THE BIOMEDICAL 30 Emergency labs SCIENCE THE BIOMEDICAL Emergency labs SCIENTIST 31

Left. Lab Wad Kowli, Ethiopia. Here in the wooden tables had to be built, reagents prepared and English speaking Ethiopians trained. Each patient had a medical card and on this the laboratory results were placed. Photo by Warren Johns. EMERGENCY AND DISASTER SITUATIONS Warren Johns is one of the authors of the WHO book: laboratory facilities in emergency and disaster situations. He talks about his experiences, followed by a review of the book by Neil Bentley OBE from the National Infection Services.

In what aid or refugee camp bringing the total to 10,000. situation did you find the use There were two , at Ta Prik: of the laboratory very important? 550 just across the border and It was detecting which Cambodians further inside Cambodia, Hospital 88. had Plasmodium falciparum, leading to slide positivity rates exceeded establishing a correct diagnosis of malaria 90% for the Ta Prik hospitals. A survey of and treatment of each patient. This was non-symptomatic people from Village 3 in 1980. Diagnosis of malaria based on indicated that over 50% were positive for clinical symptoms alone is not reliable malaria. In the five villages of Ta Prik, – it can result in unnecessary expenditure 70% of the 10,000 were infected with and inappropriate use of antimalarial falciparum malaria. and a delay in establishing a correct diagnosis and treatment of a patient. The What action was taken? use of the laboratory made a considerable At the end of August the difference to the quality of the health care International Committee of the Red Cross of Cambodian refugees in 1980. (ICRC) gave the go ahead for the Ta Prik malaria control knock-down project. What were the circumstances like? Control measures to reduce transmission There were five villages, 40 included: mosquito bed nets, DDT kilometres south of Aranyaprathet, on residual spraying, fogging with the Thailand/Cambodian border. The area Malathion, and . was known as Ta Prik. In June 1980, 3,000 Local Cambodian health workers were Cambodians from the Sakeo Holding trained to make thick and thin blood

IMAGES: WARREN JOHNS IMAGES: WARREN Centre were resettled in the villages smears. Each smear was attached by tape SCIENCE THE BIOMEDICAL Emergency labs SCIENTIST 33

Below. Patients with malaria; mother and baby, Ta Prik, Cambodia. Overleaf. Microscopists at the Ta Prik lab, Cambodia. Photos by Warren Johns.

roads and no telephone, I found the UNHCR/WHO emergency kits were poorly prepared. Essential stains and methanol were missing. Only 300 slides were provided. A Sahli haemoglobin kit (known to be not accurate) was included (without reagents). I could not understand why ESR racks had been included. Clearly, I could not do any lab work. I returned to Khartoum and purchased the missing items.

Did this inspire you to write manuals and books? Yes, I sat down and asked myself “what is necessary and should be included in an emergency laboratory kit?” Later I wrote a manual for Save the Children, Establishing a Refugee Camp Laboratory (1987). The Introduction from that book states: “A refugee camp laboratory […] does not need to be sophisticated or able to perform Ten deaths occurred during this period. The a large range of tests. All that is required is a small number of basic tests which are previous year, 1,000 people died of malaria. done well and which contribute medically and epidemically useful information.” to a small card bearing the patient’s name, The malaria eradication programme age, sex and location ― there was a place began on 8 September 1980 when 68 people So, what happened in Sudan? to write the blood smear result. The other from Village 1 were started on treatment. We established three labs, two in the side had space for details of treatment, the Previously out of a total population east of Sudan (Wad Kowli and Safawa) and number of days and a space for the of 10,000 some 3,000 were infected and one in the west (Umbala), with a total staff signature of the drug administrator. Blood 7,000 exhibited symptoms. When the of nine. In Sudan, early 1984, Save the smear kits were prepared and distributed programme came to an end after six Children had one expatriate staff member to workers in each village. weeks, only 30% were symptomatic. In and nine local staff. By mid 1985, there ICRC had its main laboratory located in all 10 deaths occurred during this period. were 80 expatriate staff and 1,000 local the Thai border town of Aranyaprathet. A The previous year 1,000 people in staff. By February Wad Kowli, the reception small laboratory was built near Hospital Ta Prik died of malaria. camp just 12 km from Ethiopia had a 550 and a dust free staining area was made population of 100,000. Between 3,000 and out of plastic, bamboo and wire. Each day, Have there been any occasions 5,000 people arrived there each day. the medical laboratory visited where things have gone wrong? the site and began training the Cambodian On 31 January 1985 I phoned a recruiting Aside from your book, what else volunteers. Blood films were stained using agency in London and was told about a would you recommend? a quick Giemsa technique. request that had just come in. Save the Two books that were indispensable to Children needed a laboratory technician me during my time in Sudan were District Was the programme successful? for six weeks to work in refugee camps in Laboratory Practice in Tropical Countries Vols 1 & 2, The problem was to control the Sudan. I got the job and arrived in Sudan by Monica Cheesbrough. population, the vector (mosquitoes), the on February 14. This six week job turned malaria and how the malaria drugs were out to be six months. Warren Johns is a medical laboratory administered and monitored. The aim was scientist who has worked for the Red Cross to set up a network that would take care not What happened? and Save the Children, among others. only of malaria, but of other health needs. On arrival in a remote area with poor He has co-authored a number of books. THE BIOMEDICAL SCIENCE 34 SCIENTIST Emergency labs

