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Perspectives: Sustainable Laboratory Capacity Building in Sierra Leone: From Ebola to COVID-19

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  • [1] Bagcchi S. Ebola haemorrhagic fever in West Africa. Lancet Infect Dis 2014;14(5):375. http://dx.doi.org/10.1016/s1473-3099(14)70034-9CrossRef
    [2] Ansumana R, Bonwitt J, Stenger DA, Jacobsen KH. Ebola in Sierra Leone: a call for action. Lancet 2014;384(9940):303. http://dx.doi.org/10.1016/S0140-6736(14)61119-3CrossRef
    [3] Wang Q, Zhang Y, Wang HY, Du HJ, Nie K, Song JD, et al. Detection and analysis of Ebola virus in Sierra Leone-China friendship biosafety laboratory from March 11 to April 20, 2015. Biomed Environ Sci 2016;29(6):443 − 7. http://dx.doi.org/10.3967/bes2016.057CrossRef
    [4] Wang LL, Wang XC, Pang MF, Hu XQ, Qi XP, Dong XP. The practice of the public health cooperation in the Republic of Sierra Leone: contributions and experiences. China CDC Wkly 2020;2(2):28 − 31. http://dx.doi.org/10.46234/ccdcw2020.007CrossRef
    [5] Duan L, Wang LL, Lu SN, Wang B, Li YB, Xu QL, et al. Development and impacts of the Sierra Leone-China laboratory for parasitic diseases testing and surveillance. China CDC Wkly 2021;3(15):327 − 30. http://dx.doi.org/10.46234/ccdcw2021.088CrossRef
    [6] Zhao JY, Lu X, Tie AL, Ngegba E, Wang LL, Sun L, et al. Molecular diagnostics and next-generation sequencing reveal real etiological characteristics of invasive Salmonella infection in febrile illness in Freetown, Sierra Leone. Emerg Microbes Infect 2022;11(1):1416 − 24. http://dx.doi.org/10.1080/22221751.2022.2076612CrossRef
    [7] Yin JH, Yamba F, Zheng CJ, Smith SJ, Wang LL, Li HM, et al. First report of N1575Y mutation in Anopheles gambiae in Sierra Leone. Infect Genet Evol 2021;92:104852. http://dx.doi.org/10.1016/j.meegid.2021.104852CrossRef
    [8] Goldstein T, Anthony SJ, Gbakima A, Bird B, Bangura J, Tremeau-Bravard A, et al. The discovery of a new Ebolavirus, Bombali virus, adds further support for bats as hosts of Ebolaviruses. Int J Infect Dis 2019;79(S1):4 − 5. http://dx.doi.org/10.1016/j.ijid.2018.11.030CrossRef
    [9] Amman BR, Bird BH, Bakarr IA, Bangura J, Schuh AJ, Johnny J, et al. Isolation of Angola-like Marburg virus from Egyptian Rousette bats from west Africa. Nat Commun 2020;11(1):510. http://dx.doi.org/10.1038/s41467-020-14327-8CrossRef
    [10] . WHO. Coronavirus disease 2019 (COVID-19) situation report – 72. 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200401-sitrep-72-covid-19.pdf?sfvrsn=3dd8971b_2. [2023-4-20].https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200401-sitrep-72-covid-19.pdf?sfvrsn=3dd8971b_2
    [11] . Ministry of Health and Sanitation, Government of Sierra Leone. Sierra Leone national action plan for health security (2018-2022). https://www.afro.who.int/publications/sierra-leone-national-action-plan-health-security-2018-2022. [2023-4-20].https://www.afro.who.int/publications/sierra-leone-national-action-plan-health-security-2018-2022
  • FIGURE 1.  Distribution of pathogen types tested and the corresponding number of tests conducted in the laboratory, 2015−2022.

    FIGURE 2.  Comparison of coronavirus disease 2019 (COVID-19) polymerase chain reaction (PCR) tests conducted by Sierra Leone-China Friendship Biosafety Laboratory with the total tests conducted in Sierra Leone.

