Human Resource Capacity Building Initiatives for Public Health Laboratories in India

Public Health Education Human Resource Capacity Building Initiatives for Public Health Laboratories in India Anuja Pandey 1, Sanjay Zodpey 2, Sunanda Shrikhande 3, Anjali Sharma 4 1 Assistant Professor, Indian Institute of Public Health, New Delhi, 2 Director, Public Health Education, Public Health Foundation of India, Gurgaon, Haryana, 3 Associate Professor, Department of Microbiology, Indira Gandhi Government Medical College, Nagpur, 4 Program Offi cer- Academics, Public Health Foundation of India, New Delhi, India Summary Public health laboratories play a critical role in disease surveillance and response. With changes in disease dynamics and transmission, their role has evolved over time, and they serve a range of important public health functions. For their effective functioning, it is important to have specialized manpower in these laboratories, which can contribute to their maximum utilization. The present manuscript is an attempt to explore the human resource capacity building initiatives for public health laboratories in India. Using three parallel methods we have attempted to gather information regarding various human resource capacity building initiatives for public health laboratories in India. Our study results show that there is a paucity of programs providing specialized training for human resources in public health laboratories in India. It highlights the urgent need to address this scarcity and introduce capacity building measures to generate human resources for public health laboratories to strengthen their role in public health action. Keywords: Capacity building, human resources, laboratories, public health, training Introduction Public health is an information intensive field that encompasses many disciplines. It is multidimensional and involves the delivery of essential public health functions. Disease surveillance is one of the eleven core functions of public health, as identified by PAHO. 1 The surveillance and control of communicable disease continues to be a major public health priority globally, and particularly in the developing countries. Adequate public health laboratory services in terms of quantity *Corresponding Author: Prof. Sanjay Zodpey, Director, Public Health Education, Public Health Foundation of India (PHFI), Plot 47, Sector-44 (Opposite PF Office), Institutional Area, Gurgaon - 122 002, Haryana, India. E-mail: sanjay.zodpey@phfi.org Website: www.ijph.in DOI: 10.4103/0019-557X.146275 PMID: *** Access this article online Quick Response Code: and quality are important constituents to control these diseases. Public health laboratories play a critical role in disease surveillance and response. They are instrumental in confirmation of etiological diagnosis during outbreaks, thereby providing a scientific basis to disease investigation and control. They also help in prevention and control of diseases by keeping a watch on early warning laboratory signals through monitoring the existing as well as emerging and re-emerging pathogens and environmental monitoring. 2 Traditionally, public health laboratories have been associated with the microbiological diagnosis of food and water, other environmental investigations, and depending on their resources and skills, the investigation of disease outbreaks. Public health laboratories operate as a first line of defense to protect the public against diseases and other health hazards. Working in collaboration with other arms of the public health system, public health laboratories provide clinical diagnostic testing, disease surveillance, environmental and radiological testing, emergency response support, applied research, laboratory training and other essential services to the communities they serve. With complex changes in patterns of disease and mortality in recent times, public health laboratories

Pandey, et al.: Public health laboratory capacity building initiatives 225 serve an important and evolving role in supporting the broad mission of public health. Apart from the traditional role they play, they are now expected to perform a wide range of functions including response to bioterrorism, environmental hazard testing and support for continually evolving public health programs. Public health laboratory personnel include specialists with knowledge of one or more scientific disciplines, with basic and advanced skills in laboratory practice and the ability to apply this expertise to the solution of complex problems affecting public health. These include the public health scientists, scientific officers and laboratory technicians with a specialization in microbiology, clinical pathology, biochemistry, life sciences, and laboratory medicine. For efficient functioning of the public health system, it is imperative to have an efficient disease surveillance system. This, in turn, demands a resourceful public health laboratory network, which is well equipped with human resources and infrastructure. Considering the important role of public health laboratories in disease prevention and control, it is crucial to have manpower with specialized skills to operate public health laboratories, to be able to identify important public health problems, and apply such information for public health action. Over the years, public health laboratory services in India have made considerable progress in terms of infrastructure and functioning. 