Prior to the Ebola virus disease outbreak in Liberia, the laboratory system was duplicative, fragmented and minimally coordinated. The National Reference Laboratory was conceptualised to address the existing challenges by promoting the implementation of effective and sustainable laboratory services in Liberia. However, in a resource-limited environment such as Liberia, progress regarding the rebuilding of the health system can be relatively slow, while efforts to sustain the transient gains remain a key challenge for the Ministry of Health. In this paper, we describe the pre-Ebola virus disease laboratory system in Liberia and its prevailing efforts to address future emerging infectious diseases, as well as current Infectious diseases, all of which are exacerbated by poverty. We conclude that laboratory and diagnostic services in Liberia have encountered numerous challenges regarding its efforts to strengthen the healthcare delivery system. These challenges include limited trained human resource capacity, inadequate infrastructure, and a lack of coordination. As with most countries in sub-Saharan Africa, when comparing urban and rural settings, diagnostic and clinical services are generally skewed toward urban health facilities and private, faith-based health facilities. We recommend that structured policy be directed at these challenges for national institutions to develop guidelines to improve, strengthen and sustain diagnostic and curative laboratory services to effectively address current infectious diseases and prepare for future emerging and re-emerging infectious diseases.
The primary focus regarding the implementation of effective and sustainable laboratory services in Liberia was accentuated with the conceptualisation of the National Reference Laboratory (NRL) in 2008.
Liberia has gradually been rebuilding its healthcare delivery system after 16 years of devastating civil conflicts which erupted in December 1989, destroyed the country’s health infrastructure
Accordingly, laboratory-based service delivery in Liberia has been basically defined in several key policy documents
Liberia’s laboratory system was initially classified into a three-tiered health system structure consisting of the: (1) National; (2) County (main political sub-divisions); and (3) Peripheral (health centres and clinics) levels.
In general, there are two main categories of laboratory services in Liberia. The first is the clinical laboratory services designated for clinical specimen testing for diagnostic purposes and the second is public health laboratory services directed at disease surveillance.
According to its mandate, the NRL has a four-fold responsibility: (1) perform diagnostic testing services on specimens for diseases with epidemic potential that are under surveillance, especially those that are immediately notifiable to the World Health Organization, now inclusive of Ebola virus disease (EVD), as required by the International Health Regulations; (2) oversee the network of public laboratory structures within the country and the provision of services through quality assurance, training, monitoring and supportive supervision; (3) assess new and available technologies; and (4) provide technical advice to the Ministry of Health.
Similar to the NRL, the NDU conducts quality assurance, monitoring and evaluation, and training. Furthermore, it coordinates procurement processes for the distribution of laboratory commodities for special programmes supported by the Global Funds, such as HIV, AIDS, malaria and tuberculosis programmes. When constructed, the regional laboratories will support the NRL in its surveillance testing (i.e., its mandate for public health laboratory services), as well as the county-level coordination of the activities of the laboratory system. In addition, they will lend diagnostic support to the laboratories at the county hospitals.
These structures are responsible solely for clinical specimen testing for diagnostic purposes. Test categories include, among others, chemistry, haematology and parasitology. Apart from the traditional structures indicated for service delivery, certain programs of the Ministry of Health are also involved in cross-cutting testing activities (laboratory clinical diagnosis and public health surveillance purposes). These programmes include: (1) the National AIDS Control Program; (2) the National Malaria Control Program; (3) the National Tuberculosis & Leprosy Control Program; and (4) the National Blood Safety Program.
Laboratory equipment, reagents and supplies for the operations of the various laboratory structures are either procured by the Ministry of Health or donated by international partners. The operation of the procurement activities is performed by two organisations: (1) the National Drug Service; and (2) the Global Fund, which supports the HIV, tuberculosis and malaria programmes. Both of these key operational processes (procurement and donations) for the effective functionality of the laboratory system in Liberia exist without defined ‘Maintenance and/or Service Contracts’.
There are two accredited faith-based and one publicly-owned laboratory training institutions in Liberia. These are: (1) the Mother Patern College of Health Sciences in Monrovia, Montserrado County; (2) the Phebe School of Nursing in Suacoco, Bong County; and (3) the Tubman National Institute of Medical Arts in Monrovia. The qualifications offered by these training institutions, based on a duration of training that ranges from 2–4 years, includes Diploma in Laboratory Science (Tubman National Institute of Medical Arts and Phebe School of Nursing); Associate of Science and Bachelor of Science in Laboratory Technology by the Mother Patern College of Health Sciences.