    FIGURE 3.  Numbers and priorities of brief training workshops conducted from 2015 to 2022.

    * Workshops centered on the control and prevention of infectious diseases, such as malaria, cholera, measles, and hepatitis, are being implemented in Sierra Leone.

    TABLE 1.  Framework of the program.

    FrameworkLaboratory operational capacity buildingPersonnel capacity building
    InputsStaff
    Technical support
    Financial resources
    Facilities
    Mentors
    Short/long-term training
    ProcessDeveloping a laboratory management system
    Extending testing capacity
    Developing a sentinel surveillance system
    Maintaining operation of the lab
    Developing a training plan
    Mentor instruction
    Learning from practice
    Encouraging further education
    OutcomesSustained operation of the laboratory
    Increased testing scope of pathogens
    Enhanced surveillance capacity
    Established professional workforce in the lab
    Improved competency of public health personnel
    Download: CSV

    TABLE 2.  Comparison of laboratory personnel competency in 2015 and 2023.

    CategoryAbilityMarch 2015March 2023
    BiosafetyOperating in biosafety level 3NoneCompetent
    Using personal protective equipment properlyNoneCompetent
    Biological waste management & disposalNoneCompetent
    Biosafety awarenessNoneAcquired
    Quality managementSample collection, transportation and preservationNoneCompetent
    Process controlNoneCompetent
    Documents and recordsNoneCompetent
    Data managementNoneCompetent
    Disease surveillancePerception of active monitoringNoneAcquired
    Process of surveillanceNoneCompetent
    Lab diagnosisNucleic acid testingNoneCompetent
    Enzyme-linked immunosorbent assayNoneCompetent
    SequencingNoneIn training
    Download: CSV

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Sustainable Laboratory Capacity Building in Sierra Leone: From Ebola to COVID-19

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  • 1. Center for Global Public Health, Chinese Center for Disease Control and Prevention, Beijing, China
  • 2. Sierra Leone-China Friendship Biological Safety Laboratory, Ministry of Health and Sanitation, Freetown, Sierra Leone
  • 3. Ministry of Health and Sanitation, Freetown, Sierra Leone
  • Corresponding authors:

    Xiaopeng Qi, qixp@chinacdc.cn

    Doris Harding, dorisharding@yahoo.com

    Online Date: July 14 2023
    Issue Date: July 14 2023
    doi: 10.46234/ccdcw2023.120
  • The onset of the Ebola outbreak in 2014 originated in Guinea and proceeded to swiftly reach Sierra Leone and Liberia (1). Unfortunately, these nations were critically deficient in their capacity for pathogenic testing and diagnostics, the availability of healthcare workers, and their supply of epidemic prevention materials, thereby impeding their ability to address the outbreak efficiently (2). This grave scenario underscored the need for support from the worldwide community.

    At the time, Sierra Leone lacked the domestic capacity for laboratory testing, including that of biosafety level 3 (BSL-3). Recognizing this constraint, the Chinese government hastily dispatched a mobile BSL-3 laboratory and corresponding technicians to Sierra Leone to facilitate testing within the country. Furthermore, the Chinese government expedited the establishment of the Sierra Leone-China Friendship Biosafety Laboratory (BSL-3) within a span of three months, observed to be operational by March 2015. It is important to note that this laboratory also conducted investigations centered on the detoxification of body fluids in Ebola survivors, fueling advancements in the understanding and management of the Ebola virus (3). The laboratory has played a significant role in the prevention and control measures during the Ebola epidemic.

    The Ebola outbreak in West Africa underscored a lack of ability to identify and diagnose emerging and re-emerging infectious diseases. While the outbreak has since ended, it underscored the necessity of strengthening the health system to better respond to future public health crises. This was underscored to the government and health practitioners. Sierra Leone, in particular, experienced a high mortality rate due to diseases such as malaria, pneumonia, diarrhea, cholera, Lassa fever, and measles. The nation continues to bear the brunt of public health crises, experiencing significant morbidity and mortality. Consistent international efforts are crucial to building the resilience and capacity of the public health system. To this end, China CDC, in collaboration with the Ministry of Health and Sanitation, Sierra Leone, implemented a multi-year capacity building program that incorporated laboratory operational capacity development and personnel capacity building (4). This article evaluates the performance and outcomes of this program (Table 1).

