Laboratory Systems

Lessons from the eHealth Africa-Emory University Schistosomiasis Study

By Tolulope Oginni and Emerald Awa-Agwu

Schistosomiasis and nineteen other diseases are classified by the World Health Organization as Neglected Tropical Diseases. It is an acute and chronic parasitic disease caused by blood flukes called schistosoma. People become infected when larval forms of the parasite (worms) penetrate their skin during contact with infested water. 

The disease can present in two main forms: intestinal and urogenital schistosomiasis. Intestinal schistosomiasis can result in abdominal pain, diarrhea,  blood in the stool, and liver and spleen enlargement in advanced cases. The most distinguishing symptom of urogenital schistosomiasis is haematuria (blood in urine). Fibrosis of the bladder and ureter, kidney damage, genital lesions and vaginal bleeding in women, and pathology of the seminal vesicles, prostate and other organs in men. In later stages, urogenital schistosomiasis may lead to bladder cancer and infertility.

The disease is endemic to Nigeria and existing data places Nigeria as home to the highest number of recorded cases in the world. While there are insufficient research data and medical records to paint a true picture of the disease burden in Nigeria, it is estimated that 29 million Nigerians are infected with the disease and almost half of this number are children.

In June and July, eHealth Africa partnered with Emory University on a study to compare three diagnostic methods to determine their effectiveness in detecting acute and chronic schistosomiasis in low-resource settings. Accurate diagnostics are crucial to yield more information about the disease and ultimately, to achieve the goal of eliminating the disease. One of the major challenges facing the elimination of schistosomiasis is that very few infected people present at the health facilities for treatment. This can be attributed to a myriad of reasons including stigma, insufficient medical services, affordability of medical services, low knowledge of the signs and symptoms of the infection, and local perceptions and myths about the disease. The wider effect of this passive case finding (that is, cases are discovered only when infected persons visit the health facilities for treatment) and poor health-seeking behavior is that there is inadequate data to support the prioritization of schistosomiasis control by decision-makers and health program planners. In addition, medical laboratory scientists and researchers are unable to make improvements to diagnostic procedures for schistosomiasis because very few patients visit health facilities to access treatment.

During this study, eHealth Africa and two Emory University MPH students also trained 10 community health workers to administer questionnaires aimed at assessing the knowledge, attitudes, and perceptions about Schistosoma haematobium infection(urinary schistosomiasis) among communities in five Local Government Areas in Kano State.

Training of Community Health Workers

Training of Community Health Workers

The responses from the survey yielded astounding local interpretations of the symptoms of urinary schistosomiasis. Community members saw red urine (haematuria or blood in the urine) as a normal and rather harmless phenomenon, a rite of passage or a sign of manhood for young boys. It was also linked to the menstrual cycle for girls or women. Yet another misconception was that it could be caused by staying long hours under the sun. Among women especially, underreporting of the disease was exacerbated by socio-cultural norms and beliefs that prevent them from handling urine samples in public.

Administering questionnaires at Sani Marshal Government Arabic Secondary School, Kura LGA, Kano State

Administering questionnaires at Sani Marshal Government Arabic Secondary School, Kura LGA, Kano State

With this understanding and the results of the study, eHA and Emory University hope to influence policies, strategies and plans around the diagnosis and control of Schistosomiasis in Nigeria.

eHealth Africa and Emory University take on Schistosomiasis in Kano State, Nigeria

Chibuzor Babalola and Angela Udongwo with eHA’s Tolulope Oginni (center)

Chibuzor Babalola and Angela Udongwo with eHA’s Tolulope Oginni (center)

Schistosomiasis (Snail fever) is one of twenty communicable diseases classified by the World Health Organization as Neglected Tropical Diseases. The disease has dire health and economic consequences including disability, infertility, stunting in children and death.