3 However, the training of human resource for public health laboratories has not advanced at the same pace. It is important to recognize the fact that it is only by capacity building of public health laboratory personnel; that physical infrastructure can be properly leveraged for optimal public health outcomes. Although efforts have been taken to strengthen the skills of public health scientists in diagnosis and surveillance of specific diseases under national health programs, the efforts towards strengthening the overall laboratory support in the country are still inadequate. Besides, there is no database available to identify the initiatives to strengthen human resource serving public health laboratories of India. Against this background the present study was undertaken to identify the human resource capacity building initiatives for public health laboratories in India. Methods The data regarding the human resource capacity building initiatives in public health laboratories was collected using a systematic, pre-defined approach using three strategies. The first search strategy comprised of using the information available on the internet. The internet search was conducted using the Google search engine. The first step in this strategy involved identifying a set of key words encompassing various domains related to public health laboratory courses/training programs. The key words included were laboratory medicine, public health microbiology, public health biochemistry and public health laboratory training. The search was limited to courses offered in India and to collaborations between Indian and foreign institutes if any. The websites of the Medical Council of India, Ministry of Health and Family Welfare and National Centre for Disease Control were searched using the key words of the identified subjects and training programs. A similar search was conducted through the websites of the World Health Organization (WHO) India, and Indian Council of Medical Research (ICMR). The search was not restricted by course duration or the type of degree/certification awarded on successful completion. Detailed information about the courses was collected from the respective institutions or from the designated websites of these institutions. Majority of the information regarding the available courses and institutions was gathered using this strategy. The second strategy involved a detailed literature review of the public health laboratory courses. Indexed and non-indexed journals in the field were identified and searched for notifications and of advertisements of courses and training programs. The third strategy involved contacting experts in the field of public health laboratories in India. This was done through E-mail and/ or telephone. They were requested to share information about the courses offered in their institutes and also to suggest the names of other institutes offering courses in the identified fields. The search strategies were directed at obtaining data on the following parameters: Name and location of the institute offering the course, theme and course duration, course structure, eligibility criteria, and the intake capacity. These parameters were incorporated in a matrix. The institutional data was entered in this matrix, and the findings were triangulated wherever possible using alternative strategies. Any other salient features of relevance to the courses were also incorporated subjectively into this matrix.

226 Pandey, et al.: Public health laboratory capacity building initiatives Results India is served by a wide network of public health laboratories which are established at five levels of functions (L1-L5) based on location of the laboratory, expected functions and facilities available. Table 1 shows the various functions and staffing of public health laboratories in India. 4 Our review shows that although there is a network of public health laboratories in India, which has been in place since long, there are no specialized courses to train health manpower in operating public health laboratories. Even with the expanding role of public health laboratories, no separate discipline dedicated to the training of human resources in public health laboratories has evolved. Consequently, public health laboratories are mostly manned by specialists, scientific officers and technicians in the field of medical microbiology, biochemistry, clinical pathology, life sciences and laboratory technology who are trained in their field of expertise, but have not received training from a public health perspective. The programs offering such training can be classified as under: 1. Microbiology Programs 2. Biochemistry Programs 3. Laboratory Technology Programs 4. Clinical Pathology Programs. Table 1: Major functions and staffing of Public Health Laboratories in India