Research Paper: Laboratory Medicine in Resource Limited Settings

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¶ … Improving the Quality of Medical Laboratory Services in Resource-Limited Settings

The critical nature of emergency medical services in Saharan and Sub-Saharan Africa is paramount as development during the 21st century is poised to arouse Africa to harness its power to become a global economic player. The Aforementioned emergency care is akin to emergency medical response teams that can arrive on-site with an onsite laboratory where blood testing, transfusion (if blood packs are obtained), where diagnosis of communicable diseases via laboratory testing is essential.

However, there are many issues associated with the availability of on-site diagnosis or locality over a large geographic region where a stand-alone facility with microbiology laboratory and diagnostic department is available. Economic constraints limit the development of such a network within the context of establishing the facilitation health structures. Tangential to the lack of resources for laboratories, are the high infection rates in African hospitals where at the highest, 25% of the wounds become infected (Loefler, 1998).

Poverty is the most cited reason for the lack of these services as, according to Loefler, "...shortage of facilities, equipment, dressings and drugs, notably antibiotics." (Loefler, 1998) Supporting variables include overcrowding in populated areas where stand-alone facilities exist, insufficient environmental hygiene conditions conducive to the spread of disease, and insufficient maggot control leading to a large infestation of flies throughout (Loefler, 1998).

Research from Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, characterized the aforementioned and observed the following.

"The relationship between the socio-economic status (SES) of a household and its sources of malaria diagnosis and treatment was explored in south-eastern Nigeria. One aim was to see if, as seems likely, the poorest people generally seek care from 'low-level' providers, such as traditional healers and community-based healthworkers, because of their severe budget constraints. Interviewer-administered questionnaires were used to collect information from 1197 randomly selected respondents from four villages where malaria is holo-endemic. An index was used to categorize the study households into SES quartiles. The self-diagnosis of presumptive malaria and the use of patent-medicine dealers for treatment were very common among all the SES groupings. Compared with the other interviewees, however, the least-poor were significantly more likely to rely on laboratory tests for diagnosis and to visit hospitals when seeking treatment for presumptive malaria. The most poor, in contrast, were significantly more likely to seek treatment from traditional healers or community-based healthworkers. Thus, even though the use of low-level providers was so common, there was still evidence of wealth-related inequity -- in terms of the probabilities of the good diagnosis and treatment of malaria. Improvements in the quality of malaria diagnosis and treatment by the providers patronised by the most-poor villagers would help to redress this inequity, at least in the short- to medium-term. (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

A case in Uganda as described by Dennis Burkitt, a physician of British descent:

"First described Burkitt's lymphoma (BL) among Ugandan children in 1958 (Burkitt 1958, 1985). Within the intervening 44 years, the disease has provided scientists with valuable insight into the pathogenesis of cancers, including the possibility of a link with a virus (Ambinder 2003). BL affects the body's lymph system and results in tumours composed of lymphocytes." (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

"Burkitt's tumours arise and grow rapidly. But in poor countries where it is endemic, many affected families can hardly afford even the cost of basic laboratory diagnostic tests, and this readily treatable condition can be a cause of considerable distress and early death in affected children. Our aim is to present an overview of some of the challenges encountered by children and their families in accessing care for BL in south-eastern Nigeria and the impact of this on the disease outcome for the children." (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

The effects of BL depend on the site of the tumour in the body. In African BL, the jaw is the commonest site, where it causes visible swelling of the cheek and loosening of the teeth (Ong et al. 2001). In non-African BL, the tumour commonly arises in the abdomen where it causes swelling and discomfort (Cavdar et al. 1994). Diagnosis is by biopsy from the suspected disease site. Common tests include a complete blood count (CBC), a platelet count, a bone marrow aspiration and biopsy, and lumbar puncture. Further tests may include radiographic examinations such as CT scan to identify occult masses, but the extensive X-ray procedures are not usually needed." (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

"The study was retrospective and covers the period January 1987 to June 2004. Included in this report are children under 15 years of age who had clinical and histopathologic diagnosis of BL and complete hospital records (sociodemographical and medical). Some cases of jaw tumour were not confirmed by histopathology because the parents had no money for this and other laboratory tests." (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

