Essential Diagnostics List

A propos of Lab Week 2018, the WHO announced the development of an Essential Diagnostic List (EDL). The first Strategic Advisory Group of Experts on In Vitro Diagnostics (SAGE IVD) met in Geneva in April. The role of the SAGE-IVD is to act as an advisory body to matters of global policy and strategies related to in vitro diagnostics (IVDs) – to guide the development of the EDL.

The EDL is, as it sounds, a catalog of IVDs that are essential for diagnosis, treatment, and management of diseases. An EDL was called for in 2016 by Dr. Tim Amukele, a clinical pathologist at Johns Hopkins and President of the non-profit organization Pathologists Oveseas, and Dr. Lee Schroeder, a clinical pathologist at University of Michigan Ann Arbor (N Engl J Med 2016; 374:2511-4). Amukele and Schroeder suggested the EDL to complement the WHO’s Essential Medicines List (EML). They suggested 19 categories of IVDs that are essential for 10 of the medicines appearing on the EML. As it stands, the initial EDL focuses on 4 disease areas: HIV, TB, Malaria, and Hepatitis B & C. The following categories are provided for each disease area: analyte, intended use, level of facility that should have the IVD, assay format, specimen type, and links to WHO guidelines and any WHO prequalified or endorsed products.

For example, in the disease area “Malaria”, the analyte P. falciparum has the intended use of diagnosis of P. falciparum. The rapid diagnostic assay format is recommended for all level facilities. The specimen type is capillary whole blood, and the corresponding WHO guideline is “Good practices for selecting and procuring rapid diagnostic tests for malaria, 2011”.

The EDL will provide countries a way to focus attention on which tests are most appropriate, which can have a huge impact on the cost-effectiveness of the health care system, and also improve the quality of the laboratory results. Cost-effectiveness can be achieved by 1) focusing on evidence-based IVDs appropriate for a specific disease burden and 2) facilitating proper utilization of medicines and other clinical supplies necessary for treatment/management. In my experience, many laboratories in resource-limited areas are developed seemingly on a whim; testing might reflect a pet project of an absentee lab director, or donated equipment. Focusing on more appropriate testing, as Dr. Amukele told Clinical Laboratory News, give a lab more bang for their buck. Dr. Schroeder indicated that “lab testing develop ad hoc is more prone to quality issues”. The hope is that providing more direction for development of lab testing will encourage greater quality control programs. One way I can see that playing out is, if more labs in a specific area adopt the same testing, a shared sample program for cost-effective proficiency testing might be developed.

The WHO hopes that countries will use the EDL to develop country-specific EDLs, based on the disease burden specific to the country. National EMLs have been successful. Personally, I am very excited about the EDL! The WHO efforts to control HIV, Malaria, and TB have highlighted the need for laboratory diagnostics. I think it’s about time that labs got a chance to show their worth! The EDL is an important step in bringing the lab out of the basement and onto the global health stage.

 

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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.  

Critical Care, Critical Labs

Sepsis is a medical emergency and a global public health concern. The Surviving Sepsis Campaign started in 2012 and has since issued International Guidelines for Management of Sepsis and Septic Shock. These Guidelines have been updated several times, and the 4th edition of the 2016 guideline have been issued. The Guidelines are written from the perspective of developed (“resource-rich”) countries, where critical care settings are equipped with tools for managing these patients. Yet, the developing world carries the greatest burden of sepsis-related mortality. Unfortunately, the developing world lacks access to many of the necessary tools for managing the critically ill patient – including basic laboratory testing.

Laboratory values are a significant part of the management of the septic patient. Take a look at the sepsis screening tool. Analytes and lab tests included in screening patients for sepsis include: lactate, creatinine, bilirubin, INR, and blood gases. The Surviving Sepsis bundles require a lactate concentration within 3 hours of presentation, and a subsequent lactate within 6 hours. The care bundle also requires a blood culture within 3 hours of presentation and prior to administration of antibiotics. Early-goal directed therapy for sepsis requires administration of crystalloid based on lactate concentrations. Basics of laboratories in the US, lactate and blood cultures are both difficult to obtain and far from routine in the resource-poor care settings.

