African Journal of Laboratory Medicine ISSN: (Online) 2225-2010, (Print) 2225-2002 Page 1 of 9 Lessons from the Field H3Africa partnerships to empower clinical research sites to generate high-quality biological samples Authors: Background: The Institute of Human Virology Nigeria (IHVN) – Human Heredity and Health Talishiea Croxton1,2 1 in Africa (H3Africa) Biorepository (I-HAB) seeks to provide high-quality biospecimens Ndidi Agala Emmanuel Jonathan1 for research. This depends on the ability of clinical research sites (CRS) – who provide Olasinbo Balogun1 biospecimens – to operate according to well-established industry standards. Yet, standards are Petronilla J. Ozumba1 often neglected at CRSs located in Africa. Here, I-HAB reports on its four-pronged approach Enzenwa Onyemata1 3 to empower CRSs to prepare high-quality biospecimens for research.Shefiya Lawal Manmak Mamven3 Objectives: I-HAB sought (1) to assess a four-pronged approach to improve biobanking Samuel Ajayi4 Sylvia E. Melikam5 practices and sample quality among CRSs, and (2) to build human capacity. Mayowa Owolabi6 7 Methods: I-HAB partnered with two H3Africa principal investigators located in Nigeria and Bruce Ovbiagele Dwomoa Adu8 Ghana from August 2013 through to May 2017 to debut its four-pronged approach (needs Akinlolu Ojo9 assessment, training and mentorship, pilot, and continuous quality improvement) to empower Christine M. Beiswanger10,11 CRSs to attain high-quality biospecimens. Alash’le Abimiku1,2 Results: Close collaborations were instrumental in establishing mutually beneficial and lasting Affiliations: relationships. Improvements during the 12 months of engagement with CRSs involved 1Institute of Human Virology Nigeria, Abuja, Nigeria personnel, procedural, and supply upgrades. In total, 51 staff were trained in over 20 topics. During the pilot, CRSs extracted 50 DNA biospecimens from whole blood and performed 2Institute of Human Virology, quality control. The CRSs shipped extracted DNA to I-HAB and I-HAB that comparatively University of Maryland, analysed the DNA. Remediation was achieved via recommendations, training, and mentorship. Baltimore, Maryland, Preanalytical, analytical and post-analytical processes, standard operating procedures, and United States workflows were systematically developed. 3Department of Internal Conclusion: Partnerships between I-HAB and H3Africa CRSs enabled research sites to Medicine, University of Abuja Teaching Hospital, Abuja, produce high-quality biospecimens through needs assessment, training and mentorship, pilot, Nigeria and continuous monitoring and improvement. 4 Keywords: biobank; training; Africa; developing country; biotechnology.Department of Medicine, University of Abuja Teaching Hospital, Abuja, Nigeria Introduction 5Department of Medicine, University of Ibadan, Ibadan, Biobanking is underdeveloped in Africa. 1,2 Obvious obstacles include sparse financial resources, Nigeria challenging operating environments, underdeveloped infrastructure, inferior logistics, and an unreliable electrical power supply.2,3,4,5 Also, preanalytical processes occurring at collection sites 6Center for Genomic and affect biospecimen quality.3 Past reports documented destitute laboratory systems, and the hope Precision Medicine, College for advancements through international declarations, funding, networking, training, and of Medicine, University of Ibadan, Ibadan, Nigeria mentorship. 6,7,8,9 7Department of Neurology, The United States National Institutes of Health (NIH) and the Wellcome Trust founded Human University of Ghana Medical Heredity and Health in Africa (H3Africa) (www.h3Africa.org) to promote genomic research in School, Accra, Ghana Africa through funding of African researchers, and provision of bioinformatics core and biorepositories located in Nigeria, South Africa, and Uganda.6 The NIH required biorepositories to complete a feasibility phase (Phase I) to qualify for the implementation phase (Phase II). The NIH also assigned H3Africa research projects to a biorepository and required projects to deposit 8Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, United States 9Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States 10Coriell Institute for Medical Research, Camden, New Jersey Read online: 11Independent Contractor, Philadelphia, Pennsylvania, United States Scan this QR Corresponding author: Talishiea Croxton, tcroxton@ihv.umaryland.edu code with your Dates: Received: 01 Dec. 2018 | Accepted: 12 Dec. 2019 | Published: 18 Mar. 2020 smart phone or mobile device How to cite this article: Croxton T, Agala N, Jonathan E, et al. H3Africa partnerships to empower clinical research sites to generate to read online. high-quality biological samples. Afr J Lab Med. 2020;9(1), a935. https://doi.org/10.4102/ajlm.v9i1.935 Copyright: © 2020. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. http://www.ajlmonline.org Open Access Page 2 of 9 Lessons from the Field an aliquot of all DNA. The bioinformatics core stored data. • Legal requirements: shipping regulations and import Beiswanger et al.10 described the process for accessing and export permits. biospecimens. • H3Africa requirements: DNA quality, minimal data set, shipping checklist, and manifest and query forms. The The NIH funded the Institute of Human Virology Nigeria ‘minimal data set’ included a biospecimen identification H3Africa Biorepository (I-HAB). I-HAB’s primary pursuit in code, de-identified participant identification code, study Phase I was to achieve international standards according to name, specimen type, date of collection, gender, age at the International Society for Biological and Environmental collection, and storage box position. The working group Repositories (ISBER) best practices.11 For example, ISBER standardised the format of each element to ensure provides requirements for biospecimen collection, processing, consistency and decrease errors. quality control (QC), storage and transport, infrastructure, quality management, safety, training, and a laboratory The working group based the contents of the standard information management system (LIMS).11 The LIMS operating procedures (SOPs) on International Air and documents and tracks biospecimen attributes from collection Transport Association regulations, ISBER best practices, through to use, depletion, and destruction. I-HAB also manufacturer’s specifications, and well-established practices referred to the International Organization for Standardization as specified. ISO 15189 standards were useful for creating (ISO) 15189 standards for clinical laboratories (https://www. SOPs and documents regarding quality management and for iso.org/standard/56115.html) and Strengthening Laboratory defining the structural elements required for all SOPs. I-HAB Management Toward Accreditation (SLMTA) (https://slmta. recommended that sites customise SOPs to their laboratories. org) for requirements pertaining to quality management, as appropriate. Regarding specific protocols, I-HAB referred to manufacturer specifications and journals. Ethical Considerations This article followed all ethical standards for research without Considering the potential imbalance between standardised direct contact with human or animal subjects. preanalytical processes according to ISBER, ISO, and SLMTA and the lack of such standards in laboratories in Africa, Needs assessment I-HAB sought to evaluate assigned clinical research sites (CRSs) and implement improvement strategies. I-HAB The I-HAB and research teams met to discuss project established a training and mentorship programme to bridge descriptions, processes, and procedures that potentially gaps and to ensure researchers obtain biospecimens of the impact a biospecimen’s quality. I-HAB reviewed study highest quality. This article describes I-HAB’s experience in protocols and other documents in consideration of engaging two H3Africa projects from August 2013 through responsibilities and procedures impacting a biospecimen’s May 2017 in preparation for Phase II.10 integrity. I-HAB assessed facilities, equipment, personnel, documents and records, specimen management, organisation, Methods purchasing, inventory, and quality assurance measures in line with underlying principles of ISBER best practices and ISO The NIH assigned I-HAB six research projects including 15189 to ensure the sites could meet protocol requirements Project A – a CRS located in Tanzania (not included in this according to industry standards. Assessments included a study), Nigeria, and Ghana, with the project’s central combination of discussion, SOP review, site observation, and laboratory hub (clinical research sites sends biospecimens to competency assessments for specifically assigned tasks. laboratory hubs for processing, testing or storage) in Ghana I-HAB offered document development, training and – and Project B, with a CRS and laboratory hub in Nigeria. mentorship, biospecimen storage, distribution, and QC to I-HAB employed a four-pronged approach of needs resolve problems identified by assessments. assessment, training and mentorship, piloting, and continuous quality improvement to help sites to collect, process, store, and transport high-quality biospecimens for future research. Training and mentorship I-HAB customised training and mentorship for Project A’s A working group of NIH experts and representatives from clinical site in Nigeria and its hub, and Project B’s hub site each H3Africa biorepository developed guidelines and according to the outcome of the needs assessment. Training protocols to guide the H3Africa consortium on biorepository and mentorship occurred at I-HAB, CRSs and hubs for groups processes for harmonisation and consistency. The documents and individuals. Training began with lectures to introduce included biospecimens deposit and access requirements, and theories, followed by exercises to provide practical experience, specific procedures for biospecimen collection, processing, and concluded with participant assessments to test competency. transport, and shipping (www.h3africa.org). For example, Mentorship provided additional time to practise procedures, the group established minimal criteria for DNA purity and to address problems revealed through training, and to review concentration to ensure quality and consistency. The processes that were required but were not covered during guidelines required submitters to maintain: training. Mentorship areas included document development • Ethical standards: ethical approval, informed consent, and revision, workflow design, supply chain management, and Material Transfer Agreements (MTA). biological transportation, and laboratory procedures. http://www.ajlmonline.org Open Access Page 3 of 9 Lessons from the Field Pilot study Continuous quality improvement Following training and mentorship, I-HAB piloted exercises I-HAB engaged sites in