"Facilities for laboratory confirmation were available but nine (22%) of the parents could not afford the fee. One of these parents had their child treated on the basis of clinical assessment only, but eight (19.5) children could not receive any treatment because the parents could not afford the cost. Frustrated by this experience, the parents either absconded or let against medical advice. Seven (17.1%) other cases had monotherapy (only cyclophosphamide), as the parents had only enough to buy this." (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

"Availability of diagnosis facilities and necessary chemotherapeutic agents at affordable cost are vital for effective management of BL. In this report, although laboratory facilities were available, they were not accessible to all the patients. Nearly a quarter of the parents could not afford the costs of confirmatory laboratory tests. One child was treated without histopathological confirmation would expose misdiagnosed cases to adverse effects of these agents with no clinical benefits at all." (Onwujekwe, Ojukwu, Uzochukwu, Dike, Ikeme, Shu, 2005)

The research clearly indicates a lack of not only a cohesive system but also a comprehensive system offering laboratory medical care with immediate access from the urban environment to elemental wild environment. Parasitical inhabitation within human tissue is a related medical issue that requires laboratory and diagnostic work. According to Chappuis, Loutan, Simarro, Lejon, and Buscher, 2005:

"Human African trypanosomiasis (HAT) due to Trypanosoma brucei gambiense or T. b. Rhodesiense remains highly prevalent in several rural areas of sub-Saharan Africa and is lethal if left untreated. Therefore, accurate tools are absolutely required for field diagnosis. For T.b. gambianse HAT, highly sensitive tests are available for serological screening but the sensitivity of parasitological confirmatory tests remains insufficient and needs to be improved. Screening for T.B. Rhodesiense infection still relies on clinical feastures in the absence of serological tests available for field use. Ongoing research is opening perspectives for a new generation of field diagnostics. Also essential for both forms of HAT is accurate determination of the disease stage because of the high toxicity of melarsoprol, the drug most widely used during the neurological stage of the illness." (Chappuis, Loutan, Simarro, Lejon, and Buscher, 2005)

"Quantitative buffy coat. The quantitative buffy coat (QBC; Beckton-Dickinson), initially developed for the rapid assessment of a better discrimination from white blood cells. After high-speed centrifugation of the blood in special capillary tubes containing EDTA, acridine orange, and a small floating cylinder, motile trypanosomes can be identified by their fluorescent kinetoplasts and nuclei in the expanded buffy coat." (Chappuis, Loutan, Simarro, Lejon, and Buscher, 2005)

"The QBC is a very sensitive technique that is very appreciated by most field laboratory workers. It also allows the diagnosis of concomitant malaria, which is very useful for patient care. With a 95% sensitivity for trypanosome concentrations of 450/ml, the QBC can detect more patients with low parasitemia than the mHCT when fewer than eight capillary tubes are used. It is as sensitive as the mini-anion-exchange centrifugation technique." (Chappuis, Loutan, Simarro, Lejon, and Buscher, 2005)

Table 1:

Items

Unit costs/details (local currency, Naira)

Total cost per child treated (Naira)

Cost per child treated (U.S.$)

Laboratory tests at first diagnosis: haematology, histopathology, biochemistry, X-ray, ultra sound

CBC = 350

18.9

Histopathology = 500

X-ray = 600

Ultrasound = 500

Biochemistry = 500

Laboratory tests during follow-up

9.6

Cost of cytotoxic drugs (for 6-course treatment regimen): vincristine, cyclophosphamide, methotrexate

Cyclophosphamide (1000 x 6) = 6000

13 500

Vincristine (900 x 6) = 5400

Methotrexate (350 x 6) = 2100

Other patient costs: bed fee, drips, infusion sets, including cross-match and screening blood for transfusion (1 unit)

Drips (@ 80 x 6) = 320

31.5

Infusion sets (@ 40 x 7) = 280

Bed fee (@ 50 x 28) = 1400

Blood transfusion (cross-match, screening for hepatitis B and HIV) = 2100

Total direct cost per child treated

21 300

US $163.8

Table 1. Direct costs of treating a 7-year-old with Burkitt's lymphoma in Nigeria

Source: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3156.2004.01348.x/full

According to Nicoll, Walraven, Kigadye, Klokke:

"The diagnostic process carried out by clinicians in any country should be supported by reliable laboratory services. In many small hospitals… [END OF PREVIEW]

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