Evaluation of Impact of CBEP Training Activities on … of...associated with EDPs, in accordance with the World Health Organization’s International Health Regulations and World Organization

DTRA/Cooperative Biological Engagement Program

Evaluation of Impact of CBEP Training

Activities on the Performance of

Targeted Laboratories in Afghanistan

DISCLAIMER

This project is funded by Defense Threat Reduction Agency (DTRA) and implemented by CH2M with University Research Co., LLC as a subcontractor providing in-country support. The author’s views expressed in this publication do not necessarily reflect the views of DTRA or the United States Government.

Developed by University Research Co., LLC

JANUARY 2016

Background

The Defense Threat Reduction Agency’s Cooperative

Biological Engagement Program (CBEP) was developed

to assist partner nation governments in addressing

obligations assumed by signing the United Nations

National Security Council Resolution 1540 (2004), which

binds States to adopt legislation to prevent the

proliferation of nuclear, chemical, and biological

weapons, and their means of delivery, and establish

appropriate domestic controls over related materials to

prevent their illicit trafficking; Resolution 1540 also

encourages enhanced international cooperation on such

efforts.

CBEP focuses on biological agents and seeks to

enhance clinical, laboratory, and epidemiological safety

and security by providing education and training,

particularly on select agents (also referred to as

especially dangerous pathogens (EDPs). CBEP also

considers member obligations under the World Health

Organization’s International Health Regulations, which

were designed to enhance national, regional, and global

public health security and require State Parties to have

or develop minimum core public health capacities to

detect, assess, notify, and respond to public health

threats.

Over the course of 25 months (January 1, 2014 -

January 31, 2016), the Defense Threat Reduction

Agency’s CBEP assisted the Islamic Republic of

Afghanistan to enhance Biosecurity and Biosafety

(BS&S) standards and procedures; and strengthen the

ability to detect, diagnose, and report outbreaks of

infectious disease, especially those associated with

Select Agents, in accordance with World Health

Organization (WHO) International Health Regulations

(IHR) and World Organization for Animal Health (OIE)

guidelines.

With a focus on select agents, CBEP has sought to improve

clinical, laboratory, and epidemiological safety and security

by conducting a baseline assessment survey and filling gaps

through the provision of training workshops.

CBEP has three main objectives in Afghanistan:

To identify and address gaps in the human and animal

public health systems;

Enhance biosafety and biosecurity (BS&S) standards

and procedures;

Strengthen the ability of human and animal public

health laboratories to detect, diagnose, and report

outbreaks of infectious disease, especially those

associated with EDPs, in accordance with the World

Health Organization’s International Health Regulations

and World Organization for Animal Health guidelines.

1 | Evaluation of Impact of CBEP Activities on the Performance of Targeted Laboratories in Afghanistan—January 2016

CPHL staff using equipment supplied by DTRA

Geographic Coverage

Laboratory personnel from five provinces in Afghanistan,

including Kapisa, Nuristan, Logar, Herat, and Balkh, were

brought to Kabul to receive CBEP training in BS&S,

Epidemiology, and Laboratory Diagnostics.

Setting

CBEP sponsored training activities in seven select

provinces in Afghanistan: Kapisa, Nuristan, Logar, Herat,

and Balkh. These were selected in coordination with the

Ministry of Public Health (MoPH).

CBEP began conducting training activities in late 2014 for

Afghan specialists to equip them with skills essential to

meet international standards in the areas of BS&S,

Epidemiology, and Laboratory Diagnostics. With a small

in-country training team, a total of 2,345 participants

have been trained as of January 2016. Training

participants came from targeted and non-targeted

provinces for a total of 32 provinces. In March 2015,

CBEP conducted a series of Training of Trainer (TOT)

workshops in Kabul for 40 laboratory professionals from

public health institutes in the five provinces. The TOT

workshops were coordinated closely with the MoPH and

officials from the Central Public Health Laboratory

(CPHL). Trainings for health professionals from the

provinces were particularly appreciated by MoPH because

this is the first time provincial health professionals have

received such opportunities.