Blood gases and lactate are particularly difficult to find and to maintain in the developing world. While there are a number of point-of-care or small benchtop devices – like the iStat (Abbott), the Piccolo (Abaxis), and the Stat Profile pHOx (Nova), it is often cost-prohibitive to maintain these devices.  The iStat and the Piccolo are examples of cartridge-based devices. All of the chemistry takes place in single-use cartridges and the device itself is basically a timer. In my experience, cartridge based devices hold up in environmental extremes better than open reagent systems. However, they are not cheap and this can be prohibitive. Cost of a single cartridge can range from $3-10 USD. In countries where patients and their families are expected to pay upfront or as they go for even inpatient medical care, and the income for a family is $2USD/day, routine monitoring of blood gases and lactate by cartridge is just not feasible. Reagent based devices like the Stat Profile use cartons of reagent for many uses. This is much cheaper – if all the reagent is used before it expires! Some healthcare settings can accommodate only 1-3 critical patients, and might not be able to use a whole carton before the expiry, even when adhering to Surviving Sepsis guidelines.

Blood cultures and subsequent treatment with appropriate antibiotics is a large part of the surviving sepsis campaign. Microbiology in the developing world is often limited to a few reference laboratories in country. Also, the number of potential infectious agents is larger in the developing world where diseases like malaria and dengue fever are common. Multiplexed nucleic acid tests might fill the gap here. Again, the cost is a major factor. Just reagents alone for a single multiplexed NAT can be over $250 USD.

In short, if the surviving sepsis guidelines really do help decrease sepsis mortality, the developing world doesn’t have a chance unless it has a greater laboratory capacity. Basic labs that we don’t think twice about can be very hard to come by in resource-poor environments. The tests already exist in forms that can be used in resource-poor settings – they just need to be cheaper, at least for those in limited resource settings. Are you listening, Abbott?

 

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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.  

The Challenges of Clinical Laboratories in Developing Countries

Achieving and maintaining quality is arguably one of the most critical tasks in clinical laboratories. Without a proper quality, clinical laboratories are essentially unsafe for patients. Poor quality results can cause mistrust between laboratories and end users, and therefore, endangers the practice of evidence-based medicine and precludes viable engagements between clinicians and laboratorians. Furthermore, poor quality clinical laboratories can hinder global efforts to fight infectious diseases and outbreaks (1).

Ensuring quality is a journey without a destination. It demands constant attention and continuous active participation of all involved in the testing processes. For example, the majority of testing transactions are mediated by clinicians. Their direct involvement in the testing processes makes them inevitable partners in ensuring quality. Thus, close cooperation and constructive engagement with clinicians is critical for laboratorians to provide sustainable quality service. However, ensuring quality can be laborious as it includes coordination with multiple bodies that are not conventional members of clinical laboratories.

The quality of most clinical laboratories in most developing countries is poor.  For example, most clinical laboratories in Africa do not meet international standards (2, 3). Why? There are several factors that contribute to this occurrence but the answer distills into the following: Lack of adequate resources, proper regulations, and supportive health care system.

Lack of adequate resources

The contributions of laboratorians in the diagnosis and management of diseases are generally under-recognized. Laboratorians in developing countries are no exception, if not worse. The lack of recognition compounded by inadequate compensation often leads to job dissatisfaction, negligence, lack of interest, and as a result, departure from the profession. The worst consequence of this phenomenon is over time depletion of qualified personnel, seeking for better opportunities elsewhere. While it is indisputable that developing countries face acute resource limitations, it is not necessarily due to lack of funding but also due to resource misappropriation, improper governance, and rampant corruption.

Lack of proper regulations

The notion that no result is better than poor quality result underscores the critical importance of quality in clinical laboratories. However, it is usually difficult to maintain quality without imposing proper regulatory requirements and enforcing strict regulations. For example, a survey conducted in clinical laboratories in Kampala, Uganda, reveals that most clinical laboratories do not meet international standards (1). Most clinical laboratories in Africa are not accredited (2). Most of the laboratories are not enrolled in external assurance programs; those enrolled do not necessarily adhere to strict follow-ups. These kinds of problems can be averted, at least in part, by introducing stringent regulatory requirements and enforcing the regulations to the details.

