I am frequently asked questions about establishing clinical lab testing in the field, or how to approach bringing lab tests on medical missions. There are three key questions that I always start with when planning diagnostic lab testing for any situation, and they are 1) what is the mission? 2) what are the needs of the population? and 3) what is the environment like?
The first question – what is the mission? – sets up the framework for the project. Is the goal to provide sustainable testing or to support a short term medical mission? An examples of sustainable testing would be establishing a new assay for permanent use in a clinic or hospital, and would require a plan for identifying and training operators, ensuring reagent availability and maintenance plans in-country, and a budget. Supporting a short term mission often requires only point of care testing. For this post, I’ll focus on supporting a short term mission.
The second question –what are the needs of the population? – helps determine a test menu. As with any diagnostic lab testing, it helps to ask the question “what are you going to do with the result?” when deciding which tests to offer. It is important to know what the medical care team is equipped to treat, what treatments are available in the community, and the cost of the treatment. It is important understand the prevalent health care issues that will be encountered by the care team on the mission. For example, if the goal of the medical mission is to provide routine healthcare to a remote environment, then you would want to know of any endemic diseases that the team would be prepared to treat. However, if the mission is surgical in nature, lab testing might need to address blood typing and viral testing, or perhaps coagulation testing.
The third question – what is the environment like? – guides the selection of testing platforms. If there will be electricity and running water, you will be able to use powered devices like a Piccolo chemistry analyzer, or platforms that require refrigerated reagents. Temperature extremes, especially heat, must be kept in mind. Many instruments can’t function over a certain temperature. A battery powered point of care instrument that is very useful in the field in moderate climates might be useless in high heat. For example, the Renal Disaster Relief Task Force of the International Society of Nephrology used the Abbott iSTAT in their response to the 2010 earthquake in Haiti. They found that this device often failed due to the extreme heat (>100 degrees F) of the field hospital environment (1). Improvisation can sometimes get around these limitations; I have used ice packs in coolers or even suitcases before to keep instruments cool enough to operate while in the field. Many times, especially for remote locations, lateral flow, whole blood based, point of care testing is the best option. There are many options available that do not require any special handling like refrigeration, and the ability to use capillary blood is a huge benefit in situations where venipuncture might be difficult.
In any situation you must know the sensitivity, specificity, cross reactivity, and limit of detection of the assays selected for the mission. You should be able to communicate any limitations to any of the care providers who might use the result. If the laboratory professional is not able to go on the medical mission, then another person should be identified as responsible for oversight of the laboratory testing. Most importantly, it is important to carefully plan for lab testing on medical missions. With thoughtful planning, adequate laboratory testing can be provided to support medical missions.
Reference
- Vanholder R, Gibney N, Luyckx VA, Sever MS. Renal Disaster Relief Task Force in Haiti earthquake. Lancet 2010;375:1162-3.
–Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.
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