continuous quality improvement. with Project A and Project B to determine preparedness for Continuous improvement is a cyclical process to improve biospecimen deposition. Sites tested processes preceding quality by identifying problems and resolving them. I-HAB biospecimen deposit including participant recruitment, reviewed biospecimen QC, and shipment packaging, biospecimen collection, processing, QC, temporary storage, temperature, and documentation. I-HAB provided additional transport to I-HAB, and documentation. I-HAB tested training or pilot exercises where appropriate to address biorepository processes succeeding biospecimens deposit nonconformities. The teams implemented corrective and including: biospecimen receipt, QC, aliquoting, storage, preventive measures before initiating Phase II shipments to transport, and documentation. I-HAB and the sites processed I-HAB. I-HAB determined improvement by the elimination MTAs, and I-HAB acquired copies of ethical approvals and of previously identified problems, improvements in DNA blank consent forms to ensure biospecimen sharing was quality, and overall improvements in efficiency. according to ethical requirements. Investigators transferred Following pilot deposition at I-HAB, Project A and Project B biospecimens collected from geographically dispersed CRSs continued to identify opportunities for improvement. Project to the study’s hub site and the hub site transferred DNA hubs monitored temperatures in shipments between I-HAB biospecimens to I-HAB for comparative QC and storage. and project hubs. I-HAB monitored biospecimens and Project A’s CRS in Nigeria was the only one to transfer corresponding data for all subsequent deposits and biospecimens directly to I-HAB, because it required assistance communicated discrepancies to the sender within one week to temporarily store and ship non-DNA biospecimens to its of discovery. Similarly, hubs continued to QC 100% of the hub in Ghana. Thus, I-HAB piloted shipments from Project DNA deposited. To ensure accuracy, I-HAB re-tested 10% of A’s and Project B’s hubs to I-HAB, from Project A’s site in the DNA received. If more than 10% of the re-tested DNA Nigeria to I-HAB and from I-HAB to Project A’s hub. was beyond acceptable range or inconsistent with I-HAB’s results, then I-HAB tested the remaining 90% (total 100%). In Shipping such instances, I-HAB tested 100% of subsequent batch Sites shipped biospecimens according to International Air shipments from the project, until the project completed two and Transport Association regulations under Class 6.2 consecutive shipments for which the QC for at least 90% of biologicals, infectious substances, and Class 9 for dry ice the DNA tested was within acceptable range and consistent (unless otherwise stated). Shipments contained Temp Tale4 with I-HAB’s results. I-HAB continued to meet with the quantitative, reusable temperature loggers, (Sensitech, projects’ staff to discuss future activities, challenges, and Beverly, Massachusetts, United States) and 3TM Warmmark strategies of improvement. Time Temperature Indicators (qualitative, disposable cards) (TelaTemp, Anaheim, California, United States) unless Results otherwise indicated. Biospecimens were documented upon Engagement activities occurred over the three years of receipt. Phase I (2013–2016), in preparation for Phase II. I-HAB observed improvements in staff proficiency, procedural Quality control efficiency, and supply upgrades. I-HAB trained 51 persons I-HAB required sites to submit QC results for the DNA in over 20 topics. I-HAB further determined improvements deposited. I-HAB also evaluated DNA for concentration in supplies by the elimination of previously identified (absorbance at 260 nanomole [nm]) and purity (260/280 issues that resulted in poor sample quality. Preanalytical, absorbance ratio) by spectrophotometry (NanoDrop, analytical, and post-analytical processes, documents, and ThermoScientific, Waltham, Massachusetts, United States), workflows were systematically created and modified based and for quality by gel electrophoresis.12,13 DNA purity of on needs assessment, training, mentorship, pilot exercises, 1.7–2.0 was acceptable. DNA with unacceptable purity was and continuous quality improvement. stored but flagged for suboptimal quality. Where specified, I-HAB and Project A’s Nigerian site investigated plasma and Project A serum for haemolysis using I-HAB’s protocol for visual The study’s investigators established a system for Phase II. grading. Laboratorians classified biospecimens from 0 The CRS in Nigeria collected, processed, temporarily stored, (normal) to 4 (extreme haemolysis) by comparing them to a and shipped biospecimens to the project’s hub in Ghana. An picture gradient of five adjacent plasma samples (numbered 0 independent, commercial contractor extracted and QC tested to 4), beginning with a normal, non-haemolysed sample and DNA. The hub stored DNA and shipped the aliquots required gradually increasing to an extremely haemolysed sample. for deposition to I-HAB. I-HAB performed needs assessment, training, and the pilot of the entire study process with the site I-HAB documented and communicated outcomes and in Nigeria, then piloted DNA shipment from Ghana to recommendations to the projects’ principal investigators I-HAB. The process of engagement with Project A’s CRS in and staff. Nigeria is summarised in Figure 1. http://www.ajlmonline.org Open Access Page 4 of 9 Lessons from the Field Site visit 1 and agreement: Pilot requirements: I-HAB shares H3Africa requirement, SOP’s, and documents, provides • Aain MTA temporary storage and pilot shipment to Accra, Ghana • Train on protocol specific procedures MTA: • Execute dry run Prepare and sign Training: Pilot exercise: Computer skills at I-HAB Sample collecon, sample processing, transport to I-HAB, temporary storage, Site visit 2 and 3 : Laboratory training: 1st shipment to Accra and Follow up on training, Basic laboratory techniques, feedback Mentorship: Revise layout for opmal quality management, and GLP Dry run at clinical site workflow, confirm specimen collecon, commodies, prepare processing, management, for dry run storage and transport. Data management. 