Lack of adequate support

Clinical laboratories in developing countries suffer inadvertent neglect and are not well-supported to ensure accurate diagnosis. The healthcare system in developing countries perceives clinical laboratories as “tools” rather than “partners” in the disease diagnosis processes. This kind of unfortunate perception is inherently flawed because clinical laboratories are indeed critical in diagnosing diseases, curbing outbreaks, addressing growing global health concerns. In that sense, laboratories and laboratorians should be deemed and treated as partners.  This is an important distinction to make because partnership fosters collaboration, respect, and recognition, encourages horizontal communications between laboratorians and clinicians, and helps garner support from clinicians, the public, and policymakers.

In summary, the majority of treatment decisions in developing countries are based on clinical judgment and empiric diagnosis (4). Because access to reliable diagnostic testing is limited or undervalued, misdiagnosis commonly occurs, resulting in inadequate treatment, increased mortality, and an inability to determine the true prevalence of diseases. Furthermore, mistrust is rampant due to poor quality results and consequently, viable engagements between the clinical laboratories and clinicians are often impaired.

Laboratorians in developing countries should set up efficient professional societies, enhance communication and diplomacy with clinicians and policymakers, and foster collaborative environment towards achieving continuous quality improvement. Strong and viable societies should then advocate for the wellbeing of clinical laboratories and laboratorians in developing countries. Furthermore, any effort from the global health community should first be directed to identifying and targeting fundamental problems in partnership with local professionals and authorities.

References

  1. Berkelman R, Cassell G, Specter S, Hamburg M, Klugman K. The “Achilles heel” Of global efforts to combat infectious diseases. Clin infect dis, Vol. 42. United States, 2006:1503-4.
  2. Schroeder LF, Amukele T. Medical laboratories in sub-saharan africa that meet international quality standards. Am J Clin Pathol 2014;141:791-5.
  3. Elbireer AM, Jackson JB, Sendagire H, Opio A, Bagenda D, Amukele TK. The good, the bad, and the unknown: Quality of clinical laboratories in kampala, uganda. PLoS One 2013;8:e64661.
  4. Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA. Laboratory medicine in africa: A barrier to effective health care. Clin Infect Dis 2006;42:377-82.

 

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-Merih T Tesfazghi, PhD, is a Clinical Chemistry Fellow with the Department of Pathology and Immunology at Washington University School of Medicine in St. Louis, MO.

Logistics, Meetings, and Evacuations

Almost perfectly timed during my classroom-to-clinicals transition period from American University of the Caribbean School of Medicine (AUC), the 2017 ASCP Annual Meeting in Chicago was an excellent opportunity to get back to my lab roots. The Annual Meeting is always an excellent opportunity to expand lab-related knowledge, learn some new clinical skills, and easily network with colleagues. Professional societies like ours are highly dependent on the partnership and collaboration of our fellow scientists, sponsors, and clinicians. I have been fortunate enough to attend two of these meetings as an award recipient bookending my pre-clinical years in medical school. In 2015, I attended the ASCP Annual Meeting in Long Beach, California as a Regional Member of the Year. This year’s Annual Meeting was held in my hometown of Chicago, where I’m proud to say I attended as a 2017 ASCP Top 40 Under Forty honoree! But these meetings are more than just conferences with awards ceremonies—at every ASCP meeting I reconnected with old friends in workshops, shook hands with our great ASCP leadership, and collaborated with colleagues in roundtables or other sessions. There is a place for all of us in laboratory medicine. Our respective insights bring something valuable to the final outcomes of improved patient care. Nowhere is this more evident than the Annual Meeting.

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Image 1. ASCP Annual Meeting Chicago 2017, Top 40 Under Forty, and ASCP CEO Dr. Blair Holladay

Among the endless list of educational events and sessions, I especially enjoyed being a collaborator in round table discussions including “The Benefits of Data Integration in Clinical Decisions.” I truly enjoy these roundtables and wish I could have done more of them! Topics included effective feedback, utilization and evaluations, education, and global health initiatives—all of which I’m sure I’ve written about in one way or another this past year. Seeing some of the content in my online Lab Management University (LMU) modules applied in real-life situations was reaffirming. Attending sessions and meeting renowned experts from informatics to hematopathology was exciting. The keynote speakers were captivating. Dr. Birx’s discussion on PEPFAR and global health initiatives clearly piqued my interests, and Drs. Caliguiri and Pritchard’s lectures on analytics and resources spoke directly to my work in cancer research. And don’t forget: it’s all worth continuing education credit—can’t beat that.