Trainings focused on:

Clinical medicine training focuses on improving health

practitioners’ ability to detect and diagnose priority


Figure 1: CBEP targeted provinces in Afghanistan

pathogens and phylogenetically-related species and

subspecies.

Epidemiology training includes basic epidemiology,

outbreak investigations, analytic epidemiology, and study

design for epidemiologists in the public and private

healthcare systems in Afghanistan.

Laboratory diagnostics training includes bacteriology,

serology, and molecular diagnostics of pathogen detection

and also focuses on diagnostic development and quality

control.

BS&S training includes practical and theoretical aspects of

internationally-accepted BS&S standards and procedures,

including waste management and sample transport.

Aim of Assessment

The purpose of this assessment is to measure the impact of

CBEP activities/health interventions on the performance of

bio-risk laboratory operations of targeted labs in

Afghanistan. The assessment aims to do a rapid evaluation

of the Human Health Labs accomplished during the period

of April-June 2014 compared with April-June 2015.

Methodology and Survey Design

The assessment was designed to be conducted at the CPHL,

three regional reference laboratories, and three provincial

level hospital labs in the seven targeted provinces. The

targeted labs include:

The central level of Central Public Health Laboratory

(CPHL) with its various departments

The Regional Reference Laboratory (RRL) of Herat,

Balkh, Nangarhar

The provincial level public health labs/hospital labs

from Kapisa, Logar, and Nuristan provinces

The assessment measured both quantitative and qualitative

information, with quantitative information captured through

facility documents and reports and qualitative information

collected through interviews with trained lab/health

officials.

Assessment Sampling

CBEP selected different levels of labs in the seven targeted

provinces as a representative sample of all the labs covered

at maximum level within the Ministry of Public Health

(MoPH).

Labs were selected as follows:

The Central level of Central Public Health Laboratory

(CPHL), all departments received 100% trainings.

The Regional Reference Laboratory (RRL) covered 100%

by the BS&S training series.

The provincial level of public health labs hospital labs

covered 80% by the BS&S training series.

Assessment Tools

The assessment tools developed CBEP, in coordination with

stakeholders, was based on CBEP activities and focused on:

The preparation and distribution of SOP booklets and

educational and learning brochures to the concerned

health facilities.

The training workshop questionnaire (QA) mainly

contains: Contents of BS&S training, epidemiology, lab

techniques learnt and shared with other lab

professionals from the past 6 months, positive changes

seen in the labs after BS&S trainings regarding case

finding, diagnosis, and reporting of communicable

disease pathogens.

The upgrade process achieved in the targeted bio-health

labs.

The procurement of digital advanced lab equipment/

supplies and consumables requested by CPHL under the

CPHL Sustainment Plan.

Details about assessment tools are listed in Annex I.

Data Collection Methodology

CBEP conducted desk reviews, field/site visits, and key

informant interviews with lab managers and ministry

officials to collect data on the impact of CBEP training

activities on the performance of targeted labs in

Afghanistan. The labs which are located in remote areas

were contacted by telephone and e-mail to provide required

information.



Assessment Findings

Lab Facility Information

Target labs: Herat, Balkh, Nangarhar, Kapisa, Logar,

Nuristan and the CPHL

1. Number of samples transported from the provinces’

major public health facilities to the provincial public

health labs.

Improvement was seen in data collection, after receiving

information about IATA regulations, sample packaging,

required documents for sample shipment and other

important information for sample processing. This led to an

established link between the CPHL and Regional Labs. The

CPHL sent 10 quality control samples to the Regional Labs

of Herat, Balkh and Nangarhar for processing.

As the system was established by CBEP, sample shipments

were not performed during April-June 2014 for comparison

to April-June 2015. However, as the system is now

established sample shipment has been initiated.

2. Number of rejected samples transported from the

provinces’ major public health facilities to the provincial

public health labs.

From April-June 2014, a total of 10 poor samples were

received and rejected by the provincial public health

laboratories. However, from April-June 2015, improvements

were seen and the sample rejection rate reduced to 0

percent.

