Global health security: how can laboratories help?

Abstract

“How did Ebola happen and could it happen again?” is a question asked countless times over the past 3 years. More often than not, the catastrophic failure of health system coherence and capacity in the three most affected countries in west Africa is fingered as the inevitable culprit, and more often than is comfortable, this failure is met with a degree of hand-wringing and not to say “Afro-pessimism”. In Cape Town last month, at the biennial meeting of the African Society for Laboratory Medicine (ASLM), a decidedly more upbeat note could be detected. The Society is young and fittingly dynamic. Panellists and plenary speakers were high-profile agency representatives from both high-income and lower-income countries (plus the odd Lancet editor), yet the highly engaged audience was largely African. Kevin De Cock, Director of the Kenyan arm of the US Centers for Disease Control and Prevention (CDC), kicked off the optimism by stating that—yes—Ebola was a health system failure, but that analysis has identified key areas for action and progress. For a start, there was a massive underestimation of laboratory and data management needs, he said, with Ebola case data arriving from multiple unlinked sources in a hotch-potch of formats. Then there was a “chasm” between laboratory results and clinical practice. The turning point came with the institution of CDC-assisted incident management systems, which rapidly improved coordination and reporting structures, and set clear goals and expectations. Building on the optimistic theme, John Nkengasong took the opportunity to introduce Africa CDC, of which he is the founding Director. One of the five functional pillars of this new agency will be laboratory systems and networks. There will be a “massive” effort to improve laboratory networks and link them to clinical care systems, Nkengasong said. Recognising the rate-limiting step of a sparse and inadequately trained workforce, he also pledged that Africa CDC would launch a laboratory leadership training programme and run roadshows on the use of state-of-the-art point-of-care tests. From a global perspective, there is now a comprehensive programme in place to strengthen countries' capacity to prevent, detect, and respond to public health emergencies of international concern, including from the perspective of laboratory systems. In 2014, the Global Health Security Agenda (GHSA) was born of a collaboration of nations, international organisations, and civil society with the mandate of aiding countries to implement WHO's International Health Regulations (IHR). GHSA's 11 “action packages” contain specific interventions with explicit targets and indicators; one package is entirely devoted to national laboratory systems, and laboratories feature heavily in several others. The undoubtedly aspirational indicator for the laboratory systems action package is “A nationwide laboratory system able to reliably conduct at least five of the 10 core tests… from at least 80 percent of districts in the country.” Core tests include PCR for influenza virus, virus culture for poliovirus, serology for HIV, microscopy for Mycobacterium tuberculosis, rapid diagnostic testing for Plasmodium spp, and bacterial culture for Salmonella enteritidis serotype Typhi. Many of these tests are already being scaled up in Africa, De Cock reminded us. Yet the notion that 80% of districts might be in a position to reach this target any time soon still seems way out of reach. The trouble is, we don't really know, said Alash'le Abimiku in a round-table discussion. What is the current capacity? Mapping and gap identification is a key baseline assessment activity in the GHSA action package, and an obvious place to start. Reliability is another concern. Good quality laboratory services in Africa are regrettably not to be counted on and formal accreditation is still all too uncommon. To aid objective evaluation of the continent's laboratory network capacity, the ASLM recently developed and validated a standardised assessment tool known as LABNET. This thoughtfully developed tool will no doubt inform the Joint External Evaluation process—a voluntary mechanism whereby countries can self-assess, and then have externally validated, their readiness to “prevent, detect, and respond” under the IHR. A functioning clinical laboratory network is an indispensable part of the health system, being vital to disease burden estimation, timely diagnosis, and monitoring of treatment response. It is also an essential component of global health security. Africa should treasure its dynamic Society, its new CDC, and its committed young laboratory professionals in its collaborative journey towards a world safe from future health threats.