I would just like to simply thank ASCP again for all the work that goes into these meetings. I know from experience that planning large events involves quite a bit of logistics. And in managing these events ASCP truly provides an excellent environment to collaborate and learn. What brought this appreciation for logistics to the forefront was a disaster that had unfolded in the week prior to the meeting. On the island of Sint Maarten, the location of my medical school and my home for two years, was absolutely decimated by hurricane Irma. The school managed to withstand for the most part intact and acted as a shelter for students, faculty, and family. While being sheltered from that storm, endless homes, apartments, and business were destroyed. Taking nothing but a suitcase or two to campus ended up the only possessions many people in the AUC community had left. The school and its administration did a spectacular job creating a stable, safe, and even comfortable environment for students and their families while evacuation efforts were organized. While AUC managed to get students off the island via military assistance and/or charter flights, evacuees were taken to the Chicago suburbs. Right after the ASCP Annual Meeting I began having conversations with contacts in the Chicago Department of Public Health and Emergency Preparedness to offer assistance. I provided contact data, relayed satellite telephone numbers to the right contact points, and provided relevant information regarding demographics, health, and needs. Both my wife (a trained nursing leader) and myself were happy to be involved with connecting critical points in this process. All the students and their families were accounted for and taken care of in the Chicago suburbs, and were later moved to the new school location relatively unscathed. Logistics from a distance can be difficult, especially when it’s behind-the-scenes. A lot of lab decisions are made that way, and ultimately we do our best for our patients.

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Image 2. Resort and villas halfway between my apartment and AUC campus on Sint Maarten before the hurricane.

 

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Image 3. Resort and villas halfway between my apartment and AUC campus on Sint Maarten after the hurricane.

The take home message: be flexible, be humble, and be helpful. If we want to improve patient outcomes, we need to work with evidence-based approaches matched with intelligent compassion. As laboratorians, we apply our scientific approach to critical life-saving algorithms. This was no exception. Lessons discussed at the Annual Meeting between networking colleagues and official sessions are accurate. Tap into your resources, keep an active and dynamic network, know what you can do and what you cannot, and always try to help. That’s what makes a good laboratorian, a good clinician, a good friend, and hopefully a good physician.

Thanks for reading! If you’re interested in donating to disaster relief for anyone affected by this year’s violent hurricane season in Sint Maarten, visit www.rotarysxm.org.

 

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Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

Guest Post: Drone Transport of Specimens

On a hot afternoon in late September 2016 the Johns Hopkins Medical Drones team drove to a flight field in the Arizona desert with 40 vacutainer tubes filled with human blood obtained from volunteers. The individually wrapped tubes sat in two custom-designed white plastic cooler boxes which had wires coming out of one end, ventilation holes at the other, and ran off the drone’s battery power. We carefully placed one of the boxes on the drone, stood back, and flew the samples around for 260 kilometers in what seemed like an unending series of concentric circles. Great. But why would doctors be involved in this exercise?

For the last 3 years, the Johns Hopkins medical drones team has examined the stability of human samples transported via drone. Our approach has been similar for each study. Get two sets of samples, fly one on the drone, then take both sample sets back to laboratory for analysis to see if there are any changes. However, until this study in Arizona we had only flown these samples up to about 40km, in mild weather, and for up to 40 minutes at a time. A request to set up a drone network in a flood-prone area of a country in Southwestern Africa made us realize that we needed to repeat the stability tests in warmer weather and for longer flights. This drone network would serve clinics that were up to 50 km away from each other, therefore requiring round-trips of at least 100km. Once we received this request it became clear pretty quickly that our previous tests flying for to 40km were not good enough for an aircraft that would have to fly in a hot environment between several clinics that were each 50km away from each other.

