founder Dr. Paul Farmer
Participants in the third annual PIH Lab Workshop and Training gather with PIH leaders including Chief Medical Officer Dr. Joia Mukherjee, fourth from left, and Co-Founder and Chief Strategist Dr. Paul Farmer, center back, below the PIH logo. 

Dr. Paul Farmer, the PIH co-founder and chief strategist for whom Haiti’s new BSL-3 lab is named, praised all of the lab leaders at the workshop and said their work reflects PIH’s fundamental ethic of accompaniment, or “sticking with it over the long haul” while sharing the burden of others.

“You’re really the best at what you do—that’s what I think when I look around the room,” Farmer told the group.

Mukherjee said PIH’s lab teams are “indispensable” and urged workshop attendees to continue their groundbreaking work.

“I think this coordination that you’re all doing together is really going to raise the standard of care for the world’s poor,” Mukherjee said. “So, thank you, because care is better when you know where you’re going. No doubt.”