2nd shipment to Accra and feedback, addion of Training: Site visit 4: QC Pilot: Connue temperature Serum/plasma Follow up Blinded serum temporarily store Connuous monitoring indicators. QC at I-HAB mentoring and plasma and shipment and improvement I-HAB, Institute of Human Virology Nigeria H3Africa Biorepository; MTA, Material Transfer Agreements; QC, Quality Control; GLP, Good Laboratory Practices; SOP, standard operating procedure FIGURE 1: Partnership to empower Project A’s clinical sites in Nigeria and Ghana. I-HAB engaged clinical sites through needs assessment, training and mentorship, pilot exercise, and continuous monitoring in preparation for sample deposition. Needs assessment ▪ I-HAB verified all mock biospecimens against the In March 2014, I-HAB’s manager, supervisor and QC officer manifest. assessed the CRS in Nigeria to compare infrastructural, ▪ I-HAB assisted in the development or modification of commodity, and staffing resources to the laboratory protocol, worksheets as appropriate. H3Africa requirements, and best practices according to ISBER. ▪ The dry run revealed that the lab technician was not The staff included an entry-level laboratory technician and proficient in computer operations. data clerk. I-HAB evaluated the laboratory, staff, equipment, • The technician participated in a four-day introductory supplies, procedures, and workflows. The I-HAB manager computer workshop, March 2014. communicated assessment outcomes and recommendations to the site principal investigator, study coordinator, laboratory During the two-day dry run, improvements maximised client technician, and data clerk as appropriate. I-HAB and Project A and staff safety, specimen integrity, and efficiency. I-HAB agreed that training, mentorship, and document development rearranged the biospecimen collection and processing area to were required for Phase II preparation. reflect the natural flow of activities. Samples were inadequately separated during processing, and storage vials popped once Training and mentorship they were frozen. Thus, I-HAB made recommendations that I-HAB provided training and mentorship for Project A’s improved biospecimen integrity: (1) upgrade the centrifuge clinical site laboratory technician and data clerk: to enable staff to process biospecimens with adequate centrifugal force; (2) separate and freeze plasma, red cells, • The laboratory technician attended a five-day workshop and buffy coat immediately, rather than freeze whole blood at I-HAB, September 2013 (Table 1). in Ethylenediaminetetraacetic acid vacutainers without • I-HAB provided customised five-day training for the processing them, and (3) replace flip cap tubes with cryovials laboratory technician, incorporating her responsibilities for biospecimen storage. I-HAB also provided Project A with per the study protocol and H3Africa specifications, order information for biological shipping materials. January 2014 (Table 1). • The I-HAB manager, supervisor, and biospecimens QC officer mentored the laboratory technician and data Pilot clerk for one day at their facility during a dry run on I-HAB performed two pilots with Project A. The first pilot February 2014. tested the CRS’s processes of enrolment, samples processing, ▪ The dry run simulated activities from participant temporary storage, and shipment from I-HAB to Ghana. The arrival through to mock biospecimen collection, second pilot contained one aliquot of all Project A’s DNA. The processing, temporary storage, and transport, pilot tested the quality of the DNA and shipment from Ghana including documentation. to Abuja. DNA was extracted at a commercial laboratory, ▪ The laboratory technician packed and transported the stored at the hub and shipped to I-HAB on dry ice by DHL mock biospecimens and the manifest using I-HAB’s Nigeria (Lagos, Nigeria). I-HAB provided the hub with daily shuttle from Project A to I-HAB. (The drivers were temperature loggers and indicators to monitor the shipment. trained in biological safety and biospecimens transport.) Upon receipt, I-HAB investigated DNA quality using http://www.ajlmonline.org Open Access Page 5 of 9 Lessons from the Field NanoDrop (ThermoScientific, Waltham, Massachusetts, red cells, buffy coat, urine, and oral fluid. The shipment United States) and agarose gel electrophoresis. Outcomes were duration was two days and temperature monitors confirmed discussed with project personnel and recommendations made. that targeted temperature ranges were maintained. I-HAB received favourable feedback regarding the shipment. Project A, clinical site (Nigeria) The clinical research site pilot occurred in February 2014. The Project A amended practices