3. Number of samples transported from the provincial

public health labs to the CPHL in Kabul

A total of 235 samples were received during April-June 2014

compared to a total 513 samples received during April-June

2015 (Figure 2). A 118 percent increase in sample shipment

to the CPHL can be seen during April-June 2015. All

provinces more than doubled samples transported with the

exception of Herat.

0

20

40

60

80

100

120

140

160

180

Kapisa Logar Nuristan Herat Balkh

April-June 2014 April-June 2015

Figure 2: Number of samples transported from the provincial public health labs to the CPHL in Kabul


Figure 3: Number of rejected samples transported from the provincial public health labs to CPHL-Kabul

4. Number of rejected samples transported from the

provincial public health labs to CPHL-Kabul

As seen in Figure 3, during the period of April-June 2014 a

total of 10 poor samples were rejected. However, from April

-June 2015, the system improved and the sample rejection

rate reduced to 0 percent. Now the CPHL does not reject

samples, but instead provides feedback when the sample

quality is poor.

5. Status of specimens received from provincial public

health labs by the CPHL.

From April-June 2014, 10 poor samples were received by

the CPHL and in the period of April-June 2015, this number

reduced.

6. Lab Incidental Injury Cases Inside the main Provincial

Public Health Labs.

From April-June 2014, rare cases of lab incidents were

present, however, this number decreased to 0 during April-

June 2015 (Figure 4), indicating improvement in the labs

BS&S programs.

7. Technical capabilities and scientific experience of the

trained personnel

Measured in the next section by:

Lab tests carried Out

Cases of infectious diseases detected

0

0.5

1

1.5

2

2.5

3

3.5



Figure 4: Lab Incidental Injury Cases Inside the main Provincial Public Health Labs.

0

1

2

3

4

5

6

7



Figure 5: Lab tests carried out at the CPHL


Lab Facility Information (CPHL)

The data shows visible improvement in numbers of tests

conducted (Figure 5) and positivity rate (Figure 6) for in-

fectious disease case detection in Bacteriology, Serology,

ELISA, Parasitology, and other departments of the CPHL.

Showing increased capability and scientific training effects

on lab personnel. This impact was the result of CBEP sup-

port through extensive renovation, provision of digital lab

equipment, SOPs, capacity development in bio-safety and

security, Good Lab Work Practices (GLWP) and extensive

support for consumables/kits, and equipment mainte-

nance. The number of tests performed increased an aver-

age of 23 percent across all areas. Virology had the highest

increase at 405 percent, while ELISA had the lowest in-

crease at 10 percent.

Detected infectious disease cases increased an average of

60 percent at the CPHL. Serology increased the most at 91

percent, while ELISA increased the least at 37 percent.

Figure 6: Cases of infectious diseases detected at the CPHL

0

500

1000

1500

2000

2500

3000

3500

4000

Virology Bacteriology Serology ELISA Parasitology and Urine


0

100

200

300

400

500

600

700

Virology Bacteriology Serology ELISA Parasitology and Urine



Has the newly supplied equipment obviously improved

the quality of the lab tests performed leading to the

increase in number of detected cases of infectious

disease of water and food pollution?

The newly supplied equipment improved Bio-safety and Bio

-security programs at the CPHL, quality of lab tests

improved, and detection of infectious diseases increased.

The WHO External Quality Assessment Scheme 2015 showed

full results in the Virology Department, a great indication of

the CPHL’s improvements in detection and overall capacity

in sample handling and testing.

Table 1: Impact of CBEP training activities on the technical capabilities of the participants

Improvement in the technical capabilities and

the scientific experience of the lab personnel

Capacity in diagnosis, management in biological waste dis-

posal, awareness in BS&S, and knowledge in lab tech-

niques and procedures improved, but still challenges are

existed in some of the provincial level labs in the field of

waste disposal, diagnosis, PPEs, and biosafety and biose-

curity guidelines (Table 1).

