three months in the clinical laboratory at primeros pasos - ckm - en - 14-09-2013

Three months in the clinical laboratory of

Primeros Pasos,

GUATEMALA

by Caroline Koch-Mathian

MISSION The Primeros Pasos organization aims to improve the quality of life of the rural communities of the Palajunoj Valley of Quetzaltenango, Guatemala, through integrated health education programs and access to medical services.

ABOUT Primeros Pasos is a non-profit, independent organization with a comprehensive outlook on health care. With the collaboration of health professionals, health educators, volunteers, and community leaders, Primeros Pasos offers quality and affordable health care and health education to the rural, underserved communities of the Palajunoj Valley of Quetzaltenango, Guatemala. Primeros Pasos incorporates and combines clinical care, health education, and community outreach programs to effectively provide preventive and primary care.

HISTORY

In late 2002, a group of Guatemalan and foreign students and doctors partnered with community members to revitalize an abandoned mission clinic located in a primarily Mayan-Quiche community outside of Quetzaltenango. The area residents had no local access to public medical services and limited resources to obtain care. The team began by bringing groups of primary school students to the clinic, combining health education with clinical care to address the high rates of childhood malnutrition and diarrheal diseases.

Between June and November 2002, free medical services, medications, and basic health education classes were provided to over 1,000 children from the local public schools. In 2004, the project became known as Primeros Pasos (standing for “First Steps”). The general population remaining without a good source of health care, the clinic, with increased funding and volunteers, began to see walk-in patients, including children not enrolled in schools and adults from the entire valley.

TODAY Primeros Pasos offers medical, pharmaceutical and laboratory services, and is also the only dental provider in the entire valley. On average, the clinic sees 4,000 walk-in patients annually and most commonly treats patients with respiratory illnesses, intestinal infections and parasites, malnutrition, dermatological issues, and hypertension. For many patients, this is their first time to receive comprehensive care. The clinic also offers health education classes year-round to participating schools and community groups.

PROGRAMS Healthy Schools, Mobile Clinics, Women's Health Education, Nutritional Recuperation, Medical, Dental, Laboratory and Pharmaceutical Services.

Statistics (why we work ?)

N°2

The Healthy School Program

N°2

The Mobile Clinic Program

N°2 The Clinical Laboratory

N°3

Who is Primeros Pasos ?

Three months in the Clinical Lab at Primeros Pasos - CKM - 14-09-2013

THREE MONTHS IN THE CLINICAL LABORATORY OF PRIMEROS PASOS, GUATEMALA 2

• 56% of the population in Guatemala

lives under the poverty line and 81% of

rural, indigenous populations live in extreme

poverty (UNDP 2008).

• In developing areas, more than 40% of

diarrhea cases in school children result from

transmission in school rather than at home

(UNICEF 2010).

• Simple hand washing, when taught, can

prevent pneumonia by at least 23%

(Rabie T and Curitis V, 2006) and diarrheal

diseases by about 45% (UNDP Human

Development Report 2006).

• According to USAID, the overall chronic malnutrition rate in Guatemala for children less

than five years old is 50%, higher than

any other country in Central America and higher than many African countries.

• Indigenous women are 3 times

more likely to die during pregnancy and childbirth than non-indigenous women (MSPAS, 2003).

• Guatemala suffers from the 2nd highest

maternal mortality rate in Latin America, behind Haiti at 290 deaths per 100,000 live births (World Bank 2008).

• About 65% percent of mothers of

malnourished children have no formal

education, and less than 20% of mothers

with a secondary education have malnourished children (Center for Economic and Social Rights, 2009).

The Healthy Schools Program provides primary students in the Palajunoj Valley with free annual clinical care accompanied by education aimed to encourage life-long healthy habits. Primeros Pasos was originally founded to specifically address the health issues confronting school children in the Palajunoj Valley. In their first year, they provided approximately 1,000 children in the Valley with free medical examinations and treatment. From these exams they discovered that there were extremely high rates of gastrointestinal parasites, contributing to the prevalence of malnutrition and diarrheal diseases.

The Primeros Pasos team developed a plan of action combining clinical exams and laboratory analysis with health education that remains the core of the Healthy Schools Program today. The program has two major components, “health field trips” hosted in the clinic and health education outreach in the schools, which combined help reach nearly 3,000 children in 10 schools in the Valley each year.

Every week, individual classes from the local primary schools attend the clinic for a “health field trip.” Students receive a medical and dental check-up, are tested for parasites, and participate in an interactive health education

class focused on basic hygiene and nutrition. In addition, every child is sent home with a toothbrush, soap, and any medication that they may need. The outreach component of the program strategically supplements the basic health lessons taught during the in-clinic visits. The team travels to the schools and

gives workshops on age-appropriate themes such as the environmental, self-esteem, domestic violence, drug addiction, and reproductive health.

