The future of the National Public Health Institute, widely known as the “reference lab,” is uncertain with the imminent end of funding from the US-based Centers for Disease Control and Prevention (CDC), according to Director Dr Nadira Ramcharran.
The laboratory, which opened its doors in 2008 with funding from the CDC, has been doing early infant HIV diagnosis, which in the past had required that samples be sent to Africa or the rapid test being administered to the baby only until after 18 months.
Importantly, the lab may soon be able to do tuberculosis (TB) culture tests that would within hours indicate whether a patient is resistant to the main drug used to fight the disease. This is being made possible through the lab’s procurement of a gene-expert machine.
Admitting that there have been some setbacks, such as the laboratory being unable to receive an important international accreditation mainly due to the fact that it has been unable to have one year of uninterrupted service, Dr Ramcharran nevertheless revealed that she is happy with some of the progress made so far as the laboratory has been undertaking some very important testing. The lab’s services have been interrupted mainly in instances where equipment has been out of operation or where there has been insufficient reagents.
In an exclusive interview with the Sunday Stabroek, Dr Ramcharran signalled that her present concern is the lab’s immediate future as it stands to lose some of its vital staff members should the Ministry of Health be unable to offer them favourable salary packages on par with what they are now being paid through CDC funding.
As of December 31 this year, the CDC would no longer be funding salaries for any staff member and the director is fearful about what the future holds for the functioning of the laboratory.
She explained that of the 11 medical technologists on staff, five are employed directly by the CDC and they may look to leave the lab unless the ministry offers them favourable salary packages, which is not a certainty.
“So, one of the concerns is that come December 31, the lab would be five medical technologists less and should that happen the entire…the entire CD4, the entire quality department will go…,” Dr Ramcharran said, before adding that the quality department is very important as it oversees all the other operations of the lab to ensure that quality is put in place.
“I am not too sure what will happen. I hope I don’t sound too negative but that is one of the realities,” the director said, candidly, before adding that the Ministry of Health has been working with the Public Service Ministry in an effort to arrive at a consensus on a favourable salary scale for the affected staff members. Currently, she said, the psyche of the staff has been affected by the impending end of CDC funding.
Since 2012, the CDC funding has been scaled down and the Ministry of Health assumed responsibility for the purchasing of items, such as reagents. The ministry also started to maintain the laboratory building and pay the salaries of some staff members.
Chikungunya testing
Meanwhile, Dr Ramcharran disclosed that Guyana will be unable to test for the mosquito-borne chikungunya virus in the near future due to some difficulties experienced in the sourcing of testing kits.
Since the virus was first diagnosed in May, she said, samples were sent to the Caribbean Public Health Agency (CARPHA) in Trinidad, which assisted in the initial stages. However, after making diagnoses in many areas and being bogged down with samples from other nations, a decision was taken to limit samples per area. “If a village was already diagnosed and they already established that there were five persons there, they would not test for that village, they would move on to another village,” Dr Ramcharran explained.
She said a decision was subsequently taken to only test samples from new areas in Guyana and the number of samples being sent out have greatly reduced as a result. So far, all the regions except for regions One, Seven, Eight and Nine have had documented cases of the virus.
She also disclosed that the reference lab took the decision to order two different brands of enzyme-linked immunosorbent assay (ELISA) kits that were already approved by the World Health Organisation (WHO) in an effort to have testing for the virus done in country. It ordered twenty kits each of the two brands but has only received one set as the second was delayed because there was a complaint from a country that has used it and distribution of this particular brand has been put on hold for the next six months. According to Dr Ramcharran, with only one set of kits the lab would not be able to verify the testing which is important. “Because if this kit is not working, although WHO has approved it, if in our setting it is not the best thing in terms of how many samples can be run at one time, how long it would take… it is like a feasibility and so we needed two to run them side by side…,” she explained.
“Offering the test to the public, we would be shooting ourselves in the foot…,” she added.
Another kit may be available but the lab needs to ascertain whether it is WHO-approved.
That aside, Dr Ramcharran said local physicians are “doing a great job” by managing patients very well and so far there have been no deaths in Guyana from the virus. “I think we have done well as a country, although the laboratory part is not there we have managed [the virus],” she said, adding that it is a viral illness and has no cure and has to be managed symptomatically.
Currently most of the diagnoses are being done clinically and patients receive the treatment for the various symptoms.
In relation to testing for the Ebola virus, which is currently wreaking havoc in some African countries, Dr Ramcharran explained that it requires “level-four” laboratory testing. “But in the entire Caribbean there is no level four facility,” she said revealing that should Guyana require testing the sample would have to be sent to the CDC in the US or the Public Health Agency of Canada. The CDC has already signalled its support if needed.
The Ministry of Health has held several stakeholders meeting on the disease and a draft protocol has been established to be used countrywide.
‘Still some challenges’
While the lab has made tremendous progress, Dr Ramcharran disclosed one of the main things that she is unhappy about is the fact that it has been unable to obtain accreditation from an international accreditation body in Canada. One of the main requirements to achieve such accreditation is the lab having uninterrupted service for at least one year.
“[We] should always have people doing the tests, should have reagents always and should have equipment working [but] that hasn’t happened for one [straight] year. We haven’t been able to do that and with the uncertainty of staffing and all of that, I would say it [the accreditation] wouldn’t be too soon,” she said.
According to Dr Ramcharran, accreditation from an international body is very important as it would put the lab “on the map.”
But she maintained that lab is the pride of the Ministry of Health, while pointing out that there is no other of its kind in the country.
Not knowing “there were all these challenges with CDC and other things,” Dr Ramcharran said she moved to the lab with the intention of offering a lot due to her clinical experience as a physician and a lab technician. With this experience, she said, she thought she would have been able to effect a lot of changes and according to her she “has done this to some extent.”
She cited the submission of a “transition plan” with the help of staff to the Ministry of Health, which forwarded it to the Public Service Ministry. The lab is yet to become part of the legal framework of the Public Service Ministry, which is what she had hoped would have happened with the transition plan but it is still “in the works.”
There were some challenges when she joined, such as no HIV kits to screen blood and some equipment not being regularly maintained, but these instances have been greatly reduced and she has helped with procurement to some extent. “There are still some challenges [but] I believe it is better,” she said.
Dr Ramcharran is a trained medical technologist who later became a general practitioner. She worked with the Georgetown Public Hospital Corporation then moved over to the TB programme as the physician before she became director of the reference lab, where she has been for the last year and a half. She is currently reading for a Master’s in Public Health.