Level of laboratory Number Major functions Staff Peripheral Laboratories and Microscopic centers (L1 labs) 8500 Laboratory diagnosis of malaria, TB, typhoid, chlorination level of the drinking water source and fecal contamination of water Laboratory assistant, medical officer District Public Health Laboratory (L2 labs) Disease Based State Laboratories (L3 labs) Regional Quality control Laboratories (L4) Disease based National reference Laboratories (L5) 650 Laboratory diagnosis and confirmation of malaria, TB, typhoid, cholera, water quality, MPN and H2S test for fecal contamination of water District public health officer, lab staff with DCP/MSc microbiology, trained lab technicians DMLT 130 Quality control of district laboratories State laboratory director, MD/MSc/ Training of laboratory personnel at the district level Bsc microbiology, MD pathology, MD/ Epidemic investigation MSc/BSc biochemistry, BMLT/DMLT lab technicians Link up with state and district surveillance units NCD risk factor surveillance Laboratory diagnosis and confirmation of TB, malaria, typhoid, cholera, polio, measles, leptospirae, dengue, hepatitis, anthrax, plague including sensitivity testing and culture 1 central and 4 regional Monitoring and evaluation of the laboratories Epidemic investigations Preparation of standard manuals of techniques for the constituent laboratories Training center for laboratory personnel and coordination of training programs for all laboratory technologists Referral laboratory for all laboratories in the network of the National Surveillance program Technical supervision and guidance to the laboratories in the country Center for the preparation and distribution of certain reagents and biological reagents for the constituent laboratories 25-30 Characterization of the strain e.g.; sero-typing, phage typing, molecular finger printing Repository of standard strains and reagents Production of diagnostic anti-sera Production of reagents for antibody detection Research in production of rapid diagnostic reagents Standardization of methods, procedures and equipment Quality assurance for constituent laboratories International EQAS of laboratory disciplines Team of microbiologists (MD/MSc), biochemistry scientists (MD/MSc), pathologists (MD), lab technicians with BMLT/DMLT Team of microbiologists (MD/MSc), biochemistry scientists (MD/MSc), pathologists (MD), lab technicians with BMLT/DMLT EQAS - External quality assessment scheme, MPN - Most probable number, NCD - Noncommunicable disease, TB - Tuberculosis, DCP - Diploma in clinical pathology, DMLT - Diploma in medical laboratory technology, BMLT - Bachelor of medical laboratory technology

Pandey, et al.: Public health laboratory capacity building initiatives 227 Microbiology programs The teaching/training programs in microbiology are as under: Undergraduate courses Undergraduate training in microbiology includes microbiology teaching in Medical schools, as a part of MBBS course and microbiology teaching as a part of BSc (Medical Microbiology) taught in science colleges across the country. In medical schools, microbiology is taught as a subject in 2 nd year of the MBBS curriculum. The course curriculum includes the study of microbes of medical importance including bacteria, fungi and viruses. However, there is no focus on public health microbiology, and most part of this training is directed towards developing the skills of medical undergraduates in diagnostic microbiology. As of now, there are 381 medical colleges in the country offering the MBBS course with an annual intake capacity of 51,979 students. 5 Bachelor s degree in Science (B.Sc.) Medical Microbiology is an undergraduate course of 3 years duration, and candidates who have studied higher secondary school with physics, chemistry and biology up to class XII are eligible to apply for this course. The course includes the study of microbes of medical importance. There is no specialized training in public health microbiology in this course as well. This course is offered by various institutes and universities across the country. Some of the premier institutes offering BSc (Medical Microbiology) include School of Health Sciences, University of Calicut, SardarBhagwan Singh PG Institute of Biomedical Sciences and Research (SBSPGI), Dehradun, Alpine PG Institute of Management and Technology Dehradun, Sai Institute of Paramedical and Allied Science Dehradun and Sri Venkateswara Institute of Medical Sciences, Tirupathi. Post graduate courses Post graduate course in microbiology can be pursued by medical as well as science graduates. Medical graduates can take Doctor of Medicine (MD) in Microbiology course, while the students with undergraduate degree in science stream can pursue Master in Science (M.Sc.) in medical microbiology. MD Microbiology is a postgraduate course with the aim of this course is to train the students of Medicine in the field of medical diagnostic microbiology. It is a 3-year course, which is presently offered by 232 medical colleges across the country with an annual intake capacity of 733 seats. 