The Mobile Clinic Program seeks to improve the health of people from remote communities in the Palajunoj Valley by assembling a mobile healthcare provider team and by providing cares directly into the areas in need. Since 2009, Primeros Pasos has been employing the use of Mobile Clinics to reach out to five distant communities in the Valley. These populations are isolated enough that travel to and from the clinic for health concerns and check-ups poses a hardship. Each year, teams of medical professionals and health educators go out into these communities for approximately four to five days and set up temporary medical, dental and pharmaceutical stations.

The Healthy School Program The Mobile Clinics Program

Statistics (why we work?)



MISSION

Provide quality clinical laboratory services to users through highly qualified and responsible personnel, to achieve prevention, prognosis and diagnosis of diseases with the best use of clinical knowledge and technology.

HISTORY A volunteer from Holland started this program in 2004. Since February 2012, Ms. Irma Mazariegos is the permanent laboratory head. The laboratory offers a variety of tests including stool tests, urinanalysis, blood glucose, hemoglobin and hematocrit levels, pregnancy tests blood and urine, sputum BK, KOH, among others. In addition to processing samples from the children enrolled into the Healthy Schools Program, the clinical laboratory’s daily activity also includes examinations of walk-in patients samples. All services are provided at low cost to people age 13 and older and are provided for free to children 12 and under.

VISION Constantly find excellence within the Lab team to work with quality, respect, responsibility, creativity and commitment to the benefit of patients, staff and the organization.

GOAL Achieve qualitative, quantitative and timely laboratory work in accordance with the health programs and the technical laboratory requirements, in order to reach permanent, effective, efficient, reliable and timely laboratory services.

SPECIFIC OBJECTIVES

• Support Primeros Pasos Health Services and Programs in the diagnosis and monitoring of patients • Conduct clinical laboratory testing with adequate quality control • File and maintain the patients results up to date (paper and electronic files) • Mobilize public and school students enrolled in Health Programs to attend the clinic and provide their samples for clinical laboratory testing • Educate the general population with healthy daily practices

JUSTIFICATION

The clinical laboratory is vital for the health of the population of the Palajunoj Valley. It provides an aid to the medical staff for diagnostic confirmation and enables to give the appropriate treatment, particularly in school population with apparently healthy clinical condition but with increasing chronic parasitism. The clinical laboratory is an essential part of Primeros Pasos, because of its central role for medical and financial support to the clinic.

POPULATION AND GEOGRAPHICAL COVERAGE

Primeros Pasos is located in Tierra Colorada Baja, one of ten communities of the Palajunoj Valley, a rural area of the municipality of Quetzaltenango, Guatemala. In addition to Tierra Colorada Baja, the Valley has nine other communities: Tierra Colorada Alta, Bella Vista, Candelaria, Chuicaracoj, Chuicavioc, Las Majadas, Llano de Pinal, Xepache and Xecaracoj (See detailed Map in Attachment 1). In total, the estimated population of the Valley is more than 15,000. Primeros Pasos is the only clinic that provides clinical laboratory testing services to children and adults in the Palajunoj Valley, Quetzaltenango. The clinical laboratory has a coverage spanning ten community schools in the valley and 11 nurseries. Walk-in patients of different ages and backgrounds surrounding the municipality of Quetzaltenango also attend the clinic. As a consequence of this extended coverage of patients, the laboratory’s activity has been significantly increased and the diagnostic panel testing expanded.

The clinical Laboratory



DETAILS OF A TYPICAL DAY AT THE CLINICAL LABORATORY

The day begins at 8:00 am when employees and volunteers from Primeros Pasos gather in front of the Calvary Church to wait for the bus. It takes about 15 minutes to get to the clinic. The primary role of the laboratory technician is to collect, prepare and analyze blood, urine and stool samples. Most of the samples analyzed are stool samples from school students to identify whether or not they are infected by parasites. The lab technician is in charge of a volunteer who learns the processes and techniques that are used in the clinical laboratory. The volunteer learns to identify many parasites including Giardia lamblia, Ascaris lumbricoides and Entamoeba histolytica. In addition to stool samples, the laboratory can also perform pregnancy tests, urinalysis, hematocrit and hemoglobin levels in blood, KOH, BK sputum gram secretions, serology, among other tests. On a typical day, we process 10 to 40 samples, which requires a lot of coordination between the lab technician and the volunteer, to ensure the effectiveness and accuracy of the patient sample analyses.

The volunteer is in charge of the sample preparation, but will also learn how to perform the analysis and read the result, that is for example, identify bacteria and parasites in the microscope. Once the analysis is made, results are reported to the medical staff so they can provide appropriate treatment. The results of the school students are delivered after the last sample is completed, accompanying other indicators, such as age, height, weight, etc… In contrast, the analyses requested for walk-in patients are communicated through a prescription filled by the doctors and are prioritized over school students’ analyses. The patients’ records are kept in a notebook written by hand and then transcribed electronically. Filing is another important activity that is routinely performed to keep detailed and up to date records.