Its close link with poor hygiene and sanitation, make its burden higher in poor, rural communities. Schistosomiasis is contracted when people are exposed to water infested by parasitic worms called Schistosomes. According to the World Health Organization, over 250 million people worldwide are affected by this disease and 90% of them live in Africa.

This public health impact drove Emory University Masters students, Angela Udongwo and Chibuzor Babalola, to partner with eHealth Africa’s Kano Lab to conduct a two-month research study in Kano State Nigeria. In this interview, they share the inspiration behind the study and their expectations for the research.

Why Schistosomiasis? What inspired this project?

We were inspired to conduct this study because of the public health impact of schistosomiasis. Nigeria is one of the Schistosomiasis-endemic countries and in fact, has the highest number of cases worldwide. Kano state is one of the five states with the highest burden of the disease in Nigeria. There is a need for more cost-effective, accurate and sensitive field applicable diagnostics to achieve the goal of eliminating the disease.

What's the purpose of this research study?

The purpose of this research is to compare the sensitivities and specifities of three diagnostic methods—polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP) and microscopy—for detecting Schistosoma haematobium (urinary blood fluke). The research will examine the appropriateness of these methods for field diagnosis in low-resource settings and for detecting both acute and chronic schistosomiasis. We are also administering questionnaires to assess the communities' knowledge, attitudes, and perceptions about schistosomiasis.

How did you end up doing this in Kano at eHealth Africa?

eHealth Africa was accepting interns from Emory University for summer research and having introduced my research idea to one of the co-founders at a previous event in my school, I applied. eHealth Africa is providing us with the lab space and equipment to conduct this research. Our project activities are supervised by the Lab team here in Kano and we are truly blessed to have this opportunity.

Their project is supervised by eHealth Africa’s Lab coordinator, Tolulope Oginni

What do you hope to accomplish at the end of the study?

The end goal of this study is to develop a device that is capable of detecting schistosomiasis among people with a low burden of infection. We intend to use the results of this research as preliminary data for future research and grant-funded projects. In the long term, we also hope that it will provide evidence to influence the improvement of policies on field diagnosis of schistosomiasis.

Innovations in Newborn Sickle Cell Screening

By ZIllah Waminaje

In Africa, 50% to 90% of children who have sickle cell die before their fifth birthday1. To improve their chances of survival, health systems must integrate Newborn Screening (NBS) for Sickle Cell Disease (SCD) with comprehensive treatment and management plans.

For almost five decades, newborn screening for SCD has been conducted using conventional procedures such as electrophoretic techniques, isoelectric focusing (IEF), high-performance liquid chromatography (HPLC) and DNA analysis, which require specialized laboratories with stable electricity, long sample processing times, expensive equipment and reagents, and highly skilled personnel. These methods, while ideal and feasible for developed countries, are inappropriate for low-resource settings like sub-Saharan Africa where 70% of SCD sufferers reside.

Screening with Sickle SCAN Device

Screening with Sickle SCAN Device

Sickle SCAN is an innovative, cost-effective point-of-care (POC) device that has been developed by Biomedics Inc. to address the challenges of SCD diagnostics in low-resource settings. It is a simple rapid point-of-care test kit that can detect the presence of Hemoglobin A, S, and C and yield results within 5 minutes using blood from a heel/ finger prick or vein. In addition to newborn screening, the Sickle SCAN device can be used for premarital/preconception genetic counseling, blood donor screening, and general screening.

Sickle SCAN

Sickle SCAN

Several features make the Sickle SCAN ideal for low-resource settings and large-scale mass screening programs. The first is that it does not require specialized technical knowledge to administer or read the test results. Anyone can be trained to use the device. The device does not require any special equipment or electricity and thus, eliminates the time, resources and logistics needed to transport samples to a laboratory. Finally, the short result turnaround time allows for the prompt identification of SC-positive babies so that early treatment can commence and survival rates can improve.