at its other CRSs to reflect MTA took seven months to process, due to unfamiliarity improvements made during the pilot. In March 2015, I-HAB with such agreements; subsequent MTAs took one to three trained 12 persons from five Project A CRSs for one week at months. The site collected and processed biospecimens, I-HAB (Table 1). Trainees were five laboratorians, one performed visual grading for haemolysis for plasma and coordinator, two nurses, and four data clerks. Nine (90%) serum, and documented the results in the manifest. Upon trainees who took pre-tests and post-tests increased in delivery, I-HAB inspected all biospecimens and imported the performance (Figure 2). The average pre-test scores were 62% data into Freezerworks (Dataworks Development, Mountlake (range 30% to 80%) while average post-test scores were 84.4% Terrace, Washington, United States). I-HAB’s QC officer (range 63% to 100%). As expected, laboratorians performed blindly re-evaluated 40 of the plasma and serum using the better than non-laboratorians on average. same visual grading methods for comparison. 92.5% of the results were consistent. Also, I-HAB temporarily stored and Project A, hub site (Ghana) subsequently shipped on dry ice 1075 biospecimens to the During Project A’s hub’s pilot in September 2015, Project A hub in Ghana using DHL Nigeria (Lagos, Nigeria): plasma, shipped 20 unique DNA biospecimens (extraction and QC at a TABLE 1: Training topics to build knowledge and skills – Project A in Nigeria. Attendee type (No.) Total number of Venue Training type (date) Topics covered staff trained Laboratory technician (1) 1 I-HAB Laboratory orientation Quality management systems (September 2013) Safety Good laboratory practices SOP writing Documentation Inventory management Laboratory organisation Use and care of basic lab equipment Overview of HIV infection and testing according to national algorithm Customised training (January 2014) Biospecimen collection Biospecimen processing Biospecimen storage Organise and document biospecimen storage Biospecimen acceptance or rejection Local specimen transport QC: Plasma and serum visual grading Temperature monitoring Standard preanalytical code Minimum information about biobank data sharing (MIABIS) Intro to computers: General operations, Microsoft Word and Excel Data clerk (4) 12 I-HAB Customised training (March 2015) Good laboratory practices Laboratory staff (5) Nurse (2) Pipetting techniques Research coordinator (1) Biospecimen collection Biospecimen labelling and aliquoting Biospecimen reception and rejection Plasma and serum processing QC: Plasma and serum visual grading DNA extraction: Theory and SOP only (no practical) QC: DNA Biospecimen storage Biospecimen shipment IATA regulations Standard preanalytical code MIABIS† Documents, records and data management Temperature monitoring Workflow I-HAB, Institute of Human Virology Nigeria H3Africa Biorepository; QC, quality control; SOP, standard operating procedures; IATA, International Air and Transport Association; MIABIS, Minimum information about biobank data sharing. †, A means to standardise data by defining minimal data elements that are common among biorepositories, such as data that describes samples. http://www.ajlmonline.org Open Access Page 6 of 9 Lessons from the Field commercial laboratory) to I-HAB by DHL on dry ice in four Project B (Nigeria) days. Ghana transferred data via a template comma-separated Needs assessment values file. The DNA was still frozen upon receipt, but temperature monitors were not included in the shipment. Also, Project B staff and I-HAB teams met three times: May, July and August 2014. The meetings facilitated an understanding there were inconsistencies between site versus biorepository of each other’s goals, requirements, expectations, and results. Only 5% of the DNA was within the acceptable purity services. Consequently, Project B requested that I-HAB range per Ghana’s result versus 25% per I-HAB (Table 2). introduce biospecimens management during its staff The average purity reported by both was below the orientation (Figure 3). The I-HAB manager and supervisor acceptable standard. Furthermore, DNA concentration reviewed Project B’s study protocol to determine averaging 2.0 ng/μl (0.1–7.1) was lower than the recommended appropriate training topics. for deposition by H3Africa consortium. NanoDrop 2000 and 8000 series have lower detection limits of 2 ng/μl and 2.5 ng/μl; Training and mentorship thus, measurements below these limits are unreliable. The The I-HAB supervisor attended Project B’s five-day study- DNA was not evaluated by agarose gel electrophoresis due to wide orientation in July 2014, which included 35 research poor DNA integrity. These samples were tagged as low quality staff. The supervisor facilitated a biospecimen management before storage and results were communicated and discussed workshop for one day, which spanned 14 topics (Table 3). She with Project A. The major benefits of the pilot were knowledge also reviewed supplies required for biospecimen collection, of Project A’s contractor’s poor DNA quality and non- processing, and storage, and made recommendations, such as compliance with the shipping procedures. for laboratory supplies. For example, I-HAB suggested supplies for shipment of biological samples, Freezerworks Continuous quality improvement basic LIMS software for sample management, and software Through remediation, problems