HRT BLK NGR KPS LGR NSN CPHL Improvement noticed in the following areas:

(Answer YES or NO)

Detection, diagnosis and reporting of the infectious

disease incidents Yes Yes Yes N/A N/A N/A Yes

Management of the Biological and Waste Disposal

Process Yes Yes Yes Yes Yes No Yes

Significant requests and needs of the staff for the

provision of PPEs inside the lab units Yes No No No No No Yes

Proper Implementation and Application of the Biorisk

operations guidelines and procedures in line with the

ministerial operation procedures SOPs

Yes Yes Yes No No No Yes

Significant awareness and responsiveness to the

concept of BIO SAFETY and SECURITY in regard to the

bio risk lab operations and procedures of the CPHL or

provincial labs

Yes Yes Yes Yes Yes Yes Yes

Increased influence of CBEP training workshops in the

experience and knowledge of the lab personnel in line

with the ministerial guidelines of the Bio risk

operations procedures

Yes Yes Yes Yes Yes Yes Yes


Discussion

Impacts

CBEP greatly impacted awareness and increased laboratory

workers scientific knowledge. This has lead to improved

biosafety and biosecurity health measures and standards in

the Afghanistan health laboratories.

In addition, biosafety cabinets provided to the CPHL,

biohazard symbols, access control improvements, an

automated electricity system, a finished and properly

secured sample storage system, and a new security camera

for the Virology Department have greatly increased the

CPHL’s functions and BS&S measures.

Gaps

Waste management still needs to be addressed at the CPHL

(installation of an incinerator), running costs for CPHL

sustainment are not covered by the MoPH or other sources

to replace CBEP support.

Refresher trainings for continuous and sustained

improvement, quality assurance systems to improve quality

of provincial, district and peripheral labs is not yet

established. Additionally, CBEP trainings only targeted

laboratory technicians. Expansion of target staff and

provinces in necessary for universal coverage in

Afghanistan labs.

A standard laboratory management information system

(LMIS) is not established, therefore the Afghanistan MoPH

is unable to provide required lab data. Sample and

equipment inventory is still in need of improvement.

Continued Activities

Per information collected from the targeted labs, regular

refresher trainings, provision of PPEs, running costs, an

inventory system for samples/equipment, equipment

maintenance and waste management are important areas to

be considered for continuous support and improvement.

Conclusion

As seen from the collected data, capacity in diagnosis,

management of biological waste disposal, awareness in

BS&S, and knowledge of lab techniques and diagnostic

procedures improved in CBEP targeted labs in Afghanistan.

Improvements were seen in data collection after receiving

information/training in International Air Transportation

Association (IATA) regulations, and sample taking,

collection and packaging.

Sample shipments were not conducted from April-June

2014, however, the system is now established and sample

shipments for quality control are being conducted from the

CPHL to the three targeted labs.

The newly supplied digital equipment, through the CPHL

sustainment component, improved bio-safety and security

programs at the CPHL, including quality of lab tests,

detection of infectious diseases and linkages among

regional labs. One good example is the reception of a WHO

external quality assessment scheme 2015 and provision of

excellent results by the CPHL Virology Department. The

result, provided by the CPHL, shows excellent performance

for the external quality assessment (EQA), which is based-

on equipment, facility, safety and personnel trainings.

H.E. the Minister of Public Health, and different involved

sectors, greatly appreciated the efforts of DTRA/CBEP and

officially requested a continuation and expansion of project

activities to the peripheral level labs. These frequent

requests by high-level authorities show the quality of

services provided by CBEP to the CPHL and regional/

provincial labs.

Some challenges still remain, such as a proper waste

disposal system at the CPHL, running costs/maintenance

of the CPHL (newly provided equipment, electricity system),

a LMIS, and quality improvement programs (QA/QC),

which will need further government and donor support.


Annex 1: Assessment Tools

The Impact of the CBEP activities on the performance of work of the Biorisk lab operations of Afghanistan Human Health

Labs accomplished during the period of April-June 2014 compared with the period of April-June 2015.

Lab Facility Information:

No. of samples transported from the major public health facilities in provinces to the provincial public health

labs.

