Challenges and opportunities of setting-up a Cholera surveillance Microbiology laboratory in a research-naïve rural setting in Mozambique

Abstract

Background: Limited microbiology capacity, important to confirm clinical diagnosis, impacts diagnostic and treatment of infectious diseases such as Cholera in LMICs. In Mozambique, is only possible in tertiary care, each serving ∼6million habitants and we implemented it in a secondary-care rural hospital, supported by Cholera Prevention and Control Project (MOCA) in partnership with the National Institute of Health (INS) and the International Vaccine Institute (IVI); Developed integrated approach comprising surveillance, vaccination campaign and WaSH, in a Cholera endemic District with challenging precarious roads and no microbiological diagnostic. Methods and materials: Key elements for the lab implementation included: engagement of international partners (IVI and KOICA) in providing a low-cost infrastructure (20”container), basic equipment and reagents; local partners (INS and MoH) engagement with local authorities in providing human resources and training both at central level and also local on-going training during project's supervision visits (every 2 months). Training package including translation of resource-rich practices to a resource-limited setting, such as using manual, instead of maintenance-intensive automated machinery, translation of standards procedures to support all levels of staff and the implementation of a stepwise quality assurance programme. Results: This lab will support MOCA's surveillance, implemented in 6 health care facilities (HCF), and the remainder districts health care network (16HCF), serving a population of 264,788 habitants. Capacity has been created for microbiological diagnostics other than diarrheal diseases and the newly implemented capacity will help focus interventions, identify and monitor outbreaks, and provide information for reports on newly emerging serotypes and changes in antibiotic resistance. Conclusion: The global roadmap to end cholera transmission by 90% in 2030 advocates for “a strategy focusing on containing outbreaks through early detection and rapid response. Through strengthening early warning surveillance and laboratory capacities, to drastically reduce the number of deaths from cholera.” Development of low- and middle-income country models of services, like this, are important to address antimicrobial resistance, burden of underreported pathogens and improve diagnosis and patient treatment and will be readily incorporated into routine clinical practice. Political commitment is crucial for the sustainability of the service and further studies should observe the impact in diagnosis and treatment of patients due to laboratory diagnosis.