Mobilizing TB Lab Services: Portalabs offer high-quality diagnostic capacity at less cost than traditional facilities
José-Angel has been coughing up blood for a month. He remembers his cellmate Luis had the same problem last year, before his release. But then, most of the 40 men in his overcrowded prison dormitory in Lima, Peru, cough most of the time. José-Angel heard that Luis was diagnosed with TB on the outside – he hadn’t troubled the well-intentioned prison health center nurses because he knew they operated with no resources at all.
Prisons are ideal incubators for tuberculosis with rates up to 100 times that of the general population. Severe overcrowding facilitates transmission of this airborne infection and lack of diagnostic capacity prevents early diagnosis and treatment of infectious cases, the mainstay of TB disease control around the world.
But TB laboratories are expensive to build -– typically in excess of $250,000 – and staffing and maintenance costs are not justified by the necessity. After all, TB is only one of many health threats affecting inmates worldwide. Linkage with external laboratories is constrained by the competing priorities of the inmates’ health and security.
Even though there is lots of TB in the Lima prison, the size of the inmate population is insufficient to warrant a permanent TB lab facility – but periodic case finding campaigns need a lab.
So the challenge is to deliver high-quality TB diagnostic capacity from time to time without the economic burden of an expensive lab sitting around unused between campaigns.
In response to this challenge we built the first Portalab – a converted shipping container – in Lima with the support of The Wellcome Trust (UK). Our prior research work in developing the non-commercial MODS (microscopic-observation drug-susceptibility) method for rapid, inexpensive detection of TB and MDR-TB (multidrug-resistant tuberculosis) by liquid culture provided the perfect tool for delivery of high-quality diagnostic testing in a short timeframe and without the need for vast incubator space.
We drew up exciting plans to move the lab around the country, undertaking sequential month-long campaigns of TB testing in all the major prisons. However, as we closed in on a final timetable a huge earthquake struck southern Peru, destroying the hospital and with it the regional TB reference laboratory in Ica, an area historically troubled by MDR-TB.
In that moment, the versatility of the portable TB laboratory was proven. We stuck the lab on a lorry and drove it down to Ica where it became the regional reference laboratory until the hospital was rebuilt. It has subsequentely been donated to the Peruvian National Institute for Health and been moved farther south to provide laboratory support in a region previously devoid of lab capacity.
A continent away in the horn of Africa, Ahmed stares anxiously at his cough-racked brother, who was always fatter than Ahmed, but not anymore. The local clinic lab hasn’t had supplies for microscopy for two months so he can’t be tested for TB and the nurse is reluctant to start treatment without a confirmatory diagnostic test. But there’s nothing available nearby.
(A peek inside Portalab’s two compartments, left.)
In a vivid demonstration of the inverse care law, Somalia is a high TB-burden country without a single TB culture lab. In the course of a TB REACH-supported project, laboratory services have started to be upgraded and this has included delivery (from Peru) of a Portalab to Hargeisa in Somaliland.
The security situation in Somalia and in conflict-affected fragile states around the globe discourages significant investment in infrastructure such as laboratories from which personnel may need to be evacuated at short notice and which may be damaged during periods of unrest. The ability to pick up and evacuate the entire Portalab and withdraw at short notice for deployment in a place of safety is indispensable, enabling otherwise unthinkable delivery of high-quality TB diagnosis.
The inherent portability of the shipping container means such laboratory conversions can be put on boats to travel up the Amazon or down the Irriwaddy, on trucks to isolated district hospitals in India or on trains to remote prisons in the Peruvian highlands, or can be brought into established camps for refugees and the internally displaced. Our original concept was for the improvement of TB diagnosis, but it is entirely feasible to expand lab testing to cover HIV, malaria and non-communicable disease laboratory services within the same facility. The only limitations are imagination and funding support.
The portability facilitates delivery to site but does not demand that the lab is constantly moving around. A brand new, fully equipped category II TB lab for under $100,000 delivered to the door of your hospital without months of builders on-site knocking down walls, cutting through cables, re-routing ventilation? Why not?
The ubiquitous nature of shipping containers provides a potential solution that organizations can exploit themselves through local conversion. In many places there are already companies that can create offices, sleeping quarters, outpatient clinics, even mini-hospitals, from containers.
alcamilabs was created in an attempt to facilitate wider use of the Portalab – the design is not a secret or patent-protected and we welcome and encourage the building of container labs by others, wherever containers can be found.
We hope to be involved in all 22 high-burden TB countries, where the unmet need is enormous, and in smaller countries with no lab at all, by proposing ways in which they can procure the lab and a comprehensive maintenance and training program with support from the Global Fund and other funding agencies. We also plan tiered pricing so wealthier countries will support discounted prices for the poorer.
We have learned a lot over the past five years about how best to build, distribute and support these labs and believe that alcamilabs can make a major contribution to the desperately needed scaling up of TB (and other non-TB) lab services in low- and middle-income countries.
Dr. David Moore is founding co-director of alcamilabs ltd. and also works as an infectious diseases and tropical medicine physician at the Hospital for Tropical Diseases in London and as director of the TB Centre at the London School of Hygiene and Tropical Medicine.