{"id":46688,"date":"2020-02-20T18:34:34","date_gmt":"2020-02-20T17:34:34","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=46688"},"modified":"2020-03-02T14:44:43","modified_gmt":"2020-03-02T13:44:43","slug":"laura-hallas-covid-19-is-a-timely-reminder-we-need-to-improve-global-diagnostic-capacity","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/02\/20\/laura-hallas-covid-19-is-a-timely-reminder-we-need-to-improve-global-diagnostic-capacity\/","title":{"rendered":"Laura Hallas: Covid-19 is a timely reminder we need to improve global diagnostic capacity"},"content":{"rendered":"<p class=\"standfirst\"><em>We need to think of diagnostic capacity beyond crises, says Laura Hallas<\/em><\/p>\n<p><!--more--><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-46124\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/11\/2018-02-01_Laura_Juan24510-1.jpg\" alt=\"\" width=\"159\" height=\"188\" \/><\/p>\n<p><span style=\"font-weight: 400\">On Friday 14 February 2020, the first <\/span><a href=\"https:\/\/www.theguardian.com\/world\/live\/2020\/feb\/14\/coronavirus-latest-updates-wuhan-hubei-china-deaths-cruise-ship-sydney-cases-covid19-live-news\"><span style=\"font-weight: 400\">case of the novel coronavirus, covid-19 was confirmed in Africa<\/span><\/a>\u2014<span style=\"font-weight: 400\">\u201cconfirmed\u201d being a crucial word. In the past few weeks, low and middle income countries (LMICs) <\/span><a href=\"https:\/\/www.reuters.com\/article\/us-china-health-diagnostics-focus\/countries-rush-to-build-diagnostic-capacity-as-coronavirus-spreads-idUSKBN2042DV\"><span style=\"font-weight: 400\">have rushed<\/span><\/a><span style=\"font-weight: 400\"> to build the capacity needed not only to isolate and treat patients suspected of having covid-19, but also to find them in the first place. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Two weeks ago, <\/span><a href=\"https:\/\/www.reuters.com\/article\/us-china-health-diagnostics-focus\/countries-rush-to-build-diagnostic-capacity-as-coronavirus-spreads-idUSKBN2042DV\"><span style=\"font-weight: 400\">only two<\/span><\/a><span style=\"font-weight: 400\"> laboratories on the African continent had the capacity to diagnose coronavirus, <\/span><a href=\"https:\/\/twitter.com\/devisridhar\/status\/1227871179962306560\"><span style=\"font-weight: 400\">raising<\/span><\/a><span style=\"font-weight: 400\"> the concern that there may be more people with covid-19 needing care in LMICs, but that we are missing them. Covid-19 is a pressing reminder that the best hope for effective outbreak control, and everyday care, is for diagnostic capacity to be prioritised before a disease ever makes headlines.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The recent surge in diagnostic capacity has been impressive. Led by the World Health Organization (WHO), Gates Foundation, and a multitude of regional organisations such as the Africa CDC, <\/span><span style=\"font-weight: 400\">massive investments<\/span><span style=\"font-weight: 400\"> have been made to expand testing capacity in Africa. <a href=\"https:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(20)30355-X\/fulltext\">As reported in <\/a><\/span><span style=\"font-weight: 400\">the <\/span><i><span style=\"font-weight: 400\">Lancet, <\/span><\/i><span style=\"font-weight: 400\">South Africa\u2019s National Institute of Communicable Diseases and Senegal\u2019s Institut Pasteur were initially the only laboratories on the continent, but by 4 February Ghana, Madagascar, Sierra Leone, and Nigeria were also able to administer testing, with the WHO since claiming capacity has expanded to 11 countries, with more joining the ranks every day. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Going from two facilities responsible for an entire continent to more widespread coverage is no doubt a substantial improvement. Yet even these gains cannot address the more fundamental challenges affecting patients every day.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">There is no shortage of information about the current state of diagnostic care in many LMICs. One <\/span><a href=\"https:\/\/www.who.int\/bulletin\/volumes\/95\/11\/17-191916.pdf\"><span style=\"font-weight: 400\">study<\/span><\/a><span style=\"font-weight: 400\"> of 10 countries in Africa, Asia, and the Caribbean discovered that just 2% of health facilities could perform basic testing such as malaria, HIV, and blood glucose tests. Another study in Uganda <\/span><a href=\"https:\/\/journals.plos.org\/plosone\/article?id=10.1371\/journal.pone.0064661\"><span style=\"font-weight: 400\">found<\/span><\/a><span style=\"font-weight: 400\"> that only 5% of laboratories in and around Kampala met WHO quality standards. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Quality diagnostics that do exist are often extremely costly\u2014a HIV test in one Ghanian programme <\/span><a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0168851004001599?via%3Dihub\"><span style=\"font-weight: 400\">costs<\/span><\/a><span style=\"font-weight: 400\"> five times the minimum daily wage. In 2013, sub-Saharan Africa&#8217;s ratio of pathologists to population was <\/span><a href=\"https:\/\/www.thelancet.com\/journals\/lanonc\/article\/PIIS1470-2045(12)70598-3\/fulltext\"><span style=\"font-weight: 400\">just 10%<\/span><\/a><span style=\"font-weight: 400\"> that of the US&#8217;s or UK&#8217;s. Many countries have no certified pathologists at all, and one study notes that it will be<\/span><a href=\"https:\/\/login.lshtm.ac.uk\/nidp\/saml2\/sso?id=KeyshieldSSO&amp;sid=4&amp;option=credential&amp;sid=4\"><span style=\"font-weight: 400\"> more than<\/span><\/a><span style=\"font-weight: 400\"> 400 years at current education levels until medical schools in sub-Saharan Africa can fill the gap. These statistics are likely underestimates of the scope of the issue, as data on diagnostic capacity and quality are not routinely gathered.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Thus far, global action on diagnostic capacity has bypassed patients\u2019 everyday needs to focus on epidemic scenarios, as we are seeing with covid-19. The International Health Regulations (IHR) and its subsequent revisions have always emphasised infectious diseases, such as cholera, smallpox, and Ebola. The <\/span><a href=\"https:\/\/www.who.int\/ihr\/publications\/9789241580496\/en\/\"><span style=\"font-weight: 400\">2005 IHR<\/span><\/a><span style=\"font-weight: 400\">\u00a0and its following 2015 (read: post-Ebola) <\/span><a href=\"https:\/\/www.who.int\/ihr\/publications\/WHO_HSE_GCR_2015.13\/en\/\"><span style=\"font-weight: 400\">workbook<\/span><\/a><span style=\"font-weight: 400\"> solidified this by explicitly focusing on the way that infectious disease affects travel and trade. The legacies of SARS, MERS, and Ebola <\/span><a href=\"https:\/\/ghsagenda.org\/home\/about-the-ghsa\/\"><span style=\"font-weight: 400\">sparked<\/span><\/a><span style=\"font-weight: 400\"> the Global Health Security Agenda, which was constructed to provide more specific guidance to LMICs looking to comply with the IHR. And alongside every meeting, conference, and regulation are parallel influxes of cash from donor countries like the US and UK\u2014money that comes with the implicit goal of keeping disease at bay, keeping it <\/span><i><span style=\"font-weight: 400\">elsewhere<\/span><\/i><span style=\"font-weight: 400\">.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Experts have made it clear that we need to think of diagnostic capacity beyond crises. We can begin to achieve this goal in several ways. Firstly, national governments can embrace the 2018 Essential Diagnostics List (EDL). Like the Essential Medicines List before it, the EDL recommends quality, cost effective diagnostics for common conditions that mark a valuable starting point for governments to begin their own national list and meet local testing needs. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Secondly, diagnostic care must be made financially viable, both through reimbursement under national universal health schemes, as well as through adequate subsidies in international programmes. Health workforce must be addressed by strengthening education pathways to pathology careers and ensuring that, upon graduation, these doctors and laboratory technicians have adequate working environments. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Finally, public health institutions should continue to support regional quality control initiatives like those run by the Africa CDC to improve disease surveillance. While much work remains, these changes would both strengthen the world\u2019s epidemic preparedness and improve everyday care in LMICs.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Ultimately, the argument for diagnostic capacity building lies with its human costs. When coronavirus testing kits <\/span><a href=\"https:\/\/www.nytimes.com\/2020\/02\/09\/world\/asia\/china-coronavirus-tests.html\"><span style=\"font-weight: 400\">ran out<\/span><\/a><span style=\"font-weight: 400\"> in Wuhan, patients were sent home with inadequate treatment, potentially to their deaths. We see the failures of diagnostic capacity when HIV diagnosis is too expensive in Ghana, TB testing requires days of travel in Tibet, or a Haitian mother cannot manage her diabetes. And then there are the millions of people who live with\u2014and die of\u2014diseases whose names they will never know. This latest epidemic should mark a turning point for these patients.<\/span><\/p>\n<p><em><strong>Laura Hallas <\/strong>is a public health student at the London School of Hygiene and Tropical Medicine. <a href=\"https:\/\/twitter.com\/LauraHallas\" target=\"_blank\" rel=\"noopener noreferrer\">@LauraHallas\u00a0<\/a><\/em><\/p>\n<p><strong>Competing interests:<\/strong> None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>We need to think of diagnostic capacity beyond crises, says Laura Hallas [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/02\/20\/laura-hallas-covid-19-is-a-timely-reminder-we-need-to-improve-global-diagnostic-capacity\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":46690,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[263],"tags":[],"class_list":["post-46688","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-global-health"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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