Since December 2018, eHealth Africa has partnered with Sickle Cell Well Africa Foundation (SCWAF), Pro-Health International and the Presidential Committee on the North- East Initiative (PCNI) to hold Sickle Cell awareness and testing outreaches in Adamawa, Bauchi, and Gombe states. Over 1000 people in all three states were screened using Sickle SCAN rapid diagnostic test kits. Patients who tested positive for sickle cell disease were immediately given routine medication and referred to sickle cell clinics.

Sickle Cell Outreach in Hong LGA, Adamawa

Sickle Cell Outreach in Hong LGA, Adamawa

Since healthcare in many African countries is community-based, rapid POC test kits like the Sickle SCAN can be easily integrated into existing health programs like routine immunization at primary health care centers or health insurance schemes to facilitate universal screening and ensure sustainability. This will ensure that relevant data on SCD births, morbidity and mortality rates and long term outcomes are captured.

Sickle Cell Awareness and Testing Outreach in Toro LGA, Bauchi

Sickle Cell Awareness and Testing Outreach in Toro LGA, Bauchi

eHealth Africa continues to work with partners to address health inequalities by ensuring equal access to quality and effective diagnostic tools to achieve universal health coverage.

How eHealth Africa supports Universal Health Coverage across Africa

By Emerald Awa- Agwu

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April 7 is World Health Day and this year, the World Health Organization (WHO) is focusing on Universal Health Coverage (UHC).

WHO: Universal Health Coverage - What does it mean?

Good health is crucial for developing economies and reducing poverty. Governments and decision-makers need to strengthen health systems so that people can get the healthcare and services that they need to maintain and improve their health, and stay productive.  However, improving access to health services is incomplete if people plunge further into poverty because of the cost of health care. WHO estimates that over 800 million people spend at least 10% of their household budget on health care which is indicative of catastrophic health expenditure (CHE).  CHE can mean that households have to cut down on or forfeit necessities such as food and clothing, education for their children or even sell household goods.

One of the targets of Sustainable Development Goal 3—Ensure healthy lives and promote wellbeing for all at all ages— is to achieve universal health coverage by 2030. Therefore, achieving UHC has become a major goal for health system reforms in many countries, especially in Africa.

Through our projects and solutions, eHealth Africa supports countries across Africa to strengthen the six pillars of universal health coverage.

1. Health Financing for Universal Health Coverage

WHO recommends that no less than 15% of national budgets should be allocated to health. We believe that accurate and up to date data, can ensure that available health funds are better allocated. In Nigeria,  we worked with several partners to map and collect geospatial data through the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) program. Data relating to over 22 points of interest categories including health facilities, was collected across 25 states and the Federal Capital Territory in Nigeria. This data helps decision-makers to distribute resources and plan interventions that target the people who need it most.

2. Essential Medicines and Health products

Vaccines are some of the most essential health commodities

Vaccines are some of the most essential health commodities

Countries decide what medicines and health commodities are essential based on the illnesses suffered by the majority or significant sections of their population. They must also ensure that quality, safe and effective medicines, vaccines, diagnostics, and other medical devices are readily available and affordable.

When essential medicines and health products are procured, it is important to maintain proper records and to ensure that health facilities do not run out of stock. eHealth Africa created Logistics Management Information System (LoMIS), a suite of mobile and web applications, LoMIS Stock and LoMIS Deliver that address challenges in the supply of essential medicines and health products such as vaccines and drugs. In Kano State, health workers at the facility level use the LoMIS Stock mobile application to send weekly reports on the vaccine stock levels, essential drug stock levels and the status of cold chain equipment. Supervisors can view the reports in near real-time through the LoMIS Stock Dashboard and plan deliveries of medicines and health products to prevent stockouts of vaccines and essential drugs, using LoMIS Deliver. LoMIS Deliver reduces errors by automating the process of ledger entry to capture the number of vaccines on-hand at the facility and the quantity delivered.

