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ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 551-555

Strategies to ensure efficient laboratory functioning while navigating through the COVID-19 crisis in developing countries: An early experience from a tertiary care centre in India


1 Department of Pathology, Homi Bhabha Cancer Hospital and Research Centre, Punjab (A Unit of Tata Memorial Centre), India
2 Department of Radiotherapy, Homi Bhabha Cancer Hospital and Research Centre, Punjab (A Unit of Tata Memorial Centre), India

Date of Submission12-May-2020
Date of Decision14-Jul-2020
Date of Acceptance15-Sep-2020
Date of Web Publication11-Jun-2021

Correspondence Address:
Sankalp Sancheti
Department of Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_613_20

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 > Abstract 


Background: The coronavirus disease 2019 (COVID 19) is a zoonotic viral infection that originated in Wuhan, China, in December 2019. It was declared a pandemic by the World Health Organization shortly thereafter. This pandemic is going to have a lasting impact on the functioning of pathology laboratories due to the frequent handling of potentially infectious samples by the laboratory personnel. To deal with this unprecedented situation, various national and international guidelines have been put forward outlining the precautions to be taken during sample processing from a potentially infectious patient.
Purpose: Most of these guidelines are centered around laboratories that are a part of designated COVID 19 hospitals. However, proper protocols need to be in place in all laboratories, irrespective of whether they are a part of COVID 19 hospital or not as this would greatly reduce the risk of exposure of laboratory/hospital personnel. As part of a laboratory associated with a rural cancer hospital which is not a dedicated COVID 19 hospital, we aim to present our institute's experience in handling pathology specimens during the COVID 19 era.
Conclusion: We hope this will address the concerns of small to medium sized laboratories and help them build an effective strategy required for protecting the laboratory personnel from risk of exposure and also ensure smooth and optimum functioning of the laboratory services.

Keywords: Coronavirus disease 2019, guidelines, laboratory, pathology, strategies


How to cite this article:
Somal PK, Sancheti S, Sali AP, Bansal S, Kalra SK, Thakur A, Gupta N, Kapoor R. Strategies to ensure efficient laboratory functioning while navigating through the COVID-19 crisis in developing countries: An early experience from a tertiary care centre in India. J Can Res Ther 2021;17:551-5

How to cite this URL:
Somal PK, Sancheti S, Sali AP, Bansal S, Kalra SK, Thakur A, Gupta N, Kapoor R. Strategies to ensure efficient laboratory functioning while navigating through the COVID-19 crisis in developing countries: An early experience from a tertiary care centre in India. J Can Res Ther [serial online] 2021 [cited 2021 Sep 23];17:551-5. Available from: https://www.cancerjournal.net/text.asp?2021/17/2/551/318113




 > Introduction Top


The coronavirus disease 2019 (COVID-19) caused specifically by a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become an unprecedented global pandemic in a short frame of time. Since its initial description from Wuhan, China, in December 2019, the virus has grasped the world in no time.[1] The first case of COVID-19 in India was reported from Kerala in late January 2020. However, it was only in March 2020 that the World Health Organization (WHO) officially declared it as a pandemic. At the time of writing this manuscript, the SARS-CoV-2 has already infected 3,588,773 patients globally with 247,503 deaths and 52,952 patients in India with 1783 deaths.[2] The pandemic has had an enormous impact on the economy, trade, and tourism worldwide.[3] To tackle this austere situation in a better way, many national and international organizations have come up with guidelines for the medical personnel involved in the treatment and care of these patients.[4],[5] Health-care workers (HCW) including doctors, nurses, paramedical personnel, and laboratory technical staff have been the frontline fighters in this pandemic.

In India, around 445 laboratories have been designated as SARS-CoV-2 testing laboratories,[6] and specific guidelines are in place for the working and functioning of these labs.[6],[7],[8] It is also important to note that developing nations like India present a unique challenge with regards to laboratory management as among more than 20,000 clinical laboratories; only over 1200 are accredited by the National Accreditation Board for Testing and Calibration Laboratories.[9],[10] It is also important to note that most of these accredited laboratories are located in the urban areas and metropolitan cities, while the laboratories located in the semi-urban and rural areas are mostly unaccredited. Due to this variability, these laboratories may not have adequate technical workforce, defined protocols for biosafety measures, and other resources in place. It becomes necessary to address this gap especially in the current situation.

