diagnostics off the grid: providing laboratory testing...
TRANSCRIPT
Diagnostics Off the Grid:
Providing Laboratory Testing
Without Municipal Power
Marcia A. Kilsby, PhD, MLS (ASCP) cmSBB
Chair, Department of Medical Laboratory Sciences
Andrews University
Berrien Springs, MI 49104
Copyright ©2011 Marcia A. Kilsby
2011 ASCP Annual Meeting/
WASPAlm XXVI World Congress
Copyright ©2011 Marcia A. Kilsby
Objectives
� Predict potential factors that must be
addressed when preparing for laboratory
outreach in developing countries.
� Propose practical solutions in performing � Propose practical solutions in performing
testing without municipal power.
� Design options to dealing with resource
and environmental challenges to providing
quality laboratory services in remote
settings.
Copyright ©2011 Marcia A. Kilsby
Globalization and
Impact on Healthcare
� Infectious diseases recognize no borders� Increased travel
� Manufacturing and transportation of goods
� Importing of foods� Importing of foods
� Health care system changes� Outsourcing
� Digital transmission of images
� Marketing surgical options
� More knowledgeable patients
� Renewed sense that we live in “one shared world”
Copyright ©2011 Marcia A. Kilsby
Laboratories in
Developing Countries
� Many countries do have progressive
clinical laboratories in capitals and, in
some instances, other large cities.some instances, other large cities.
� Rural situations maybe vastly
different.
Copyright ©2011 Marcia A. Kilsby
Clinical Laboratories
from:
Highly automated with quality systems in
place comparable to those in the United
States.
to:
Rudimentary that lack any type of up-to-
date instrumentation, reagents and
supplies, and often function under
“make-do” conditions.
Copyright ©2011 Marcia A. Kilsby
Laboratory Services
Delivery
Significant difference from those in the
developed world is inconsistency in quality and
sophistication of the laboratories services sophistication of the laboratories services
within each country.
Copyright ©2011 Marcia A. Kilsby
Laboratory Personnel
� Key differences:
� Education
� In many countries training is based on diploma programs, two or three years in length.length.
� Universities are now initiating baccalaureate degree programs.
� Often there are no national standards or accrediting bodies.
� Quality of the education is based on the institution.
Copyright ©2011 Marcia A. Kilsby
Laboratory Personnel Continued
� Staffing
� Large facilities – personnel better educated
� Rural – may have only basic on-the-job training with no formal education for the position. Note: there are exceptions.
� Resources
Copyright ©2011 Marcia A. Kilsby
CASE STUDY
Copyright ©2011 Marcia A. Kilsby
Case Study Scenario
� A team is setting up a new clinic in a remote
area of equatorial Africa
� The closest medical facility is five hours away
in a four-wheel drive vehicle in the non-rainy in a four-wheel drive vehicle in the non-rainy
season (inaccessible during the rainy season)
from the sight selected
� Malaria, bacterial meningitis, and intestinal
parasites are endemic
Copyright ©2011 Marcia A. Kilsby
Case Study Scenario
� Identify the key diagnostic tests that need to
be performed.
� List the equipment required to perform those
tests.tests.
� If the equipment requires electricity,
determine how the equipment will be
powered.
� List all reagents and supplies necessary to
perform those tests.
Copyright ©2011 Marcia A. Kilsby
Case Study Scenario
Continued
� If the testing requires standards and controls,
determine where they will be procured,
transported, and maintained.transported, and maintained.
� Determine how suitable water for testing will
be obtained.
� Establish a biohazardous waste disposal plan.
Copyright ©2011 Marcia A. Kilsby
Challenges To Consider
In Outreach Ventures
� Length of Stay – short term, long term
� Facility or “lack thereof”
� Equipment – What is available on site and is � Equipment – What is available on site and is
it functional?