    FrameworkLaboratory operational capacity buildingPersonnel capacity building
    InputsStaff
    Technical support
    Financial resources
    Facilities
    Mentors
    Short/long-term training
    ProcessDeveloping a laboratory management system
    Extending testing capacity
    Developing a sentinel surveillance system
    Maintaining operation of the lab
    Developing a training plan
    Mentor instruction
    Learning from practice
    Encouraging further education
    OutcomesSustained operation of the laboratory
    Increased testing scope of pathogens
    Enhanced surveillance capacity
    Established professional workforce in the lab
    Improved competency of public health personnel

    Table 1.  Framework of the program.

    • When the Sierra Leone-China Friendship Biosafety Laboratory was founded in 2015, it initially lacked operational capabilities. This deficiency was addressed through a comprehensive program that furnished the laboratory with skilled staff, necessary facilities, and a relevant management system — an essential foundation for maintaining laboratory operations.

      The implementation of this program gradually enhanced the laboratory’s testing capacity, expanding from initial testing for only the Ebola virus to including several other types of pathogens by the end of 2022 (Figure 1). This laboratory, designated as the National Reference Laboratory for Viral Hemorrhagic Fevers in Sierra Leone, was responsible for testing samples from unexplained severe cases or suspected instances of hemorrhagic fever to determine the responsible pathogens. Concurrently, the program instituted a sentinel surveillance system to manage surveillance of hemorrhagic fever viruses, diarrheal pathogenic bacteria, and mosquito vectors. This bolstered disease diagnosis and early warning capabilities for infectious disease outbreaks (5-7), with all gathered samples tested within the laboratory. Given the persistent risk of severe diseases like Lassa fever and Ebola within the country, in addition to the identification of new pathogens (8-9), this sentinel surveillance system facilitates early detection of outbreaks and enhances the country’s preparedness for such situations.

      Figure 1. 

      Distribution of pathogen types tested and the corresponding number of tests conducted in the laboratory, 2015−2022.

      The continued capacity enhancement in the laboratory facilitated the swift establishment of testing for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus at the pandemic’s early stage. As of February 5, 2020, the Sierra Leone-China Friendship Biosafety Laboratory has fully developed both sequencing and reverse transcription-polymerase chain reaction (RT-PCR) detection capabilities for the SARS-CoV-2 virus, which positioned Sierra Leone among the first African countries with this testing ability. The laboratory, serving as a public health facility, was appointed the national testing site for the SARS-CoV-2 virus. It began testing its first suspected coronavirus disease 2019 (COVID-19) sample on February 14, 2020, signifying the onset of emergency COVID-19 testing in Sierra Leone. The first positive nucleic acid sample was detected in the laboratory at 2:00 a.m. on March 31, 2020. The Sierra Leone government announced the country’s first COVID-19 case that same day (10). Up to December 2022, the laboratory had tested 131,708 samples from suspected COVID-19 cases, which constituted 34.4% of the national testing volume in Sierra Leone (Figure 2). Among these, 2,697 were positively confirmed, representing 34.7% of all confirmed cases in the country.

      Figure 2. 

      Comparison of coronavirus disease 2019 (COVID-19) polymerase chain reaction (PCR) tests conducted by Sierra Leone-China Friendship Biosafety Laboratory with the total tests conducted in Sierra Leone.