Several cancer centers across the world have been forced to scale-down their services due to the published reports of cancer patients suffering from COVID-19 behaving poorly in comparison to the general population. On the other hand, Tata Memorial Centre Mumbai, India's largest cancer center, has continued its service toward the cancer patients even with the scaled-down operations.[11]

Herein, we share our experience in managing the resources and workfoce during this difficult time. We hope that it will be useful for the small and medium laboratories to help formulate their own guidelines for optimum functioning and staff protection from COVID-19.


 > Need for Protection of Laboratory Personnel and Our Experience Top


Homi Bhabha Cancer Hospital, Sangrur is a dedicated cancer hospital and the pathology department has separate hematology, biochemistry, histopathology, immunohistochemistry, cytopathology, and frozen section units. Although our hospital is not designated as a COVID-19 center, the workspace and manpower management presents a unique challenge to minimize the risk of transmission of infection along with streamlined hospital/laboratory functioning.

As part of the hospital preparedness in dealing with the current pandemic, a patient triage area has been set up at the hospital entrance where all the patients are screened for fever and any other respiratory symptoms. In addition to this, a detailed questionnaire pertaining to recent travel history to any affected area, contact with known or suspected COVID-19 patient is recorded at the triage area. If a patient presents with any respiratory symptoms or has a recent history of travel or contact with a known/suspected COVID-19 patient, he/she is sent to the designated COVID-19 hospital for further evaluation, testing, and treatment. For any patient visiting the hospital, only one attendant is allowed to accompany him/her and both have to wear a mask compulsorily and sanitize their hands.

The fear and anxiety related to COVID-19 is gripping humanity universally and the laboratory workforce is no exception to this. As the pathology laboratory deals with a variety of samples, the laboratory personnel are at risk of getting exposed to the virus, hence, it is imperative to undertake all the necessary precautions to prevent such transmission from suspected patients. These precautions need to be implemented right from the time the patient enters the hospital.

With respect to the laboratory, it is also important to identify the biomaterials which can be possible sources of contamination and to formulate risk mitigation strategies to protect the laboratory personnel.

The WHO recommends that all specimens collected for laboratory investigations be regarded as potentially infectious and laboratory personnel need to adhere rigorously to the standard precautionary measures.[12],[13]

The biomaterials identified as possible sources of contamination in the laboratory include:[14]

  1. Unfixed/inadequately fixed surgical and cytological specimens including tissues for frozen sections
  2. Fine-needle aspiration (FNA) cytology specimens for which rapid on-site evaluation (ROSE) is performed
  3. Aerosol producing procedures such as centrifugation and vortexing of fluids
  4. Surface contamination due to leakage of fluids during dissection of fresh or inadequately fixed specimens
  5. Tissue samples derived from autopsies.


In addition to the identification of these high-risk samples, proper disinfection of surfaces, instruments, maintenance of good hand hygiene, and rational use of personal protective equipment (PPE) play an important role in minimizing the risk of infection.

After reviewing the various national and international guidelines in place,[13],[14],[15],[16],[17] we have broadly stratified the strategies into various components which will be discussed under the following subcategories:

  1. Utilization and training of laboratory staff
  2. Sample collection
  3. Sample processing
  4. Surface and equipment disinfection and decontamination
  5. Special areas for consideration (Frozen, ROSE, etc.,)
  6. Sample discarding.



 > Utilization and Training of Laboratory Staff Top


Hand hygiene, social distancing, practicing respiratory hygiene, and appropriate PPE are amongst the most important preventive measures against COVID-19. It is extremely important to train the staff continuously and ensure that all these preventive measures are strictly followed in the laboratory.