The laboratory workload and monthly activities vary (See Attachment 2). When school groups come to the clinic, the lab is a busy place. Unlike some days, there are a lot of walk-in patients. The day ends at 1:00 pm, the laboratory and glassware are thoroughly disinfected, so the area is completely clean out for the next working day.

DAILY ACTIONS IN CLINICAL LABORATORY

Clean the working area

Collect stool samples from children of the

Healthy Schools Program and label them

appropriately

Receive walk-in patient samples with

prescription

Prepare and analyze the samples (urology,

coprology, hematology, serology, BK and

rapid tests)

Discard contaminated materials

Wash and sterilize glassware

Write down the test results in the

examination form

Report the test results both in the

laboratory notebook and in the electronic

files (Archives)

Report the test results to doctors and

collabore in the final diagnosis

Analyze test results (statistics)

Share knowledge with doctors or

volunteers

Impart knowledge with medical and nurse

students

Educate children during the mobile clinics’

days

COLLABORATIVE ACTIVITIES

Collection and analyses of stool samples from the children enrolled in the Healthy School Program and in the Mobile Clinics Program; Sensibilization of school students during the conferences with the purpose of orienting and expanding knowledge on healthy habits; Collaboration with the medical team to provide the knowledge and experience on the clinical diagnosis; As a volunteer, you are encouraged to develop a project on the basis of your work done at the laboratory. To illustrate, a Report of the Healthy School Program and in the Mobile Clinics Program in 2012 is provided in Attachment 1.

FUTURE OBJECTIVES Increase the Laboratory’s capabilities and

testing panel to facilitate and strengthen

the patient’s diagnosis, in regards to the

different pathologies observed;

Continue offering Laboratory services at an

affordable price to help the Primeros Pasos

organization to continue being a sustained

economic player for a better health in the

Palajunoj Valley.

FOR MORE INFORMATIONS

Interested in volunteering or in donating? [email protected]

Check out the Primeros Pasos Website at: http://www.primerospasos.org

or contact me for any question at: [email protected]

Thank you to all the Primeros Pasos team! Thank you for your warm welcome, for the awareness you taught me, and for this life experience…


mailto:[email protected]

http://www.primerospasos.org/

mailto:[email protected]

ATTACHMENT 1

INTRODUCTION

As a volunteer in the Clinical Laboratory in the Primeros Pasos (PP) clinic from August to October 2012, I did

participate in the collection and patient sample analyzes, and in particular, of stool samples from the kids enrolled

in the Healthy Schools and Mobile Clinics Programs. The two Programs, running over the school year, have been

designed based on the geographical and socio-economic environment of the Valley (Map 1), to address children

health issues.

The Healthy Schools Program reach out school children from five communities that are well deserved with public

transportation, and have running water and electricity (Zone 1 on the Map, including Llano del Pinal, Xecaracoj,

Xepache, Chuicaracoj and Tierra Colorada Baja), whereas the Mobile Clinics Program is intended to reach out the

most remote communities (Zone 2 on the Map including Candelaría, Bella Vista, Chuicavioc, Las Majadas and

Tierra Colorada Alta). Those communities are indeed not well deserved by public transportation, people need to

travel by foot to get to their home place, and there is neither running water nor electricity.

In the Mobile Clinics Program, the PP staff - assembled as a mobile Healthcare provider - is visiting the schools to

perform the training, diagnosis and treatment on site. In contrast, children enrolled in the Healthy Schools

Program, are going to the clinics with their class.

Three months in the Clinical Lab at Primeros Pasos - CKM - 14-09-2013 1

OBJECTIVE

This report summarizes the data collected from the two Programs running over the school year 2012. It is intended

to give an insight into the Child Health status in terms of prevalence of parasitic infection, in the indigenous

Palajunoj Valley, Guatemala, and show how the geographical and socio-economic development of the 10

communities of the Valley influence it.

This report is also intended to identify key indicators that, together with other information, can help the Primeros

Pasos Organization to monitor the effectiveness of its different Programs, to build initiatives and consolidate

priorities in response to the different factors putting the health of the children of the Valley at risk.

RESULTS

Kids’ attendance to school, proportion of stool samples collected, type of sample collected, and prevalence and

distribution of the gastrointestinal parasites identified, were reported for each program respectively, and over the

duration of the school year 2012.

The coverage of patients is slightly higher in the Mobile Clinics Program where 78% (1037/1329, Graph 7) of the

kids registered attended school and thus underwent a clinical examination and received treatment, versus 70%

(1487/2132, Graph 2) for the kids from the Healthy School Program.