3. Health systems governance

Health system governance according to the WHO is governance undertaken with the aim of protecting and promoting the health of the people. It involves ensuring that a strategic policy framework exists and providing oversight to ensure its implementation. Relevant policies, regulations, and laws must be put in place to ensure accountability across the health system as a whole (public and private health sector actors alike).  Effective health systems governance can only be achieved with the collaboration of stakeholders and partners who will support the government by providing reliable information to inform policy formulation and amendments. Over the years, we have worked with several partners to provide this support.

4. Health workforce

Health systems can only deliver care through the health workforce

Health systems can only deliver care through the health workforce

The attainment of UHC is dependent on the availability, accessibility, acceptability, and quality of health workers1. They must not only be equitably distributed and accessible by the population, but they must also possess the required knowledge and skills to deliver quality health care that marries contextual appropriateness with best practices.

Recognizing this, eHA supports the Kano State Primary Health Care Management Board (KSPHCMB) to improve health service delivery by providing health workers in Kano State with access to texts, audio courses, and training modules through an eLearning solution. Through the eLearning web and mobile-enabled platform, health workers can gain useful skills and knowledge on a wide range of topics. Read about the pilot of the eLearning solution here.

In Sierra Leone, we work with the Ministry of Health and Sanitation (MoHS), U.S. Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFENET) to implement the Field Epidemiology Training Program (FETP). Through FETP, public health workers at the district and national level gain knowledge about important epidemiological principles and are equipped with skills in case/ outbreak investigations, data analysis, and surveillance. This positions Sierra Leone to meet the Global Health Security Agenda target of having 1 epidemiologist per 200,000 population. In addition, we support Sierra Leone’s MoHS to build additional capacity in frontline Community Health Officers (CHOs), who are based at the Chiefdom level through the management and leadership training program. CHOs are often the first point of contact for primary care for the local population and the MLTP program equips them to provide better health services and improve health outcomes at their facilities.

5. Health Statistics and Information Systems

In line with our strategy, we create tools and solutions that help health systems across Africa to curate and exchange data and information for informed decision making and future planning.  The Electronic Integrated Disease Surveillance and Response (eIDSR) solution has been used in Sierra Leone and Liberia to transform data collection, reporting, analysis, and storage for a more efficient response and surveillance of priority diseases. Its integration with DHIS2, a health information system used in over 45 countries, makes it easy for health system decision makers to visualize data and gain insight into the state of public health. Read more about our other solutions Aether and VaxTrac. In addition, we also support the Nigeria Center for Disease Control and Prevention (NCDC) by creation and maintenance of a data portal which serves as a repository for all datasets that are relevant to detecting, responding and preventing disease outbreaks in Nigeria.

6. Service delivery and safety

Staff at the Kano Lab

Staff at the Kano Lab

The Service delivery and safety pillar encompasses a large spectrum of issues including patient safety and risk management, quality systems and control, Infection prevention and control, and innovations in service delivery. With our experience working to respond to polio and ebola virus emergencies across Africa, we support health systems to mount prevention and control programs at the national and facility level. We are also committed to creating new technologies and solutions that can help health providers to develop better models of healthcare. We also construct health facilities ranging from clinics to laboratory and diagnostic facilities that utilize state of the art technology to correctly diagnose diseases such as Sickle Cell Disease, Meningitis, and Malaria.

Our Sokoto Meningitis Lab has been at the forefront of meningitis testing and surveillance in Northern Nigeria, offering reliable and prompt diagnoses to support the prevention of future outbreaks.

eHealth Africa continues to work with governments, communities and health workers so that everyone can obtain the quality health care, in a prompt manner and from health workers and facilities within their communities, thus achieving universal health coverage.

eHealth Africa renovates Njala University research center with CDC funding

eHealth Africa (eHA) in partnership with U.S. Centers for Disease Control and Prevention (CDC), has renovated the  Njala University research center at Tiwai Island, in a drive to support one-health surveillance activities in Sierra Leone. The project was funded by CDC, with the objective of improving knowledge and infrastructure capacity at Njala University research center to perform routine Ebola and infectious disease surveillance.