No. of samples transported from the major public health facilities in your province to the provincial public

health lab that were rejected by the provincial public health lab.

Total No. of Samples TRANSPORTED to provincial labs


Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=

No. of Samples Transported to provincial labs that were REJECTED


Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=


No of samples transported from the provincial public health lab to the Central Public Health Lab (CPHL)

Kabul

No of samples transported from the provincial public health lab to the Central Public Health Lab (CPHL-

Kabul) that had been rejected by CPHL Kabul

The status of the specimen received from provincial public health labs by CPHL.

Total No. of Samples TRANSPORTED to CPHL April-June 2014 April-June 2015

Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=

No. of Samples Transported to CPHL that were REJECTED


Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=

Status of the specimen received from provincial

public health labs by CPHL

Received in Good & appropriate condition?

YES

NO

Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=


Lab Incidental Injury Cases Inside the main Provincial Public Health Lab.

Technical Capabilities and scientific experience of the trained personnel

Lab Tests Carried Out


Lab Incidental Injury Cases April-June 2014 April-June 2015

Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=

CPHL N= N=

Total No. of Lab Tests Carried Out April-June 2014 April-June 2015

Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=

CPHL N= N=

Cases of infectious diseases detected April-June 2014 April-June 2015

Herat N= N=

Balkh N= N=

Nangarhar N= N=

Kapisa N= N=

Logar N= N=

Nuristan N= N=

CPHL N= N=

Improvement in the technical capabilities and the scientific experience of the lab personnel?

The newly supplied equipment has obviously improved the quality of the lab tests performed leading to the increase no.

of the detected cases of infectious disease of water and food pollution?

Yes………………………NO………………….

Lab Tests carried out at the CPHL various departments:


Total No. of Lab Tests Carried Out April-June 2014 April-June 2015

Virology N= N=

Bacteriology N= N=

Serology N= N=

ELISA N= N=

Parasitology and Urine N= N=

Total : N= N=

Total No. of Positive Lab Tests Carried Out April-June 2014 April-June 2015

Virology N= N=

Bacteriology N= N=

Serology N= N=

ELISA N= N=

Parasitology and Urine N= N=

Total : N= N=

Total Equipment’s Maintenances at CPHL N= N=


Improvement noticed in the following areas: (Answer YES or NO)

HRT BLK NGR KPS LGR NSN CPHL

Detection, diagnosis and reporting of the

infectious disease incidents

Management of the Biological and Waste Disposal

Process

Significant requests and needs of the staff for the

provision of PPEs inside the lab units

Proper Implementation and Application of the

Biorisk operations guidelines and procedures in

line with the ministerial operation procedures

SOPs

Significant awareness and responsiveness to the

concept of BIO SAFETY and SECURITY in regard

to the bio risk lab operations and procedures of

the CPHL or provincial labs

Increased influence of CBEP training workshops in

the experience and knowledge of the lab personnel

in line with the ministerial guidelines of the Bio

risk operations procedures


Qualitative Information:

In your opinion, what positive changes can you observe in this year, compare to the last year, after CBEP project

implemented?

بوده اند؟ CBEPبه نظر شما چه تغییرات مثبت را از پارسال تا امسال مشاهده مینمایید که ناشی از تریننگ های پروژهء

_________________________________________________________________________________________________

Which areas remained uncovered, or which gaps are present to have them in our future plan/ attention?

کدام ساحات تا اکنون نیز به حالت خود باقی مانده اند و یا خالء هایی وجود دارند که باید در آینده به آن توجه صورت گیرد؟

_________________________________________________________________________________________________

Please briefly write your opinions and suggestions for betterment of CBEP project, especially training sessions:

و بالخصوص بخش تریننگ های آن به صورت خالصه تحریر نمایید: CBEPنظریات و پیشنهادات تان را در قسمت بهبود عمومی پروژهء

_________________________________________________________________________________________________

Documents

Evaluation of Impact of CBEP Training Activities on … of...associated with EDPs, in accordance with the World Health Organization’s International Health Regulations and World Organization