6 MSc. Medical Microbiology is a 2-year program. In many institutions, it is a 3 year program in which 1 st year is dedicated to learning medical subjects like anatomy, biochemistry, and physiology. Eligibility criterion for the course varies across institutions. Most institutions require the candidate to have a B.Sc. with 55% marks in BSc. Some M.Sc. programs are also available for candidates with MBBS, BDS, BUMS, BHMS, BAMS, B.Sc. (Nursing), BMLT and B. Pharm. Reputed institutions conduct an entrance examination for entry into the program. Prominent universities offering this M.Sc. course are the University of Calicut, SRM University and Chettinad University. Many Medical Colleges also offer MSc. Medical Microbiology. Since the focus of both these courses is to train the postgraduate in medical diagnostic microbiology, there is no special training regarding public health laboratories. Doctoral courses Doctor of Philosophy (PhD) in Medical Microbiology is offered by many universities across the country. This course is available for candidates who have either completed MSc. (Medical Microbiology) or M.D. (Microbiology). Biochemistry programs Public health laboratories also need support of staff trained in biochemical investigations for optimum delivery of its functions. This need is catered by postgraduates trained in Medical Biochemistry. At present there are 202 colleges offering MD Biochemistry course with an annual output of 501 candidates. 7 Similar to medical microbiology, medical biochemistry courses are also offered at B.Sc. and M.Sc. level. Biochemistry is also a part of undergraduate medical curriculum. PhD (Biochemistry) is offered at various Universities across the country. There is no specialized training in public health biochemistry at present. Laboratory technology programs There are courses for laboratory technicians where aspirants of medical laboratory technology can take up courses both at diploma and bachelors level. The B.Sc. program in medical laboratory technology is offered by different medical colleges/institutions across the country. Lab technicians need 10 + 2 as the eligibility and duration

228 Pandey, et al.: Public health laboratory capacity building initiatives of the course is 1 year. Diploma in Medical laboratory Technology (DMLT) is available for candidates having a minimum qualification of SSC (10 th Standard). This 1/2-year course trains candidates in basic laboratory techniques. Most public health laboratories are manned by technicians having either the bachelor s or diploma in laboratory technology. There is scope to introduce subject on public health laboratory training in these courses. Clinical pathology programs At peripheral and district level laboratories, the responsibility of laboratory diagnosis is usually served by professionals with Diploma in Clinical Pathology. This is a 2 year course open to candidates with MBBS qualification. This course is offered by many medical colleges across India. Other capacity building initiatives Capacity building through National Health Programs National Health Programs for diseases such as malaria introduced the concept of public health laboratories. A major impetus to public health laboratories was seen after the reinvigoration of tuberculosis control program in India that went all out to detect and treat pulmonary TB cases under the Revised National Tuberculosis Control Program. Other programs like National AIDS Control Program also have undertaken efforts to train the public health laboratory staff in quality assurance and provided the much necessary public health focus to the experts in the medical field. Most of these national programs provide short-term trainings for the public health laboratory staff in disease specific areas. Their training in a broader public health focus is still limited. Role of Integrated Disease Surveillance Project Integrated disease surveillance project (IDSP) was launched in November 2004 with the objective to strengthen disease surveillance in the country by establishing a decentralized State-based surveillance system. One of the important components of this project is to strengthen the public health laboratories in the country. For this purpose, IDSP has supported procurement of laboratory equipment and human resource development for laboratory staff. This has been achieved through training of microbiologists and laboratory technicians at national and state level and training for laboratory assistants working at Community Health Centers and Primary Health Centers. Training of Microbiologists and Laboratory technicians at State and District level focuses on the overview of disease surveillance and IDSP, quality assurance mechanisms and biosafety issues. Training of laboratory assistants deals with an overview of IDSP, specimen collection storage and transportation, testing, biosafety issues. Both these trainings are short term and of three to six days duration. 8 Discussion Capacity building initiatives related to public health can be defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. 