in DNA concentration and for remote temperature monitoring and alerts, which remain purity, and temperature monitoring improved as observed in use by Project B. The I-HAB supervisor trained the project from Project A’s hub’s subsequent shipment to I-HAB. The analyst in Freezerworks customisation and operations over first Phase II shipment occurred in April 2017. The shipment five days, in late July 2014. Consequently, the analyst contained 402 DNA samples, 100% met H3Africa successfully customised the software, and adopted recommendations for concentration (Table 2). Purity Freezerworks as the LIMS for biospecimen management. improved to 38% acceptability per Ghana’s results and 45% per I-HAB. Temperature monitors confirmed that cold chain Pilot was maintained. In January 2015 I-HAB drafted a protocol outlining pilot procedures. The teams attained ethical, legal, and regulatory Phase II is ongoing. Thus, I-HAB continues to monitor requirements for the pilot. The MTA took one month to execute. compliance with shipping regulations and H3Africa requirements, and I-HAB will partner with Project A to Site visit: devise resolutions if challenges arise. Through July 2019, I-HAB project Project A has deposited 15 333 non-DNA biospecimens at Conference calls and agreement: orientaon, freezerworks I-HAB for temporary storage and shipment to Ghana and I-HAB shares H3Africa policy documents and laboratory training and deposited 7535 DNA samples for long-term storage. processes. discussion of pilot 100 Pre-test % Post-test % Pilot: Staff orientaon Pilot requirements: 90 Hub ships and training: • MTA 80 biospecimen, Biospecimen • Pilot protocol and transfers 70 management, DNA • Idenfy laboratoryelectronic data to extracon, shipping consumables 60 I-HAB. I-HAB and documentaon provides • Train on 50 plus one-on-one infeedback. freezerworksfreezerworks 40 30 MTA 20 prepare and sign Pilot report: Remediaon: H3Africa 10 Communicate Training deposion: 0 outcomes in and Biospecimen Connuous monitoring aff aff aff aff aff on rse e k wring and t t t t t is rs ler ler k rk rk praccal and data and improvement s s s s s a u u c c cle cle duringb exercises deposit La abL La b b b La La y l i N N ud Da ta ta ta ta meeng t D a Da Da S I-HAB, Institute of Human Virology Nigeria H3Africa Biorepository; H3Africa, Human Lab, laboratory. Heredity and Health in Africa; MTA, Material Transfer Agreements. FIGURE 2: Project A’s training scores in Nigeria March 2015. Project A’s pre-test FIGURE 3: Partnership to empower Project B’s clinical site in Nigeria. I-HAB and post-test training scores according to staff designation. Two persons were engaged clinical sites through needs assessment, training and mentorship, pilot absent during the pre-test; thus, those scores are missing. exercise, and continuous monitoring in preparation for sample deposition. http://www.ajlmonline.org Open Access Score (%) Page 7 of 9 Lessons from the Field TABLE 2: DNA quality control results for Projects A and B. Sample Project A: Ghana† Project B: Nigeria‡ no. First pilot shipment First Phase II shipment Pilot shipment First Phase II shipment September 2015 April 2017 June 2015 November 2016 Concentration Purity Concentration Purity Concentration Purity Concentration Purity (ng/μ1) (260/280) (ng/μ1) (260/280) (ng/μ1) (260/280) (ng/μ1) (260/280) I-HAB Project A I-HAB Project A I-HAB Project A I-HAB Project A I-HAB Project B I-HAB Project B I-HAB Project B I-HAB Project B 1 3.10 1.30 1.79 0.00 187.90 161.70 1.30 1.30 204.60 115.00 1.86 1.89 49.34 63.50 1.87 1.82 2 7.10 1.90 2.10 0.00 198.90 197.50 1.24 1.22 71.50 74.90 1.79 1.83 52.25 58 1.83 1.85 3 2.30 0.00 1.41 0.00 134.60 138.30 1.14 1.13 16.80 17.50 1.78 1.73 78.47 77.80 1.87 1.87 4 2.00 0.10 2.09 0.00 127.00 143.20 1.86 1.61 53.30 55.00 1.81 1.91 49.34 54.70 1.84 1.81 5 1.80 0.50 2.29 0.00 160.90 275.90 1.16 0.74 48.00 46.00 1.78 1.88 76.87 95.00 1.86 1.85 6 0.10 0.00 0.26 0.88 213.40 223.30 1.38 1.38 120.70 115.00 1.86 1.89 136.50 147.10 1.84 1.86 7 6.30 3.30 1.79 3.66 154.50 143.70 1.66 1.68 69.10 74.90 1.80 1.83 93.86 99.40 1.85 1.84 8 0.20 3.20 1.71 9.18 300.30 345.00 1.71 1.88 15.00 17.50 1.88 1.73 190.60 175.60 1.83 1.78 9 0.20 0.00 2.48 1.47 174.10 247.00 1.41 1.39 50.90 55.00 1.82 1.91 162.80 159.90 1.80 1.81 10 2.30 2.90 1.68 1.97 152.00 63.00 1.49 1.59 46.70 46.00 1.80 1.88 80.11 81.5 1.84 1.95 11 1.00 0.20 2.27 0.00 336.00 320.80 1.69 1.72 - - - - 61.07 66.20 1.84 1.88 12 1.40 0.00 1.10 0.86 152.80 139.90 1.11 1.07 - - - - 83.82 86.40 1.82 1.77 13 1.90 1.30 1.31 4.70 149.40 164.70 1.40 1.41 - - - - 74.11 66.70 1.81 1.79 14 3.90 0.00 1.77 1.22 136.40 126.80 1.71 1.75 - - - - 87.65 95.10 1.86 1.86 15 0.10 0.00 0.14 0.85 259.60 242.40 1.73 1.84 - - - - 132.5 130.6 1.82 1.87 16 0.50 0.00 1.19 0.90 172.20 201.10 1.31 1.30 - - - - 83.41 92.20 1.86 1.84 17 0.80 0.00 1.69 1.21 232.00 216.30 1.19 1.20 - - - - 62.40 65.10 1.86 1.80 18 1.00 3.10 1.21 2.63 178.30 247.60 1.15 1.17 - - - - 87.18 81.30 1.89 1.84 19 3.00 0.40 1.69 0.00 78.72 Not 1.46 1.49 - - - - 61.51 78.10 1.75 1.79 Provided 20 1.30 0.00 1.87 0.12 143.70 198.60 1.42 1.45 - - - - 90.71 98.20 1.83 1.77 Average 2.02 0.91 1.59 1.48 209.78 222.50 1.54 1.57 69.66 61.68 1.82 1.85 89.73 93.62 1.84 1.83 Minimum 0.10 0.00 0.14 0.00 78.72 63.00 1.11 0.74 15.00 17.50 1.78 1.73 49.34 54.70 1.75 1.77 Maximum 7.10 3.30 2.48 9.18 514.50 507.70 1.89 1.95 204.60 115.00 1.88 1.91 190.60 175.60 1.89 1.95 Note: Data set in