Hand hygiene

The WHO advocates the use of regular training programs aimed at promoting best hand hygiene practices among HCW and ensuring the availability of the necessary equipment. Cleaning hands using an alcohol-based hand rub or with water and soap should be done according to the instructions known as “My 5 moments for hand hygiene.” An effective alcohol-based hand rub product is defined as one containing 60%–80% of alcohol.[18]

Personal protective equipment

The WHO has issued guidelines for usage of PPE, including masks. WHO advocates the usage of N95 masks for all aerosol-generating procedures which may be undertaken by HCW. The aerosol-generating procedures with respect to the pathology laboratory will be discussed in detail in individual sections. At all other places, the laboratory staff are advised to use a three-ply surgical quality mask.[19]

Social distancing

The WHO advocates maintaining physical distance (a minimum of 1 m) from other individuals as part of preventive measures.[19] In recent times, social distancing has gained much importance and has been advised by many experts as an important measure to avoid transmission of infection. It seems that this habit is bound to become a part of day-to-day routine for many years to come.

Keeping all these guidelines in mind, we have ensured that all the laboratory staff are regularly trained in hand hygiene practices, usage, and disposal of masks. Alcohol-based hand sanitizers with 70% alcohol are kept at every workstation for hand sanitization. The staff is encouraged to follow good microbiological practice and procedure guidelines as outlined by the WHO.[20] The staff is also encouraged to keep themselves updated with regards to the issuance of any new guidelines.

To ensure that the entire staff is not exposed at the same time, the entire staff has been divided into two teams with alternating rotations. The two teams have no direct interaction between them. While working in the laboratory, social distancing is advocated during routine interaction between members of each team.

In addition, the staff is screened every day at the triage area set up at the hospital entrance for fever and any respiratory symptoms. Any person suspected of having any symptoms is requested to stay at home or seek medical advice.

In addition to this, the entire staff is trained regularly regarding the handling and processing of samples, sample disinfection in accordance with the current recommendations. All these measures are discussed subsequently in detail.


 > Sample Collection Top


The sample collection area in our hospital is already segregated from the main laboratory. The laboratory personnel in charge of sample collection have been provided with appropriate PPE (gloves, N 95 mask, face shield, and plastic apron). Samples are then segregated to the clinical laboratory, histopathology, and cytopathology, respectively. All the patients coming to the sample collection area are instructed to compulsorily wear masks and sanitize their hands before entering. Blood collection is done as usual wearing appropriate PPE.

As it has been noted that the virus can persist on paper at least for 24 h, a paperless electronic requisition is preferred and we follow the same. Our laboratory information system is linked to the hospital information system to ensure the availability of all reports in electronic format. Laboratories where such electronic format is not available can send the reports on registered E-mail of patients or clinicians to avoid multiple visits of patients.


 > Histopathology Top


All the surgical pathology specimens are received in formalin-filled, properly sealed containers with an adequate amount of formalin to cover the tissue. Specimens are opened in a separate designated grossing area and the residents/staff in these areas are provided with appropriate PPE (gloves, N 95 mask, face shield, plastic apron). Fixation and grossing protocols are followed as usual.


 > Cytology Top


Samples that are received in the cytology laboratory include sputum, bronchoalveolar lavage, pleural effusion, pericardial effusion, urine, and ascitic fluids. All cytology samples are collected in an appropriately labeled, leak-proof; tightly capped containers and the personnel processing these samples wear appropriate PPE and are adequately trained to handle spill decontamination.


 > Sample Processing Top


Histopathology

The specimen is fixed for 24 h or at least overnight and the resident is provided with a face shield, mask, and disposable apron while grossing. Since brushes used for inking can be potential sources of retained organisms, cotton wisps are used wherever possible. All the fresh or partially fixed specimens as well those for grossing with chances of splashes or spills must be handled under biosafety cabinet (BSC) level II according to guidelines.[13],[14],[15]

However, in case of unavailability of these, incompletely fixed samples, especially those of the lungs and gastrointestinal tract, should be preliminarily grossly sectioned without extracting the samples from the jars followed by direct injection of formalin in the tissue. In our laboratory, all specimens are grossed after ensuring adequate fixation.