The status of the existing laboratory structure and service delivery system in Liberia is characterised by numerous challenges, which were uncovered during the EVD outbreak in Liberia that became a major public health problem in the country and the sub-region.
Lack of integration between public health surveillance and laboratory diagnostic services, resulting in fragmented service delivery.
Lack of a well-defined organisational structure with clearly-defined objectives, including existing duplications of roles and responsibilities within the tiered laboratory systems to support an effective leadership and management system.
Lack of adequate financial resources for infrastructure support and operational costs.
Inadequately trained laboratory workforce, including inadequate deployment across the country.
Unavailability of maintenance and service contracts for procured and/or donated laboratory equipment and supplies to sustain the effective operation of the laboratory infrastructure.
Lack of adequate biomedical equipment technicians to maintain and repair laboratory equipment.
Unstable electric power supply and inadequate water supply for laboratory service utilisation.
Lack of effective Laboratory Information Management System for coordination, operations, and the efficient functionality of the various tiered systems.
Despite these challenges, efforts were directed at the development of a National Laboratory Policy to prioritise the delivery of laboratory services within the health system.
We recommend that a joint public–private partnership team be established to conduct a comprehensive technical assessment of the laboratory system within the country and provide appropriate recommendations to combat emerging infectious diseases. Enhancing the laboratories’ capacity for research requires: the availability of essential equipment and appliances; development of relevant and sustained human capacity through continuing education, on-the-job training and mentorship; formulation and adherence to guidelines and standard operating procedures, and compliance with Good (Clinical) Laboratory Practice and other international standards, such as ISO 15189.
The EVD outbreak in Liberia has necessitated improved laboratory capacity to respond to an epidemic of emerging infectious pathogens as well as support for the development of a suitable research platform during such public health emergencies. Accordingly, we propose a framework to strengthen the laboratory system of the country based on a preparedness strategy to mitigate future outbreaks of emerging and re-emerging infectious diseases (See
Proposed mechanism for strengthening the laboratory system in Liberia.
Laboratory and diagnostic services in Liberia have encountered numerous challenges regarding their contributions toward the strengthening of the healthcare delivery system in Liberia. These challenges are a consequence of limited trained human resource capacity, inadequate infrastructure, and lack of coordination among the four tiers. Diagnostic services are skewed in urban health facilities as compared to those in rural communities, and also skewed in favour of private and faith-based health facilities when compared to public health facilities. These disparities are markedly observed throughout the country and significantly impact patient care and emergency situations. The lack of in-country diagnostic laboratories for the diagnosis of viral haemorrhagic fevers, such as Lassa fever and EVD, prior to the EVD outbreak, confirmed the limitations and challenges the country faced with regard to diagnostics services. Prior to the EVD outbreak, suspected Lassa fever specimens were transported to Sierra Leone for diagnostic confirmation, which significantly increased the duration of the reporting and turnaround time for case confirmation, especially in a Lassa fever-endemic country, such as Liberia. Limited training of laboratory personnel in molecular diagnostic techniques, and laboratory response in a health emergency, were also a major challenge.
Disease surveillance on the national level has been limited to a paper-based system. Protracted turnaround time and delay in reporting has been a key diagnostic and service delivery challenge in most areas, predominantly in rural settings. Surveillance of diseases has been limited to those in humans and not in animals. In the recent EVD outbreak, active case findings were primarily based on the assumptions of humans as the portals for sporadic outbreaks or re-emerging infections. EVD being a zoonotic disease, its surveillance in animals such as bats, monkeys and other primates should also receive adequate attention from the laboratory diagnostic and public health surveillance systems. Furthermore, hunting communities should also be considered as sources of information gathering and active case findings.
As with our West African neighbours and other countries in sub-Saharan Africa, Liberians have close cultural ties and extended families across the porous borders. Cultural practices, such as eating bush meat (including monkeys, bats, gorillas, etc.), are common cultural norms which could expose communities to zoonotic-associated diseases, such as EVD.
The authors acknowledge the contributions of the Incident Management System of Liberia’s Ministry of Health, as well as international organisations, in strengthening the laboratory system in Liberia.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
None.
The first draft of the manuscript was written by S.B.K., J.B.D., C.L.W. and P.S., and reviewed for scholarly contents by C.B.E., F.K.B., G.T.M. and M.W.S.K. Laboratory resources and materials were provided by S.B.K., P.S., C.B.E., F.K.B. and G.T.M. Suggestions for modifications were made by J.B.D., C.L.W., P.S., C.B.E., F.K.B., G.T.M. and M.W.S.K., and subsequently incorporated by S.B.K. The final version of the manuscript was approved by all authors.