� Reagents, Standards, Controls
� Resupply potential in country
� Supplies /Disposables
� Transportation/Airline regulations
Copyright ©2011 Marcia A. Kilsby
Additional Challenges
� Water
� Biohazard & Chemical Waste Disposal
� Cost of Testing
� Climate� Climate
� Permanent documentation of patient testing
results
Copyright ©2011 Marcia A. Kilsby
Personal Challenges
� Our own passion for “laboratory testing
perfection”
� Tolerance for dealing with the unexpected
and the absence of the “comforts of and the absence of the “comforts of
home”
� Tolerance for the presence of “critters”
� Ability to be flexible and non-judgmental
Copyright ©2011 Marcia A. Kilsby
Personal Challenges
Continued
� Understanding the cultural dynamics that
involve clinical diagnostics:involve clinical diagnostics:
� from patients’ perspectives
� from that of other healthcare practitioners
Copyright ©2011 Marcia A. Kilsby
One of the GREATEST
Challenges
ELECTRICITY!!!!� Available?� Available?
� Voltage ?
� Stability?
� Reliability and Predictability?
Copyright ©2011 Marcia A. Kilsby
Sharing Glimpses of My
Recent Personal Journey into
Healthcare OutreachHealthcare Outreach
Copyright ©2011 Marcia A. Kilsby
OPTIONS AND
PRACTICAL SOLUTIONS
Copyright ©2011 Marcia A. Kilsby
Point of Care Equipment
� Advantages� Easy to use
� Small and portable
� Uses reagent cartridges or stripsUses reagent cartridges or strips
� Concerns� Availability of cartridges/strips in country
� Cost per test
� Stability in conditions of extreme temperature and humidity
� Management of who is performing the testing
Copyright ©2011 Marcia A. Kilsby
Regular Laboratory Equipment
No municipal power -
Use a generatorUse a generator
Copyright ©2011 Marcia A. Kilsby
Generators
� Determine size of generator necessary to
yield the power required
� Check for availability and COST of the
fuelfuel
� Establish whether a power conditioner is
needed
� Do NOT get the biggest generator
available – right size it
Copyright ©2011 Marcia A. Kilsby
Portable Equipment
� Runs off both electricity or battery pack
� Battery pack must be rechargeable from
� 110v110v
� 220v
� car battery
� solar panel
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Portable Laboratory
Instrumentation Assemblage
� Microscope with Lumin®
� Hematocrit Centrifuge
� Large Centrifuge – 8 well, 15ml capacity
� Hand-Cranked Centrifuge� Hand-Cranked Centrifuge
� Hemocytometer
� Cell (Talley) Counter
� Colorimeter
� Glucometer
� Rechargeable Battery
� Solar PanelCopyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Hemocytometer Use Without
Mouth Pipetting ☺
Copyright ©2011 Marcia A. Kilsby
LUMIN
(Epi-flourescence Light Source)
Copyright ©2011 Marcia A. Kilsby
Chemistry
� Albumin
� Calcium
� Creatinine� Creatinine
� Glucose
� Total Bilirubin
� Total Protein
Copyright ©2011 Marcia A. Kilsby
Hematology
� Hematocrit
� Hemoglobin
� Cell Counts by Hemocytometer � White Blood Cells� White Blood Cells
� Red Blood Cells
� Reticulocytes
� Eosinophils
� Differentials
� Sickle cell screening
Copyright ©2011 Marcia A. Kilsby
Microbiology
� Gram stains
� Direct Examination of Throat specimens
� Direct Examination of Urethral Pus� Direct Examination of Urethral Pus
� Acid-Fast staining
Copyright ©2011 Marcia A. Kilsby
Parasitology
� Malaria smears
� Fecal concentrates
Copyright ©2011 Marcia A. Kilsby
Urinalysis
� Urine chemistries
� Microscopic examinations
Copyright ©2011 Marcia A. Kilsby
LUMIN®
� Sputums for Tuberculosis
� Acridine orange for malaria
� Any procedure that needs a fluorescent � Any procedure that needs a fluorescent
microscope
Copyright ©2011 Marcia A. Kilsby
Reagents
� Determine if equipment can handle
open source reagents if proprietary
reagents are unavailable
� Use Reagent Packs/Kits� Use Reagent Packs/Kits
� Find in country
� Transport from the U.S.