any countries are term without information vulnerable to disasters technology, reliable mains and emergencies, electrical supplies and piped moreover infectious water. Annex 3 includes do not a check list for laboratory Mrespect regional and country suppliers. This could be boundaries within our global enhanced to include explicit village. In recent times the world advice on selecting commercial has witnessed and responded to kits with heavy consideration of large scale incidents of the performance characteristics international concern, such as Zika and manufacturers established history in Brazil (2015), Ebola in West Africa (2014) for supplying quality materials, possibly and the current Ebola outbreak “at time of HEALTH without the need for a cold supply chain. writing” in DRC Central Africa. The WHO In resource-poor countries, internal works with partners to improve outcomes LABORATORY laboratory quality control testing can be of emergencies and disasters and to minimal, and cost driven. It is important manage the health risks associated with that the tests performed are reliable and them. A rapid response to detect, prevent FACILITIES IN accurate and the limitations are and manage is required to understood. Purchasers need to interpret minimise loss of , limit the economic EMERGENCY quality performance characteristics, which impact in fragile regions, and control the include sensitivity and specificity of the spread of disease. test prior to the selection and procurement This WHO regional publication: Health AND DISASTER of reagents and supplies. laboratory facilities in emergency and disaster This book is recommended as an situations provides a complete 368-page SITUATIONS. ideal reference guide when developing guide to establishing testing facilities in diagnostic laboratory services at pace in an emergency. The book begins with the difficult field conditions. It is clearly laid initial assessment of needs and continues 2ND EDITION, out in a progressive step-wise style and to guide through the selection of required ONLINE OPEN ACCESS. uses plain language suitable for those facilities, equipment and supplies for whom English is not a first language. alongside useful checklists. There is The book is intended for use in emergency consideration of scenarios faced in in operators first language, knows situations, by local or international emergency situations, including portable, how to interpret or forward results, managers with existing laboratory mobile, temporary and established knows procedure to record results”. and experience, but not laboratory facilities and the equipment The publication includes health and necessarily in an emergency capacity. that can be used in each. The essential safety guidelines for the safe handling In such situations, access to functioning selection criteria for laboratory staff is and disposal of samples. In recent computers, internet and resources, such considered. It is often not possible to disasters, laboratory-acquired infections as printers and paper, may be scarce. recruit sufficient numbers of trained staff have claimed the of laboratory and For this book to be utilised in such a and volunteers in emergency situations. healthcare personnel. Annex 16 states situation, printed copies would be The publication does not refer to the that preparation and use of bleach is a very essential. Printed copies would enable management of these situations. important addition that will contribute this publication to be used as a handbook Generic competency checklists for basic to the safety of laboratory personnel. where notes can be made to reflect the procedures, to ensure quality results, and Establishing temporary testing facilities in local situation and decisions. safety of personnel could be included in resource-poor settings with challenging This review covers the laboratory sections supplementary annexes. Such a list healthcare and transport infrastructure is of the book (and not the water sections). should include: “Understands health and considered in this publication. This latest safety procedure for tests, knows sample edition recognises common issues and Neil Bentley OBE is Head of Technical requirements, knows which samples to recommends options that are realistic Services, National Infection Services, reject, has a copy of procedural instructions and can be safely sustained in the short- Public Health England.