9 Capacity building for public health laboratories has acquired increased importance since the introduction of International Health Regulations 2005 (IHR 2005) 10. Article 5 of the regulations requires that all countries be able to detect, assess, notify and report on public health issues of international significance and control any potential public health event of international concern. In order to achieve the same, it is important to build capacity of public health laboratories, both in terms of infrastructure and manpower. However, many countries still lack behind in this endeavor. Inadequate laboratory capacity in developing countries has been termed the Achilles heel of global efforts to combat infectious diseases. 11 This study attempted to explore the various human resource capacity building initiatives in public health laboratories in India. Our results show that public health laboratory training has not developed as a specialized discipline in India. In spite of a large network of public health laboratories in place, most of the staff in these laboratories do not have a specialized training to work in public health laboratory. Furthermore, there are no induction courses for staff working in public health laboratories. Although there are capacity building initiatives for diagnostic laboratories in India, there is lack of courses for public health laboratory staff. Most laboratory courses continue to have a diagnostic focus and neglect the larger lens of public health while studying pathogens and disease agents. There is an urgent need to address this issue so that all efforts in upgrading infrastructure of public health laboratories can be used to optimum capacity. It should be recognized that in spite of so many courses for medical and paramedical laboratory training, there are

Pandey, et al.: Public health laboratory capacity building initiatives 229 virtually no courses for public health laboratory training. As a first step, there is scope to include public health laboratory training as a part of the course curriculum of medical and paramedical laboratory courses before long term specialized courses are launched. In service short term courses can also serve to sensitize the existing staff on public health perspective. It should also be noted that all the existing courses are offered under different roofs, and there is a need to integrate the training in public health laboratories for coordinating the efforts for disease surveillance. We also observed that there is short term training programs for vertical national health programs. However, they are mostly situation and disease specific. There is a need to amalgamate these efforts for efficient training of the staff avoiding duplication of efforts and to provide a broader picture to the public health laboratory staff. Role of partnerships in capacity building measures also needs to be explored. Through the development of active, mutually supportive relationships with local health officials and the establishment of important protocoldriven clinical and laboratory surveillance, there is scope to assimilate efforts for disease surveillance with preparedness, response, training and communication. References 1. The Essential Public Health Functions as a Strategy for Improving Overall Health Systems Performance: Trends and Challenges since the Public Health in the Americas Initiative, 2000-2007. Available from: http://www.paho.org/english/dpm/ SHD/HR/EPHF 2000-2007.pdf. [Last cited on 2012 Jun 09]. 2. Public health laboratories. Available from: http://www. whoindia.org/en/section3/section323.htm. [Last cited on 2012 Apr 28]. 3. Roadmap for public health laboratories in India. Available from: http://www.zoonoses.phfi.org/pdf/lab_policy_9_may_ ver_2_0.pdf. [Last cited on 2012 May 23]. 4. Laboratory Networking for IDSP. Available from: http://www. nicd.nic.in/index2.asp?slid=478&sublinkid=149. [Last cited on 2014 Aug 10]. 5. List of Colleges teaching MBBS. Available from: http:// www.mciindia.org/informationdesk/forstudents/ ListofCollegesTeachingMBBS.aspx. [Last cited on 2014 Aug 10]. 6. Colleges and Courses Search. Available from: http://www. mciindia.org/informationdesk/collegescoursessearch. aspx?n=37. [Last cited on 2014 Aug 10]. 7. Colleges and Courses Search. Available from: http://www. mciindia.org/informationdesk/collegescoursessearch. aspx?n=26. [Last cited on 2014 Aug 10]. 8. Training Strategy-IDSP. Available from: http://www.whoindia. org/linkfiles/idsp_trainingstrategy.pdf. [Last cited on 2012 Jun 09]. 9. Sanchez JL, Johns MC, Burke RL, Vest KG, Fukuda MM, Yoon IK, et al. Capacity-building efforts by the AFHSC-GEIS program. BMC Public Health 2011;11 Suppl 2:S4. 10. World Health Organization. International Health Regulations 2005. 2 nd ed. Geneva, Switzerland: World Health Organization Press; 2008. 11. Berkelman R, Cassell G, Specter S, Hamburg M, Klugman K. The Achilles heel of global efforts to combat infectious diseases. Clin Infect Dis 2006;42:1503-4. Cite this article as: Pandey A, Zodpey S, Shrikhande S, Sharma A. Human resource capacity building initiatives for public health laboratories in India. Indian J Public Health 2014;58:224-9. Source of Support: Nil. Conflict of Interest: None declared.