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Research began on Tiwai Island in the early 1980s, with studies on primates, other mammals, forest dynamics etc. This research was vital for disease and one-health surveillance activities as Sierra Leone, ebola virus disease outbreak was traced to bats and primates. However, over the years, the facility had fallen into disrepair and was unusable. Renovation of the Tiwai Island research center commenced in November 2018. eHA has now completed renovations on the entire campus including storage room; kitchen, meeting areas, and dormitories. The facilities were equipped with solar power, which now provides uninterrupted power on a daily basis, solar powered water supply in order to ensure adequate water supply during the dry season.

Those who had visited the Tiwai Research Center before now, would agree with me that there is much difference after the renovation. We are happy that this facility is now ready for use. Communities and stakeholders associated with Tiwai are very grateful. This was made possible through funding from the CDC and renovations by eHealth Africa.
— Dr. Lebbie, Head of Department of Biological Science, Njala University- Head of the Njala Research Center
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CDC has been working with Njala since the Ebola outbreak. CDC has a strong relationship with the Njala team and helping them to have more capacity to do testing to look for viruses, including the Ebola virus that caused the outbreak here. We are looking for other viruses that are in the environment so that we can know more about our environment, learn to live safely with it, and prevent outbreaks from happening. We want to prevent disease outbreaks, and we’re doing that by helping the people of Sierra Leone find those viruses themselves – to study them here so that they don’t rely on outside help. We have seen great success with Njala University and their team doing this work here. CDC is eager to continue to support that effort because we’re so impressed by what’s been done already.
— Dr. Brigette Gleason, Surveillance and Program Lead CDC Sierra Leone Country Office

These renovated structures go to benefit not only Njala University students and faculty and  Sierra Leone’s Ministry of Health and Sanitation (MoHS), but also international researchers.

We will be inviting international auditors who will be resident here to do research; and through that, job opportunities would be opened to the community.’
— Dr Lebbie

Partnering to Address Sickle Cell Disease in Northern Nigeria

By Muhammed Hassan

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According to the U.S. Centers for Disease Control and Prevention (CDC), Nigeria alone accounts for more than 100,000 new sickle cell births every year1. Statistics from African region of the World Health Organization (WHO) puts the prevalence of the Sickle cell trait in Nigeria at 20% to 30%2. In sub-Saharan Africa, very few control programs exist and those that do exist, lack national coverage or the facilities to manage patients. Proactive, routine screening for sickle cell disease is not common practice so diagnosis is usually made when a severe complication occurs.

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At eHealth Africa, we aim to improve the quality and availability of healthcare for underserved populations and to increase access to timely and quality diagnostic services. We partnered with Sickle Cell Well Africa Foundation (SCWAF), Pro-Health International and the Presidential Committee on the North- East Initiative (PCNI) to hold a two-week outreach in Bajoga LGA, Gombe state, and Toro LGA in Bauchi State from the 2nd-16th December 2018.

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The team hosted community and school outreaches in both LGAs. Beneficiaries of the outreaches in both LGAs were educated about Sickle Cell Disease (SCD), inheritance, signs and symptoms, and the importance of genotype testing for SCD and prevention. Free genotype tests were conducted using the Sickle Scan Rapid Test Kit.

Patients who tested positive for SCD and those who presented with severe complications were given routine medication, advised on first-level crisis management and referred to tertiary hospitals. eHealth Africa captured, stored and analyzed the results of the tests. The analyses provided insight into the geographic distribution of patient and the average age distribution of patients who tested positive for SCD and the categories of complications presented at the outreach.

eHealth Africa, Pro-Health and SCWAF presented these results at stakeholder meetings in both states and provided evidence-based recommendations to enable the states to tackle Sickle Cell Disease. Going forward, eHA intends to work with Pro-Health to develop a comprehensive data collection tool which will support tracking and follow up of SCD patients in Prohealth Sickle Cell Clinics.