 > Cytology Top


Certain steps involved in routine sample processing in cytology including the opening of the sample containers, removing tightly fitted caps of the tubes, diluting, shaking, vortexing, and centrifugation can be potential sources of aerosol generation, hence, centrifugation should be done only if absolutely necessary and ideally in a Class II BSC according to guidelines. In case of a limited resource setting where BSC is not available, centrifugation should be done using capped tubes. Following centrifugation, the lid of the centrifuge should be opened gently and the samples should be rested for 5 min followed by gentle removal of the caps. Adequate precautions need to be taken by the laboratory personnel during sample processing in accordance with these guidelines.[16]


 > Surface and Equipment Disinfection and Decontamination Top


It is not yet certain how long the virus survives on surfaces, but it seems likely that SARS-CoV-2 behaves like other coronaviruses. Kampf et al. noted that human coronaviruses can persist on surfaces such as metal, glass, or plastic for up to 9 days, and can be effectively inactivated by surface disinfection procedures with 62%–71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 min. Other biocidal agents such as 0.05%–2% benzalkonium chloride or 0.02% chlorhexidine are less effective.[12] In addition to the type of disinfectant that can be used, attention should also be paid to the contact time, dilution, and expiry date after the working solution is prepared.[20]

Based on findings of different studies done on the inactivation of coronaviruses by formalin, glutaraldehyde, and effect of temperature, it is reasonable to assume that formalin-fixed paraffin-embedded tissue block would lower risk of coronavirus infectivity significantly.[12]

In our hospital, the surface used for grossing/grossing station is cleaned with 0.1% hypochlorite solution after grossing is completed. In addition to this, all the working surfaces along with the laboratory furniture, doorknobs, computer keyboards, microscopes, and other equipment are decontaminated with 0.1% sodium hypochlorite solution twice a day.

In the event of a sample spill, the decontamination of laboratory surfaces is done immediately using a 1% sodium hypochlorite solution.[16]


 > Special Areas of Consideration Top


Frozen section in times of coronavirus disease 2019

Frozen section is a high-risk procedure in histopathology wherein the combination of cryostat aerosolization and fresh tissues favor high risk of transmission and thus should be avoided wherever possible.

In our hospital, we have reduced the frequency of frozen section to only those cases in which it will change the course of patient management. While performing the frozen section, appropriate PPE (gloves, apron, face shield, and N95 mask) are worn by the operating technician and the resident. The cryostat is decontaminated every day with 70% alcohol.


 > Rapid Onsite Evaluation in Cytology Top


ROSE is restricted to selective cases weighing the risks and benefits of the procedure for each patient. Performing FNA or ROSE by cytopathologists is considered as close contact, thus wearing a full PPE kit is mandatory as per guidelines. However, in a developing country like India, this might not be feasible due to the limited availability of the PPE kits. As per the guidelines issued by the Indian Academy of Cytologists, in cases with the unavailability of PPE, the attending resident should be provided with a surgical gown, cap, N95 mask, and face shield while performing FNA/ROSE. Furthermore, the drying of the smears by shaking or air blowing is discouraged.[16] Further, these samples are processed as described before.


 > Sample Discarding and Biomedical Waste Management Top


All the residual samples are discarded in appropriate disinfectants which include 0.1% sodium hypochlorite solution, 0.5% hydrogen peroxide, and 62%–71% ethanol. Biomedical waste is processed as per local/institutional regulations and as mandated by pollution control policy and guidelines made by the Central Pollution Control Board, India.[17]


 > Conclusion Top


The present pandemic underscores the need for adoption of standard safety precautions by the laboratory personnel in a pathology laboratory to minimize the risk of infection. Social distancing, good hand hygiene, and maintaining preventive measures while performing specific procedures form the cornerstones of this preventive strategy. It is also essential that the hospital staff follow these preventive measures outside the hospital environment as well. A tailored strategy encompassing all these measures needs to be formulated by all the laboratories to ensure the safety of the laboratory personnel and optimize the laboratory functioning to navigate through this crisis in an efficient manner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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World Health Organization. Coronavirus Disease (COVID-19) Technical Guidelines: Laboratory Testing in 2019-nCoV in Humans. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance. [Last accessed on 2020 May 08].  Back to cited text no. 8
    
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World Health Organization. Infection Prevention and Control During Health Care when Novel Coronavirus (nCoV) Infection is Suspected: Interim Guidance, World Health Organization; 2020. p. 1-5. Available from: https://www.who.int/publications-detail/infection-preven tion-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. [Last accessed on 2020 May 08].  Back to cited text no. 13
    
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