As part of the largest cross-border field simulation exercise ever held in Africa, the mobile laboratories for the EAC region that the German government funds through the German Development Bank KfW, had to operate under realistic emergency-response conditions for the first time. What did the exercise involve and how did the laboratories perform?
Wearing a blue gown and protective clothing, a laboratory technician concentrates hard as he examines a specimen in a glove box, equipped with special filters. It takes ten minutes to inactivate the sample and make it safe. Safety is paramount because he could be handling very infectious organisms such as Ebola or Marburg. One small slip could prove fatal not only for him but for others too.
These are very real concerns for the lab technicians, but today – for once – they are not for real. They are key players in a four-day cross-border Field Simulation Exercise to test preparedness for pandemic responses - the largest exercise of its kind ever to be held in the EAC region. Almost 300 participants and observers took part in a complex, multi-disciplinary and cross-border simulation in 23 different locations in the vicinity of Kenya-Tanzania border at Namanga. The simulation was designed to test both regional responses and operating procedures and a One Health multi-sectoral approach that recognises that pandemics are not just a health issue, but affect the economy, trade and agriculture, tourism, immigration and many other sectors too. More details about the simulation exercise is provided in a separate article.
A timely response
This cross-border exercise was convened by the East African Community (EAC) Secretariat with support from the “Support to Pandemic Preparedness in the EAC Region” project, which the German development agency GIZ implements on behalf of the German Government. GIZ contracted WHO as the technical lead in the exercise and several other regional and international institutions and organizations joined the simulation. It could not have been timelier for countries in the East African region: Right now, neighbouring Democratic Republic of Congo (DRC) is experiencing with the second ever largest outbreak of Ebola, just three years after the world's largest outbreak in West Africa resulted in over 11,000 deaths. At the time of exercise, the outbreak in the DRC has killed nearly 1,400 people and infected over 2,000, and already spread across the border into southern Uganda. On-going conflict and threats to health workers in the DRC have made containment very difficult, and as borders are also very porous and difficult to control, there is a very real threat that the Ebola virus could spread to other countries in the East African Region and beyond.
A three-year project to provide mobile labs to East Africa
As part of the cross-border Field Simulation Exercise, two mobile laboratories were set up in a small room at the health facility in Kenya, and another one on the Tanzanian side of the border in a school room (because there was no room at the health centre). During the exercise, these labs played a key role in analysing mock samples from patients.
The labs are part of a three-year project, funded through German Development Bank KfW on behalf of the German Government, to establish a network of mobile laboratories in East Africa. In total nine mobile laboratories will be provided to the EAC countries and staff from each country are being trained to set them up and use them. The project, being implemented with technical assistance from Bernhard Nocht Institute for Tropical Medicine in Hamburg, is in the initial roll-out training phase. This simulation exercise was the first time trained staff had had a chance to set up and use the mobile laboratories in realistic conditions in the field.
Easily transported equipment
The equipment for each mobile laboratory is stored in 15 hard black boxes that can easily be transported in one large vehicle, and it takes around three hours for the laboratory team to set everything up. The boxes contain all they need, from cables to sockets for connecting directly to electricity supplies, as well as back-up generators to ensure there is no disruption in the power supply supplies that could endanger staff handling infectious samples.
All the lab staff taking part in the exercise are enthusiastic about the mobile laboratory. “It works very well. It is very safe and the lab staff are kept safe,” says participant Abdi Roba, a medical technologist from the National Public Health laboratory in Nairobi. Under the German project he received training at Bernhard Nocht Institute for Tropical Medicine (BNITM) in Hamburg for one month, and then further follow-up training from the BNITM team at the EAC headquarters in Arusha,Tanzania.
The equipment is low maintenance, and the project is also training engineers to maintain the labs. They can also be used by veterinary services, which would be very useful in a Rift Valley Fever outbreak, such as the one being mimicked in the Field Simulation Exercise. Many infectious diseases that pose a threat in the region are zoonoses, which pass from animals to humans.
The exercise scenario for the labs
In the simulated exercise scenario, laboratory results from patients at the health clinic indicate that what looked like an RVF virus is now showing some significant genetic variation and seems in fact to be an unusual and novel virus. Scientists refer to the emerging disease as East Rift Fever (ERF). It shares many of the characteristics of Rift Valley Fever, such as rapid onset, fever and haemorrhagic symptoms. There are growing concerns that this new virus is capable of human-to-human transmission and some anecdotal evidence that this has already started to happen, but the means of transmission are still unknown. A patient admitted to a health facility in Kenya with the suspected East Rift Fever virus variant dies soon after admission.
And the scenario becomes even more dramatic: The number of cases starts to escalate rapidly, as more reports came in of people infected with the disease who have had no contact with animals. There are also reports of health care workers being infected, and this is causing fear and panic and putting immense strain on local resources. All this suggests human-to-human transmission and local and international media interest in the outbreak increases steadily.
Health workers and lab technicians taking part in the exercise are expected to respond to this unfolding scenario and the information they receive as they would in their real jobs, using the equipment they have and following the region’s recently adopted pandemic preparedness Contingency Plans and Standard Operating Procedures. How and why they respond is monitored by exercise facilitators and evaluators, and assessed during and after the exercise to determine strengths and weaknesses in pandemic preparedness.
Speeding up diagnostics
Mobile laboratories for EAC countries shift the frontiers of diagnostic efficiency in outbreak detection in Africa. “It’s a huge advantage to have the mobile laboratory on site,” says Lyndah Makayotto, the exercise facilitator at the Namanga health facility, on the Kenyan side of the border. “Otherwise samples would have to be sent to Nairobi, and it would take four hours to get there and four to six hours for the results to come through.” In a genuine emergency, such a delay could be critical in containing an outbreak. Felix Zelote, from the Regional Laboratory in Arusha, Tanzania, agrees: “The lab is usually the first point for diagnostics, but for anything complicated we have to send to Dar es Salaam – and that can take up to two weeks. So mobile labs would be very useful for speeding this process up.”
Hopes for the future
Dr. Florian Gehre, a microbiologist at the BNITM in Hamburg, is along with his colleague Dr. Muna Affara one of the two German project coordinators supporting the training and running of the East African regional laboratory network for outbreak detection. He says that, unlike other emergency mobile labs in use in Africa which have to be deployed from Europe or elsewhere, these will eventually be owned and managed by EAC member states. The nine laboratories will be placed in Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda and lab technicians are being trained from each of these countries.
A second phase of training is currently being rolled out. “We would like to see in the long term that partners will continue this initiative,” says Dr. Gehre. “From the response so far, I think there is a real commitment from the partner states to make this work.”
As the cross-border field simulation exercise vividly illustrated, this network of mobile laboratories will enable countries to respond in a timely, flexible way to disease outbreaks as they occur, ensuring that valuable time is not lost in any emergency response. For Dr. Affara and Dr. Gehre, the current outbreaks of Ebola in DRC underline the urgency and importance of the project.