January 19 - Central Public Health Labs

We got the unique opportunity to start our day at Central Public Health Laboratories (CPHL). The CPHL is where all the nation’s biological samples are sent - blood, urine, and tissue samples, for example. Having visited the peripheral and regional health centers and hearing about where the pathology samples ended up, it was really energizing for us to have the opportunity to go down to CPHL to get an understanding of how the samples are processed once they end up there. (We really have Dr. Dan Milner to thank for the introductions that led us there, as well as the CPHL leadership that was very welcoming and accommodating) On top of that, we wanted to understand what was really the cause for the long turnaround time for doctors and patients who are waiting for their results back home.

The Hub System

We made our usual introductions and were soon given a presentation on the hub system by Rebecca Nakidde, who is responsible for the National Transport Hub System. Key health centers serving large populations are organized into hubs - these hubs include a minimum of HC4s and other facilities which contain lab capabilities. These hubs serve to collect samples from other peripheral centers (~20) by motorcycles or ‘boda’ riders. There are vehicles which then each serve 4-5 hubs, collecting samples from each biweekly and delivering them to the CPHL. The turnaround time (TAT) for delivery has been reduced significantly since the transport system shifted from using the Posta system for the second stage of transporting samples to CPHL vehicles. The current TAT for sample delivery from collection is ~5-9 days from the original 30 days.

Infographic showing the Sample Transport Network

However, there are challenges for the pathology samples. The Transport System is supported by funds for infectious diseases from organizations such as the USAID. As such, the system caters for the delivery of blood and other samples testing for infectious diseases, though it also carries pathological samples. Key consequences of that include the fact that healthcare workers (HCWs) collecting samples for these diseases such as HIVs are more aware of the transport system. There are also electronic dashboards and containers catered for such samples while health facilities are often told to improvise -- as we have witnessed in regional hospitals. Some of these facilities use urine sample containers to contain core needle biopsies of the breast and interestingly or rather unfortunately, the samples get confused and sometimes sorted incorrectly at the CPHL when the sample request form indicating the details of the samples are not securely attached to the container. Dr. Annet attributes the main challenge of pathology process a lack of coordination among the different stakeholders involved in the process, including the lack of coordination of effort in improving the system.

Sample Reception point for samples being delivered from all over the country

As for the sample timeline, we learnt that sample delivery takes 5-9 days. Distribution of the samples to their respective locations (Mulago hospital for tissue samples, for example), take a day or less. When the samples arrive at pathology labs, the results can be expected in around 10 days. What was interesting is that the largest cause of delay was seen to be the delivery of results back to the requestor, which Rebecca said can take more than a month.

All in all, it was a fruitful visit that helped us understand the pathology pathway from a higher level and helped us establish relationships with people who are able to provide an overarching view of the pathology pathway. We were also told that we can reach out to the program director, Dr. Susan Ndidde for collaboration and to facilitate our future work.

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Lunch with Dr. Ononge

We spent lunch at Mulago Guest House to catch up with Dr. Sam Ononge, whom we have met in August. Dr. Sam is a professor and clinician in obstetrics and gynecology at Kawempe hospital. He is a close contact to Dr. Moses Galukande, who had supported our early discovery of breast cancer challenges. We had mostly a casual conversation over lunch, but he also shared about the different pathology labs that are available in the nation. One thing we learnt was that the there is a pathology lab in Mbarara University, which does pathology testing on its own samples and slightly reduces the load on Mulago. This will be the case for Lira University Hospital when Dr. Francis Olwa’s lab is setup with equipment.

TLDR;

• Pathology timeline lacks coordination

• The longest component for testing is the return of results, which can take more than a month. The transport and pathology work takes ~20 days.

• Non-communicable diseases (NCDs) do not have as much support as infectious diseases, which can be observed from the infrastructure (testing and transport of samples) present at CPHL.

• The Transport System is well-planned and has been making improvements in shortening TAT. There remains challenges on intricacies on-the-ground to improve uptake of the transport system and adherence to the proper procedures by different stakeholders.

• The administration at CPHL would be a good collaborator for our project

Monkey at Mulago Guest House