Establishing a simple and sustainable quality assurance program and clinical chemistry services in Eritrea.

BACKGROUND: As chronic diseases become more prevalent in developing nations, establishment of sustainable clinical chemistry services will become increasingly important. The complexity of automated instruments, coupled with a lack of resources and skilled workers, will present a challenge for these countries. METHODS: A system emphasizing simplified instrumentation, single source reagents, technical education and support, and simple QC algorithms was established in the small African nation of Eritrea. The same reagents were used on different analyzers, as well as the same lot numbers of QC material. To allow traceability of Eritrea results to an accredited US laboratory, the reagents and QC materials were identical to those used in a large university hospital in the US, and patient samples were frequently exchanged between locations. RESULTS: QC values for 23 clinical chemistry tests in the Eritrean National Health Laboratory compared well to values obtained in the US, showing some statistically different values but no clinically significant differences. QC values were also stable over time in Eritrea. Patient sample values from Eritrea correlated well to values from the US, with r values ranging from 0.71 to 0.99. For 9 chemistry tests, small regional laboratories in Eritrea produced QC and patient values that usually compared well to those from the Eritrea National Health Laboratory, but markedly discrepant values were occasionally observed that prompted investigation. CONCLUSION: A simple but sustainable national laboratory system has been established in the developing nation of Eritrea.

Impact of a multidisciplinary intervention for diabetes in Eritrea.

BACKGROUND: When hemoglobin A1c (HbA1c) testing was made available to diabetic patients in the nation of Eritrea, the majority of values were markedly increased. As a result, a multidisciplinary clinical education program was instituted in Eritrea and the rate of HbA1c testing was increased to monitor progress. METHODS: In February 2003, a cooperative diabetes project was initiated in Eritrea to train diabetes educators, enhance physician education, create patient-teaching materials, and promote glucose monitoring. Two additional visits were made in 2003 and 2004. HbA1c values from January 2003 to November 2004 (n = 3606) were reviewed to assess diabetic control for the population and for a subset of individual patients (n = 350). A cohort of 209 diabetic persons were evaluated for demographics, treatment, and prevalence of complications. RESULTS: The cohort of 209 patients was 34% female and had a mean (SD) age of 50.5 (15.5) years and diabetes duration of 8.6 (6.3) years. Prevalence of hypertension was 37% and proteinuria 6%. For diabetes treatment, 59% received insulin therapy, 35% received oral agents, and 6% received nonpharmacologic treatment. HbA1c values improved significantly between the 1st 6 months of 2003 (median 10.9%) and the last 6 months of 2004 (median 8.5%; P <0.001). Individual patients in whom 2 HbA1c values were measured > or =3 months apart showed a significant mean decrease of 0.5% (P <0.001). CONCLUSIONS: Our experience suggests that the combination of sustainable upgraded laboratory services and training in clinical management leads to sustainable improvement in diabetes care in developing countries.

Determining the burden of tuberculosis in Eritrea: a new approach.

OBJECTIVE: To obtain an estimate of the prevalence of new cases of smear-positive tuberculosis in Eritrea using a new low-cost approach. METHODS: The study was designed to include a sample of 35,000 people divided between 40 clusters. The clusters were selected by sampling proportional to population size. In each cluster, census data were obtained from eligible individuals. Individuals aged 15 years or more were questioned about cough and its duration and smoking and were asked to provide two samples of sputum (spot and morning) for examination by fluorescence microscopy. FINDINGS: A total of 38,032 individuals were included in the study. Of the 19,197 individuals aged 15 years or more, 18,152 (94.6%) provided at least one sample of sputum. Fifteen individuals fulfilled the case definition, providing a prevalence of new cases of smear-positive tuberculosis of 90 per 100,000 (95% confidence interval, CI, 35-145 per 100,000) individuals aged 15 years or more and 50 per 100,000 (95% CI, 19-80 per 100,000) in the total population. CONCLUSION: The estimated prevalence of new cases of smear-positive tuberculosis obtained from our study is considerably lower than the estimate published by the World Health Organization. The new methodology for surveys to determine the prevalence of tuberculosis that we used is feasible in the field. This methodology should be validated in other countries and compared with other methods for measuring prevalence.

Use of a major medical center clinical laboratory as a reference laboratory for a developing country: ordering patterns help set laboratory priorities.

BACKGROUND: The test menus for developed and developing countries may differ, depending on many factors, including the expected volume of testing, disease frequency and therapies available, clinical impact of the test, technical skill and equipment needed, cost, the patient population served, and whether alternative testing sites are available, and some of them may not be exactly known. We assessed test priorities in a developing country by making a broad range of tests available and then assessing which tests were actually used by the physicians in the country for the care of their patients. METHODS: The Barnes-Jewish Hospital laboratory and Washington University Medical Center provided patients in the developing country of Eritrea access to the same tests as patients in St. Louis for all analytes that are stable at 4 degrees C, the lowest temperature that could be used for shipping. RESULTS: The use of the St. Louis laboratories increased steadily from 1998 to 2001. More than one-half of the physicians in Eritrea used the reference laboratories, with requests for thyroid function and female fertility representing 48-71% of the test requests over the 4 years evaluated. The high degree of utilization for these test batteries was not predicted. Testing for thyroid function, female fertility, and lipid panels are now performed, or soon will be performed, in Eritrea based on the experience of the reference laboratory system. The reference laboratory system is continuing so that the test priorities of the country can be evaluated on an ongoing basis and specialized tests can be made available at a low cost. CONCLUSION: The experiences of a reference laboratory for a developing country can help to identify unanticipated priorities for medical testing within the country.