In May of 2018, the WHO released the first-ever list of essential diagnostics to improve diagnosis and treatment outcomes to the delight of many champions of antimicrobial resistance across the globe. In Africa, the release of this list was particularly exciting to one doctor in Nairobi, Kenya, who has long been an advocate for the development of such a list.
ReAct Africa, reached out to Professor Gunturu Revathi, Associate Professor of Clinical Microbiology at the Aga Khan University in Nairobi, for her perspective on finally having a standardized essential diagnostics list and what she feels this development will bring to help contain antibiotic resistance, especially for work in Africa.
Why is the WHO essential diagnostic test list important to help contain antibiotic resistance and what does it mean for Africa, and specifically Kenya, in your opinion?
– So far, developing countries have been promoting empirical management strategies of infectious diseases popularly propagated by health ministries as a Syndromic Approach to diagnosis and management. Essentially posters were printed and pasted on the walls of all clinics on the methods of how to look at a patient’s symptoms and with minimum history and NO diagnostic support – to go ahead and prescribe medications. Usually the medication came in a prepackaged combination of agents to cover the most common conditions at the same time. Algorithms were available on how to arrive at a reasonable diagnosis for respiratory infections, gastroenteritis, STDs, urinary tract infections and other diseases. There was no emphasis – or even scant reference – to specific diagnosis through lab investigations or radiological /imaging studies.
“In fact all fevers were treated as either malaria or typhoid with medications to cover both. This scenario of use of multiple antimicrobial agents with no diagnosis over a long time paved way for development of resistance to the agents used among common bacterial agents due to unnecessary over exposure to multiple agents.”
– In fact all fevers were treated as either malaria or typhoid with medications to cover both. This scenario of use of multiple antimicrobial agents with no diagnosis over a long time paved way for development of resistance to the agents used among common bacterial agents due to unnecessary over exposure to multiple agents.
– It remains true that most of the ministries of health (MOH) in Africa do not have a National Diagnostic Policy or National Clinical Laboratory Policy. What the WHO list of essential diagnostic tests should do, is to mount the pressure for such a policy to be inducted and to pave a way for resource allocation for proactively promoting diagnostics in health care facilities. I remain hopeful that this is what will eventually happen.
– Further, the utter lack of antimicrobial resistance data in low- and middle income countries is usually due to the absence of diagnostic labs with standard microbiology capacity. Evidence based clinical practice and rational use of antimicrobials is only possible with the help of specific diagnostics. Consequently, pushing the agenda items of AMS is futile and impossible without providing diagnostic support to the treating physicians. Therefore, a normal progression of having the WHO essential diagnostic list is the development of diagnostic labs, however rudimentary, as a practical approach to systematically managing infectious diseases and tracking antimicrobial resistance data.
What specific aspects of the diagnostic list apply to Africa and is it comprehensive enough for Africa?
– The list contains most of the tests to support diagnosis of infectious diseases. Almost all microbiology lab tests are listed there.
“Where the list fails is – low- and middle income countries do not have the labs that are equipped and the human capacity on the ground — that needs to be built over time.”
– Where the list fails is – low- and middle income countries do not have the labs that are equipped and the human capacity on the ground — that needs to be built over time. The healthcare workers human resource is a challenge. There are barely any clinical microbiologists to man the labs that are already in existence and just as alarming is an acute shortage of clinical pathologists. Further, the shortages of consumables and other resources to conduct the diagnostic tests may be a hindrance to fully benefiting by just having an official WHO list. Standard culture sensitivity tests are needed for critical clinical samples like CSF and blood which can support rational antibiotic prescriptions, which may not always be available in the situations where they are needed.
What actions does Africa need to take in order to implement aspects that address African specific situations? And how can Africa optimize the benefits of having a diagnostic list within its own context?
– Education. Developing countries and their partners have to prioritize funding for high standards of teaching and training in all publicly managed university medical schools. The lack of basic clinical knowledge and skills remains the root cause of irrational use of all kind of medicines including antibiotics. Physical infrastructure with the basic instruments of training on the proper use the facilities are equally important.
– Recently in Kenya, external funded dialysis machines have resulted in the provision of dialysis to be widely available all over Kenya, which is a highly laudable effort. However, healthcare associated infections reported with multi-resistant organisms have spread across the country. Bacteriology cultures are not available in these dialysis centers and serious peritonitis in these patients cannot be diagnosed in these patients, forcing the clinician to use broad spectrum antibiotics blindly to save the seriously sick high risk patient. This is just one example out of numerous similar situations promoting blind use of antibiotics and promoting antibiotic resistance.
– The list of essential lab tests is similar to having essential medicines list of WHO. It is a sterling document that we are happy to have and moving forward, we anticipate, as earlier mentioned, that it will be useful in enabling an environment for a positive national diagnostic policy.
“However, what we (low- and middle income countries) need to realize is, that this document cannot bring the much needed lab services to citizens. Governments will have to do it. Essential medicines list has been around for some time but in low- and middle income countries babies/patients still die in public facilities due to lack of basic drugs.”
– However, what we (low- and middle income countries) need to realize is, that this document cannot bring the much needed lab services to citizens. Governments will have to do it. The essential medicines list has been around for some time but in low- and middle income countries babies/patients still die in public facilities due to lack of basic drugs. The WHO have the statistics of deaths due to absence of simple and cheap drugs like ampicillin/penicillin/ even IV fluids or IV sets to administer fluids. While the WHO, having listed the essential medicines very well, cannot provide these essential medicines to the public facilities where the very poor citizens of low- and middle income countries seek healthcare. I am afraid the same is true for list of essential lab tests.
What do the next steps look like?
– The urgent steps ideally are immediate investments in laboratory capacity and clinical/healthcare worker training. Unfortunately, the recent lecturers, medics and nurses strikes in Kenya are not encouraging. However, utilization of the WHO essential diagnostic tests lists should be of great value to all African healthcare workers.
Professor Gunture Revathi
Professor Gunturu Revathi has 25 years of professional experience in teaching undergraduate and post graduate medical students and in clinical diagnostic work. She is a member of several national and international professional bodies such as ISID, ESCMID, KACP, APECSA, and ERS, Technical advisory committee for National Program for Tuberculosis and Leprosy, National committee on Infection prevention and control, National Antimicrobial Stewardship committee, Kenya National committee on Infectious and Parasitic Diseases Research Program (IPDRPC), National working group for Clinical Management and Referral guidelines of Ministry of Health, Global Antimicrobial resistance Partnership (GARP).