bold for Project A Ghana signifies purity that is beyond the acceptable range of 1.7–2.0. Data set in bold for Project B Nigeria signifies DNA shipped frozen on dry ice. I-HAB, Institute of Human Virology Nigeria H3Africa Biorepository. †, I-HAB compared its DNA concentration and purity results for the first pilot and first Phase II shipment with Project result’s. Acceptable range for purity is 1.7–2.0, according to H3Africa’s submission guidelines. The Phase II results displayed are a subset of 402 actual results; however, the averages and minimum and maximum values represent the 402 actual results. ‡, I-HAB compared DNA concentration and purity results for the first pilot shipment conducted at controlled ambient and frozen temperatures, and the first Phase II shipment with results of Project B. TABLE 3: Training topics to build knowledge & skills – Project B in Nigeria†. Training Attendee type (No.) Total number of staff trained Venue Topics covered Project activation workshop Medical doctor (20) 35 Project B Biospecimen collection (July 2014) Laboratory scientist (6) DNA extraction: Theory and SOP only (no practical) Research assistant (6) Temperature monitoring Community officer (5) Biospecimen shipment Other professional (9) Biospecimen processing Documents, records, and data management Biospecimen storage Quality assurance Freezerworks training Programme analyst (1) 1 I-HAB Freezerworks configuration (July 2014) User defined fields Entry form Barcode labels Import Export Freezers Security Freezerworks sample management Biospecimen entry Batch entry Batch update Simple and advanced searches Printing barcode labels Pilot remediation Laboratory scientist (1) 2 Project B Shipping documentation (July 2015) Data officer (1) Biological shipping DNA QC DNA extraction Freezerworks navigation Standard preanalytical code H3A documentation I-HAB, Institute of Human Virology Nigeria H3Africa Biorepository; SOP, standard operating procedures; H3A, Human Heredity and Health in Africa. †, I-HAB provided three major trainings for Project B. The didactic training included theory and practical exercises. In June 2015 Project B extracted, QC tested, and shipped Plasma-4, and serum-5) and one at a controlled ambient biospecimens to I-HAB by road via TRANEX (Lagos, Nigeria) temperature (DNA-5). I-HAB conducted DNA QC as specified in one day. There were two shipments: one on dry ice (DNA-5, above. Outcomes and recommendations were communicated. http://www.ajlmonline.org Open Access Page 8 of 9 Lessons from the Field The pilot identified areas that required improvement before experienced issues with DNA quality that could be Phase II. The hub forgot to send the manifest and the query circumvented via an assessment. Both examples demonstrate form prior to the shipment. Both shipments contained that assumptions of competency risk financial and biological insufficient refrigerant and were warm. The qualitative resources. They also demonstrate the imperativeness of temperature indicators were not activated prior to shipment training and monitoring. and the quantitative temperature loggers were misplaced. The logger for controlled ambient temperature was placed in The key to effective training is to establish a foundation of the frozen shipment, while the logger for frozen shipments harmonised guidelines, procedures, and minimal requirements was placed in the controlled ambient temperature shipment. that align with project goals and best practices. The Nevertheless, 100% of the DNA had acceptable purity and biorepository should utilise standard and customised training concentration (Table 2). The benefit of the pilot was to learn that encompasses theory, practical exercises, and post-tests. of issues with biospecimen shipping procedures. Training achieved staff competency and eliminated issues revealed by needs assessments, pilot exercises, and continuous Continuous quality improvement monitoring. Both projects improved in performance following I-HAB provided remedial training for the laboratory manager training; however, biological shipping may require refresher and study coordinator in July 2015 (Table 3). The training training or additional practical exercises. occurred over five days and included biological packaging and shipping, operations of temperature indicators and Training and mentorship contribute to the future cadre of monitors, DNA extraction, and DNA QC using NanoDrop. knowledgeable researchers and generate business towards I-HAB demonstrated proper document completion over sustainability. Non-laboratorians demonstrated knowledge of Skype calls. Following these preventative measures, the first biospecimen management after training. Freezerworks Phase II shipment, containing 1000 DNA specimens, training empowered Project B’s analyst to customise and commenced without errors in documentation or packaging operate the LIMS. Also, the knowledge gained by Project A’s (November 2016). Temperature monitors demonstrated that technologist empowered her to recommend changes to the the target temperature was maintained. Also, the concentration of DNA improved from 15.00 ng/ml – 69.66 ng/ml to study protocol, suggest areas of training for all sites, and train 78.72 ng/m – 514 ng/ml and 100% of DNA was within laboratory staff on Project A’s other clinical research sites. acceptable range (Table 2). Project A and Project B requested additional services such as additional training and