� Often bulky
� Subject to luggage weight restrictions
Copyright ©2011 Marcia A. Kilsby
Reagents Continued
� Make from scratch on site
� Requires in country availability of basic chemicals if regulations prevent transportation of some chemicals in transportation of some chemicals in passenger luggage
� Involves time to find the sources
� May require electronic balance for measuring ingredients
� Might be able to use “Dash, pinch, smidgeon” pre-determined formula
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Reagents Continued
� Transport premeasured aliquots:
� Pellet form
� Blister-type packetsBlister-type packets
Copyright ©2011 Marcia A. Kilsby
Homemade
Pelletized
Reagent
Copyright ©2011 Marcia A. Kilsby
Reagent Controls and
Standards
� Transport from the U.S.� Problem with transporting blood products� Problem with transporting blood products
� Make own standards
� (for some analytes this is virtually impossible)
Copyright ©2011 Marcia A. Kilsby
Strip Tests
� Should be endorsed:
� In addition to urine chemistries, are
available for:available for:
� Malaria
� HIV
� HBV
Copyright ©2011 Marcia A. Kilsby
Supplies
� No kimwipes – try locally produced facial
tissues or TP
� Need parafilim – use locally available
plastic wrapplastic wrap
Copyright ©2011 Marcia A. Kilsby
Insects
� Natural insecticides
� Create moats
� Water� Water
� Oil
� Make “teepees”
� Build insect traps
� Cornmeal for ants
Copyright ©2011 Marcia A. Kilsby
Water Mote with Fly Deterrent
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Protecting
supplies
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Insect Trap
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Mold
� Use sealed containers
� Make silica gel pouches
Recharge in:Recharge in:
� Microwaves if available
� Sunshine
� Dry heat oven
Copyright ©2011 Marcia A. Kilsby
Biohazard Waste
� Use available rigid plastic containers –
soft drink or water bottles
� Fill with bleach water before disposableFill with bleach water before disposable
� Build an incinerator
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Water
� For reagents and controls:
� Deionized water
� frequently not available economically
� If available, volumes insufficient� If available, volumes insufficient
� Reverse osmosis water
� Solar still water
� Local bottled filtered water
� Works for most basic testing reagents
� Not acceptable for calcium testing
Copyright ©2011 Marcia A. Kilsby
Solar Still
Copyright ©2011 Marcia A. Kilsby
Hand
washing
Station
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Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
In-Country SolutionsIn-Country Solutions
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
Outreach Opportunities
� Mission trips sponsored by:
� Churches
� Humanitarian groups
� Physicians
� Educational activities:� Educational activities:
� Workshops
� Train-the-trainer sessions
� Academic Institutions in developing countries
� Consultation work
� International outreach initiatives with American professional organizations, such as ASCP!!!! ☺
Copyright ©2011 Marcia A. Kilsby
“Sometimes we never know when or how
our work will ultimately affect the lives of
others.”
Kathy BrysonKathy Bryson
Director
Servants in Faith and Technology
Lineville, AL
Copyright ©2011 Marcia A. Kilsby
SHARE YOUR EXPERTISE
AND
PASSION FOR SERVICE!PASSION FOR SERVICE!
Copyright ©2011 Marcia A. Kilsby
Thank You for Attending.
I hope YOU were
blessed!blessed!
Marcia A. Kilsby
Copyright ©2011 Marcia A. Kilsby
www.andrews.edu
www.andrews.edu/cas/mls/research/index.html
www.globalcarepartners.org
Copyright ©2011 Marcia A. Kilsby