A total of 71% (1058/1487, Graph 3) of stool samples were collected from kids enrolled in the Healthy School

Program, whereas a total of 44% (459/1037, Graph 8) were collected from kids enrolled in the Mobile Clinics

Program.

Interestingly, we can observe that for both the Healthy Schools and the Mobile Clinics Programs, some of the kids

brought empty samples or even urine samples (Graphs 4 and 9).

The calculation of the prevalence of parasitic infection shows that kids from the Healthy School Program are less

infected by parasites: 65.8% (Graph 4) versus 85.8% for the kids from the Mobile Clinic Program (Graph 9).

They are infected by, in order of prevalence: Endolimax nana (36.6% and 40.0%), Blastocysitis hominis 35.0% and

33.0%), Ascaris Lombricoides (5.0% and 15.0%), Entamoeba histolytica (8.9% and 4.0%), Giardia lamblia (5.3% and

5.0%), Entamoeba coli (5.8% and 4%), for the Healthy Schools Program and for the Mobile Clinics Program,

respectively.


CONCLUSION

When the Primeros Pasos clinic travels to the schools, they can attend and thus treat more kids. However, in the

Mobile Clinics, fewer kids bring their stool sample, which impacts the quality of diagnosis and treatment: the

Laboratory examination cannot be performed to identify parasites, and orientate the clinical diagnosis towards

the most appropriate treatment.

The low proportion of stool samples collected during the Mobile Clinics can be explained by different reasons:

- Difficulties in the management and planning of the Mobile Clinics due to limited material resources (the

Mobile Clinic team has to go to the schools either by motorcycle or by foot, a selection only of drugs and

medical equipment can be brought), and limited human resources (the medical staff has to be split to run

the PP clinic at the same time);

- Geographical constraints (remote community schools);

- Type of population (low socio-economic level, big classes, kids of all ages , unfocused kids, …etc)

The “mobile or on-site” clinics are of particular importance due to the highest rate of parasitic infection observed

in these remote communities.

The prevalence of parasitic infection is a direct indicator of the sanitary conditions in the communities. Infection to

parasites is acquired through fecal-oral transmission mostly via the cyst form, from contaminated water and food,

or from animals. For Ascaris L., infection is done through ingestion of the embryonated eggs, from contaminated

soil. They cause dysentery, chronic diarrhea, nutrition impairment, developmental disabilities…etc. Their presence

reflects poor living and sanitary conditions (no adequate disposal of fecal waste, limited access to drinking

water,…), poor hygienic habits, closeness with domestic animals, child malnutrition, …etc.

Also, the fact that some of the kids brought empty or urine samples instead of stool samples, emphasizes the

importance of the planning and education, and their impact in the quality of diagnosis and treatment: how much

ahead of time information and education should be provided before samples collection and clinical examination,

how often it should be done, and how focused it has to be, towards the kids and the teachers. The content of the

message shall be kept simple, short, easy to understand and very practical.

Samples collection may eventually be disconnected and organized before the day of the clinical examination, to

optimize the in-clinic visits or mobile clinics, and time spent with the kids. All kids are preventively treated on site

by anti-parasites medicines, most often with Metrodinazol. If a stool specimen gives evidence of a specific parasite

that cannot be treated by Metrodinazol, the kid will receive specific treatment afterwards.

Having the lab results available before the clinical examination takes place, may help optimizing the diagnosis, and

treatment, and allow a better control of the prevalence of parasitic infection in the Valley.


As a conclusion, in a difficult environment such as the indigenous Palajunoj Valley, which is today socially and

economically still under development, and where geography is a determining factor to access basic resources as

water, electricity and public transportation, the most distant communities (Zone 2 on the Map) are locations

where the child health is the most at risk, as shown by the data collected from this retrospective study, i.e. by the

highest prevalence of parasitic infection.

The Mobile Clinic Program has a high potential to significantly improve the Health of remote communities.

The data reveals the difficulties of implementing the Mobile Clinics Program. The efforts put into a thorough

planning and management of human and material resources should therefore be encouraged and continued.

Mobile Clinics are indeed a very interesting pathway to develop to bring diagnosis and treatments to the patients

rather than the patients to the clinic.

Data reporting such as kids’ attendance to school, proportion of stool samples collected, type of sample collected, and

prevalence and distribution of the gastrointestinal parasites identified, may serve as useful indicators for the

Primeros Pasos Organization to implement and monitor over the years, to evaluate the effectiveness of their Child

Health Education and Prevention strategies.

Such indicators shall be considered together with other parameters such as weigh, size, overall clinical and dental

status, …etc, to build a complete monitoring of the Child Health Program. The above retrospective analysis is only

intended to give some guidance and examples of key indicators, to continuously improve and control the

effectiveness of the Programs developed by the Non-Profit Organization Primeros Pasos.


ATTACHMENT 2


three months in the clinical laboratory at primeros pasos - ckm - en - 14-09-2013

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