storage of non-DNA biospecimens. Project B deposited 6000 DNA specimens as of September Both projects also gave public testimonials at scientific 2019. For each shipment I-HAB monitored the documentation, meetings that prompted interest and trust of other researchers. packaging, temperature monitors, and DNA QC. In May 2017, I-HAB noticed a decrease in DNA quality. Investigation The pilot process allows biorepositories to identify challenges revealed that a new employee had extracted the DNA; thus, in the cascade of processes leading to biospecimen deposit I-HAB trained him in August 2018. DNA quality improved in that may only be revealed by a real-time trial that involves all the next shipment received in September 2018 and has direct and indirect processes. For example, the pilots remained within the recommended concentration and purity. identified and eliminated errors in shipping that can only be I-HAB will continue to monitor related activities and liaise unmasked by full trial. Due to the peculiarities of packaging with Project B to investigate and resolve identified problems. and International Air Transport Association regulations associated with international biological shipments, on-site Discussion mentorship is useful to reinforce procedures learned during Researchers inexperienced with processes that influence training, according to the trainees’ true environment and biospecimen integrity may attain high-quality biospecimens resources. Consequently, I-HAB incorporated site visits to for research by partnering with a biorepository and assist sites to execute their first shipment to I-HAB. establishing a system of needs assessment, training and mentorship, pilot, and continuous quality improvement that Our outcomes mirrored the successes and challenges observed is based on best practices. It is beneficial to start with general in other laboratory development programmes in sub-Saharan meetings and needs assessments to understand the intended Africa that incorporate assessments, training, and mentorship. goals and procedures and whether resources and capabilities Generally, training and mentorship improved laboratory are well aligned. Even if a scientist or contractor claims to be performance and empowered a new cadre of professionals.14,15 to be proficient, they should be subjected to a standardised Problems in biospecimen acceptability,3 documents and assessment to ensure competency. Had Project A subjected its records, information management, and supplies were contractor to assessment, it would have learned of the common; however, training and mentorship facilitated contractor’s poor performance prior to study activation. The improvements.16,17 Literature suggests that relapses may occur contractor had not resolved issues with purity that were after training, particularly in documentation.14 Thus, I-HAB’s indicative of protein contamination (purity ratio below 1.7) method of continuous improvement shall be critical to as of the first Phase I shipment. Likewise, Project B’s new hire maintain improvements. http://www.ajlmonline.org Open Access Page 9 of 9 Lessons from the Field Conclusion reported in this publication was supported by the National Human Genome Research Institute of the National Institutes Biobanking in Africa is expected to increase and improve of Health under award numbers UH2HG007008 and with greater knowledge and resources.6 However, CRSs with UH3HG007008 (PI: Alash’le Abimiku). abilities to meet best practices to collect, process, and store biospecimens of good integrity and quality are scarce. Partnerships between competent regional biorepositories Data availability statement and research investigators may build human capacity and Data are available within this article. improve biobanking practices and biospecimen quality by adopting an approach of needs assessment, training and mentorship, pilot, and continuous quality improvement. The Disclaimer improvements in quality may improve performance, increase The views expressed herein are our own and not an official staff morale, and contribute to sustainability of the biobank, position of the funder or affiliated institutions. research entity, and biobanking industry. References Lessons learned • Clinical research sites and biorepositories may partner to empower clinical 1. Mayne ES, Croxton T, Abimiku A, et al. Genes for life: Biobanking for genetic research sites to generate high-quality biospecimens via needs assessment, research in Africa. Biopreserv Biobank. 2017;15(2), 93–94. http://doi. training, pilot, and continuous quality improvement. org/10.1089/bio.2017.0007 • It is critical to standardise guidelines, procedures, and minimal criteria early on 2. Gasmelseed N, Elsir AA, DeBlasio P, et al. Sub-Saharan centralized biorepository to inform training and activities. for genetic and genomic research. Sci Total Environ. 2012;423,210–213. https://doi.org/10.1016/j.scitotenv.2010.07.054 • Standardised guidelines, procedures, and minimal criteria should be rooted in well- established requirements such as ISBER best practices, ISO 15189, and SLMTA. 3. Croxton T, Swanepoel C, Musinguzi H, et al. Lessons learned from biospecimens shipping among the human heredity and health in Africa biorepositories. Biopreserv Biobank. 2017;15(2), 103–110. http://doi.org/10.1089/bio.2017.0009 Acknowledgements 4. Matimba A, Tybring G, Chitereka J, et al. 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