The Impact:

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Post-Ebola Liberia: eHealth Africa strengthens laboratories in readiness for future infectious disease outbreak

Prior to the Ebola Virus Disease (EVD) outbreak in 2014, the Liberia public health laboratory system had weak capacity to detect, report and respond to public health emergencies. In order to fulfill our mission to build stronger health systems, eHealth Africa (eHA) supported Liberia’s laboratory system from 2014 - 2018. eHA’s lab support program has improved effectiveness of the laboratory system by providing human capacity support for four years, as well as improved electronic submission of lab reports by providing internet connectivity at priority labs (ELWA, Redemption, LIBR & Bong) since 2014.

Test samples in an eHA supported priority lab in Liberia

Test samples in an eHA supported priority lab in Liberia

The Bong lab is situated at the Phebe Hospital Compound, Bong County. In October 2014, it was one of the regional laboratories selected by Liberia’s Ministry of Health (MOH), the United States Navy (US Navy) and other partners for testing suspected Ebola samples as part of the fight against the 2014 West Africa EVD outbreak. The Bong lab and other identified priority labs faced a few similar capacity challenges, including the lack of skilled staff, lack of adequate equipment and poor internet connectivity. eHA provided lab support by developing technology for capturing of lab data, provided internet connectivity to enable the labs submit the data electronically and also provided human capacity support, including recruitment and training of lab desk officers.

Roberto Koimenee is one of the four lab desk officers that eHA worked with via the laboratory support program. He is deployed at Bong Lab to enter Ebola virus disease (EVD) data and report daily samples test results to the Liberia’s Ministry of Health and eHealth Africa.

From Roberto
‘’I got involved with eHealth Africa-Liberia through an application and CV submission during the Ebola outbreak in September, 2014 in Liberia. I was called by eHA for an interview which was followed by training as a Lab Desk Officer. I was assigned to Bong EVD Lab. I was motivated to work in the lab because I wanted to help in the fight against Ebola in Liberia. Since eHealth is a technology driven company, with my knowledge in data management, I decided to help in this fight against Ebola by entering data from samples tested and submit report for decision making at the National level.

I have more than eight years of experience as an Administrative staff and four years of experience as a data officer at eHealth Africa-Liberia, where I have won some performance awards. I love managing database and solving data issues. I am a person who thrives to work out things when it’s difficult to do and work independently to solve complicated problems”, he explains.  

I participated in a three-day training conducted by eHA and this training impacted my life and work by increasing my knowledge in the following topics: Sample handling storage, and processing; Confidentiality/Document control, Data entry and analysis. Today, I know how to control and secure patient information and report accurate and reliable results to requisite and identified individuals responsible to receive said information or results.

The part of the training I like the most was the off-line tracker although it has not been fully utilized by Bong Lab. The off-line tracker is so unique in that it tracks all data or information in all the four (4) regional labs in the country (Liberia). Each lab can see and access information including reports/results of specimen tested. This system can be used without internet. However, that training especially the off-line tracker needs to be fully utilized for the safety, reliable and secure of lab information/data.

Although I worked with other institutions before eHealth Africa came to Liberia, but life was not too good for me and my family. My salary was too small to cover all my expenses including undertaking house construction project. But after I was employed by eHA, my salary was encouraging that enable me and my family to live better life.’’

Roberto’s wife, Christiana Hne Koimenee, believes her husband made a good decision working for eHA in the fight against Ebola in Liberia, even though she expressed fear over her husband doing one of the riskiest jobs, and comes to the conclusion it was worth it.

‘’It was sad and worrisome for individuals like my husband to be at the frontline to test Ebola specimen. But it was also historical for him and those who stood firm to help in the process of fighting Ebola in Liberia.”
— Christiana Hne Koimenee
Roberto Koimenee and family

Roberto Koimenee and family