After the 3-hour 260km flight, we took both sets of samples back to the Mayo Clinic laboratories in Scottsdale, Arizona and performed 19 different tests on the samples. Each pair of samples was compared to check for differences between the flown and not-flown sample sets. Although results from sample pairs were similar for 17 of the 19 tests, small differences were seen in Glucose and Potassium, which do also vary in other transport methods. We suspect the differences seen in this test arose because the not-flown samples were not as carefully temperature controlled as the flown samples in the temperature-controlled chamber. This study (which is the longest flight of human samples on a drone to date) shows that drones can be used for blood samples even for long flights in hot conditions. However, the temperature and other environmental variables must be well-controlled to keep the blood stable.

 

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-Dr. Timothy Amukele is an Assistant professor in the Department of Pathology at the Johns Hopkins School of Medicine and the Director of Clinical Laboratories at Johns Hopkins Bayview Hospital. He is also the Medical Director of two international research laboratories in Uganda and Malawi. He has pioneered the use of unmanned aerial systems (colloquially known as drones) to move clinical laboratory samples.

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-Jeff Street is an unmanned systems engineer and pilot at the Johns Hopkins School of Medicine with more than 10 years of experience in the development of new and innovative vehicles. He is leading the Johns Hopkins aircraft development efforts for a wide range of medical cargo applications.

 

 

 

Here’s to Fresh STARTs: Sustainable Transitions And Reachable Targets

From the title, you might be able to tell that I’ve been busy on Lab Management University (LMU). Going through the online modules and lessons in the LMU certificate program I mentioned this past May, I’ve been able to hone several skills in interpersonal communication, resource management, and project leadership. (A worthwhile investment through ASCP which I highly recommend!) Another thing that’s kept me quite busy over the last two years has been Zika-virus and mosquito-related public health initiatives both inside and outside the laboratory. In a recent blog post, I discussed the correlation between measuring success in projects like these just as one would with common lab-centric goals. And, as a conclusion to that hard work, this will be my last directly-related Zika/public health post. Transitioning to the second half of medical school, I’ll be leaving behind a true grassroots project that not only reached countless people but has the promise to be sustainable after my departure from the island of Sint Maarten back to the states.

As with many times in life, I would say fresh starts are a welcome chance to reflect and grow upon things you might have learned or goals you might be closer to finishing. What has been made clear to me in my time working through classrooms, cases, exams, and projects is that the “jargon” we use as laboratorians is definitely worth its weight. It isn’t full of hollow charges for metrics and goals; it’s about real data and real solutions. Having the ability to apply my prior experiences in laboratory medicine throughout medical school—both inside and outside the classroom—has been an invaluable benefit. The general principles that guided my last blog post reflected simple goals (i.e. turnaround time compared with public health metrics) which utilize fundamental models of data collection, adjustment, and success. The essential model I described a few months ago is now a mainstay of a project that will continue to improve public health statistics slowly as time goes on.

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The model as it stands now consists of clear steps to identify problems which require interventions, highlight gaps in current practice, data collection from literature exists currently, collaboration with partners in a community of trust, and continuing those partnerships as improvements are made incrementally over time. The model has been repeated and successfully modified for these last two years from on-campus blood testing with procedural write-ups and data evaluation, to teaching school-aged children about mosquito prevention, to partnering with local government officials and having your projects adopted into their portfolio, and visiting individuals in their homes to discuss health and prevention.

To keep it brief, I’ve had an amazing experience here being able to lead and contribute to a wonderful and impactful project such as this. It has become increasingly clearer to me throughout this work that the values and skills programs like LMU teach are directly parallel with successes in various clinical settings. From the bedside to the laboratory to public health in the field, the lessons of how to effectively engage people and solve problems are critical. My time in laboratories before medical school, the daily grind of classwork here, and the projects I’ve been able to write about have all given me the space to try these skills on real situations—and hopefully that will make me the best clinician I can be after medical school is completed. Check out my “highlight reel” of partnerships, workshops, and active management in Zika prevention below.

Be sure to check back here next time, I’ll be writing from my hometown as I’ll explore ASCP’s Annual Meeting in Chicago, IL this coming September and report back on why it’s important to network and stay involved with our great professional community. Thanks for reading!

