August 10 - 31, 2010: final weeks in the lab

I'm actually at home now, but I'll try to finish this up for you. Since the last posting I have spent a bit more time in Maputo on the weekends than I had for a while. At the lab we have fallen into a routine of practicing bacteriological techniques, monitoring the bacterial meningitis protocols, holding weekly journal club sessions and weekly didactic training sessions. The last of the didactic sessions that I conducted was on the Neisseria and Moraxella species.

We also have received a shipment of cryptococcal antigen test kits, a latex agglutination test that is useful for getting started with yet another meningitis protocol. This is the principal etiologic agent of meningitis in HIV+ patients, and one can often detect the antigen in blood prior to development of symptoms. There is some controversy about what to do in such circumstances, but fluconazole is available for treatment. Jose Paulo managed to get a dozen or so CSF samples from the Central Hospital lab so we have been trying out the test kit. On the first try we actually found a positive sample, and as luck would have it, it was positive at a 1:5 dilution but negative undiluted, so I got to teach about the prozone phenomenon as one possible explanation.

By the end of August, we still didn't have the water purification system installed, but the plumbers have come twice to figure out what needs to be done to get ready for installation. If I were living anywhere near Home Depot, I could do this myself in a morning, but they are making a big production out of it. As I prepared to depart, another new biosafety cabinet was moved into the hallway outside the lab where it is sitting until someone takes the front panel off so that it will fit through the door. I'll never see this in operation either. The centrifuge and water bath have been on order since last February, and with constant badgering Jose Paulo has extracted a promise of delivery by October.

Three months is not a lot of time to get a non-functional lab with untrained staff operating, but I think we made real progress. I hope I have left something of value behind with these talented young people. For sure, we have built friendships, confidence and trust in the group. Lena and Charlotte will actually be hired soon and start receiving salaries. Anisha will be hired as a contractor because she does not hold Mozambican citizenship. We lost Yara in the recruitment process because she didn't make the equivalent of our "cert." The Minister of Health made the decision that her pharmacy and nutrition training were too valuable to set aside for a career in the lab, so he wouldn't reverse the HR ruling.

As I prepare to leave, the lab is trying to negotiate a regular flow of clinical samples from the Central Hospital and regional hospital labs. There is a problem with carving out a role for the lab that increases the quality of clinical lab diagnosis without threatening the autonomy of the labs at the various hospitals. I have had conversations with Beth (CDC lab advisor) and Ilesh Jani (the INS director) about this, and they will need to work on the problem. To date the relationship-building had been left to us in the lab.

Here are a few pictures of laboratory operations. As usual the order didn't come out as I expected. The picture at the conference room table is an example of a weekly meningitis protocol meeting with other stakeholders. you can see Jose Paulo and Anisha on one side of the table opposite Winston Tighlman (caucasian physician from San Diego) and Tomas Zimba, the PI on the protocol. Tomas is also the chief of the Bacteriology Laboratory at Maputo Central Hospital. This meeting is in part about the relationship building that I mentioned earlier. Winston is from Chip Schooley's group, and he is in Maputo for a year to try to help strengthen medical services on the wards. His stay is funded by some industry funding that Schooley has managed to patch together. At the present, he is trying to facilitate and improve communications between residents, ward nursing staff and lab personnel in the hope that an increasing number of clinical lab diagnostic procedures will actually result in reports that make it back to the patient charts.

The other pictures are taken in the lab. They include a group picture of Jose Paulo who is actually peering into an empty container (hence the amusement of the others) together with Anisha on the left, and Charlotte and Lena (on the extreme right). The other pictures are of Charlotte examining biochemical test results for a group of enteric bacilli, and someone holding an example of an antibiotic susceptibility test. Oh yes, there is also a picture of Anisha looking at a Gram stain of a clinical sample. It's a really good group. You can see that they are now capable of performing bacteriology lab procedures at a BSL-1 level.

It is noteworthy that they are learning to do bacteriology the same way that I did it 40 years ago because that's the current practice in Mozambique. They are capable of learning updated procedures when the facilities become available. There is one Bactec blood culture machine in the "Urgencia" lab at the Central Hospital, but I haven't seen any other instrumentation in the microbiology labs that I visited. There is instrumentation for Clinical Chemistry and Hematology labs, however, so there is reason to expect that the Bacteriology labs will acquire it eventually. Also note that I have visited only hospital labs in Maputo. In the outlying provinces, things are said to be much less well-developed.

So, there you have it.....the lab as I left it early this month.