    • This multi-year program is focused on providing long-term training in laboratory biosafety, quality management, and testing techniques related to viruses, bacteria, and parasites. A training plan was developed specifically for personnel working in the laboratory, additionally, long-term mentors were dispatched to Sierra Leone. The comprehensive training curriculum covered areas such as pathogen characteristics, specimen collection, data entry, operational standards, personal protection, correct utilization of equipment, materials management, and biosafety. Training was delivered through a combination of lectures, simulation exercises, and practical sessions under the supervision of skilled Chinese technicians.

      When operations began in the lab in 2015, a total of five local staff members were recruited for training. Following an eight-year period, 19 local lab technicians have undergone training in the laboratory. Among this group, four have successfully secured scholarships for master’s or doctoral programs outside Sierra Leone. Ongoing training has been used to bolster the competency of local staff in areas such as biosafety and biosecurity, quality management, disease surveillance, and laboratory diagnostics (Table 2). This trained local workforce played a significant role in laboratory testing and diagnostic processes throughout the COVID-19 pandemic. This team ensured that the laboratory was able to conduct tests on a daily basis and report results to the Sierra Leone Ministry of Health and Sanitation within 24 hours of receiving a sample.

      CategoryAbilityMarch 2015March 2023
      BiosafetyOperating in biosafety level 3NoneCompetent
      Using personal protective equipment properlyNoneCompetent
      Biological waste management & disposalNoneCompetent
      Biosafety awarenessNoneAcquired
      Quality managementSample collection, transportation and preservationNoneCompetent
      Process controlNoneCompetent
      Documents and recordsNoneCompetent
      Data managementNoneCompetent
      Disease surveillancePerception of active monitoringNoneAcquired
      Process of surveillanceNoneCompetent
      Lab diagnosisNucleic acid testingNoneCompetent
      Enzyme-linked immunosorbent assayNoneCompetent
      SequencingNoneIn training

      Table 2.  Comparison of laboratory personnel competency in 2015 and 2023.

      In the past years, the program successfully conducted or sponsored 37 short-term training courses, collectively reaching 1,061 participants from across the country. This initiative significantly strengthened Sierra Leone’s capacity for pathogenic testing at the district level. The curriculum spanned diverse topics such as pathogen collection, biosafety, surveillance, quality control, pathogenic diagnosis, and disease control. It encompassed diseases such as Ebola, Lassa fever, plague, anthrax, monkeypox, Marburg, malaria, typhoid fever, and SARS-CoV-2, among others (Figure 3).

      Figure 3. 

      Numbers and priorities of brief training workshops conducted from 2015 to 2022.

      * Workshops centered on the control and prevention of infectious diseases, such as malaria, cholera, measles, and hepatitis, are being implemented in Sierra Leone.
    • The development of Sierra Leone-China Friendship Biosafety Laboratory during the Ebola outbreak and its subsequent crucial involvement in managing the COVID-19 pandemic have significantly fortified Sierra Leone’s laboratory capabilities in both preventing and controlling infectious diseases, as well as responding to health emergencies. The COVID-19 pandemic reiterated the critical necessity to uphold global health security. This is particularly true in terms of enhancing all countries’ capacities in observing, detecting, and responding to infectious diseases, which are vital measures in the successful containment of such pandemics.

      The program is aligned with the Sierra Leone National Action Plan for Health Security (2018–2022) (11). Successful execution of this initiative strengthens Sierra Leone’s disease surveillance processes, emergency preparedness, and personnel proficiency. Consequently, the capacity of the public health sector to prevent, detect, validate, and report to both local and international bodies, and respond to incidents or outbreaks of emerging or re-emerging infectious diseases of significant public health concern, is substantially improved. This enhancement ultimately benefits the health and well-being of the people of Sierra Leone, as well as the global community.

      Given the constraints of limited resources, additional measures must be taken to sustain the operation of this laboratory. This includes nurturing a competent local workforce and maintaining ongoing surveillance. These efforts are crucial for bolstering the country’s integral capacities as stipulated under the International Health Regulations (IHR) 2005, thereby augmenting the health security of both the country and the wider sub-region.

    • We thank our Chinese and Sierra Leonean colleagues.

    • No conflicts of interest.

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