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Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

 

Planning Lab Testing for Medical Missions, Part 2

Last month I blogged about key points to consider when preparing to do lab testing in the field. Here I will expand on using point of care testing in medical missions. Point of care testing is easy to use and relatively easy to access, making it very attractive for use in the field or on medical missions. In fact, it is tempting to take these tests and go rogue – it’s not uncommon for point of care diagnostics to be obtained by non-laboratory professionals and tossed in luggage to be used by short-term medical teams. However, this is not in the best interest of the patients or the community. Helping establish point of care testing for medical missions is one very important way that a laboratory professional can get involved in this kind of outreach.

Proper utilization and quality assurance practices are just as critical in the outreach situation as at home in a large lab. Perhaps even more so; for example, in areas with high disease prevalence, false positives and negatives can significantly affect patient care and population health. Under-diagnosis due to false negatives means that those who need treatment might not get it, just as over-diagnosis due to false positives may cause patients to get unnecessary treatment. Unnecessary treatment, especially for infectious diseases, harms the community by contributing to drug resistance.

Most point of care tests, especially lateral flow tests, have built-in controls which lessens the need to run QCs with patient testing. However, it is important to know the limitations of the testing. Sometimes point of care testing systems that are not available in the United States are selected for use in outreach in foreign countries. It’s more likely that an American medical team would be unfamiliar with the tests. A laboratory professional can help establish or at least verify the validity of the tests, including limits of detection and accuracy, before they are deployed. Also, it is often helpful to have the results interpreted for the end user. Little interpretation is needed for the more straightforward qualitative tests that simply give a positive or negative result. Even with these tests, the limit of detection should be available to the provider, especially if this is significantly different from that which the provider is accustomed. Tests that involve titration, such as some of the rapid typhoid and syphilis testing, benefit from having an explanation of what the titers mean clinically available to the end user.

Other tests with results that are prone to confusion are point of care versions of assays more commonly performed in clinical laboratories. Difference in reference intervals for the POCT compared to a conventional test can be particularly confusing. For example, the results of a lateral flow point of care C-reactive protein assay have a different reference interval than results from high-sensitivity C-reactive protein assays used in clinical labs. Using the incorrect reference interval to determine whether a result is normal can lead to over- or under-treatment, which is contrary to the purpose of diagnostic testing. Yet, when using point of care tests in the field, there is not a neat little interpretive comment accompanying the result.

So, how can this be remedied? If the laboratory professional is also on the team, they can be available to provide information as needed. However, if the team is not so fortunate as to have their own laboratory professional, another way to provide the information is to provide a short guide to cheat sheet that briefly explains how to use test results.

Proper utility is also important, especially in areas with high burden of disease or in areas where there is no confirmatory testing. Consider rapid tests for H. pylori. These typically detect antibody to H. pylori, which can be found in up to 70% of asymptomatic populations. The rapid test is of little utility since positive results only indicate the presence of antibody and not necessarily an active infection. Consider using rapid screening tests, such as for HIV, when confirmatory testing is not available. Sometimes a second screening test that employs a different method than the first can be used as a confirmatory test if nothing else is available.

Consider environmental limitations of the testing when selecting tests for use in the field. Many tests are unreliable at extremes of temperature and humidity. This might not always be obvious even when quality controls are used properly. For example, Tang et al (1) showed that the effect of temperatures and humidity similar to what was experienced in Louisiana after Hurricane Katrina on quality control material for a POCT glucose meter system caused significantly depressed results. Also keep in mind that exposure to environmental extremes can reduce the shelf life of POCT and related reagents. If using POCT long term, it is good practice to routinely test a known standard – even on tests with built in quality controls such as the test line on lateral flow tests – to ensure there has not been degradation in quality due to the environment.

Preparing POCT for medical missions is a great way for a laboratory professional to get involved in global health and outreach. From helping to select appropriate tests, to verifying test validity, to teaching proper utilization of testing and providing interpretive guideline, the laboratory professional is a vital part of a medical mission – even if they never leave their lab!

  1. Tang CS, Ferguson WJ, Louie RF, Vy JH, Sumner SL, Kost GJ. Ensuring quality control of point-of-care technologies: effects of dynamic temperature and humidity stresses on glucose quality control solutions. Point of Care 2012;11:147-51.

 

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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.