Evaluation of laboratory workers competency on loop mediated isothermal amplification (LAMP) technology for malaria diagnostics: a technology transfer assessment study (LAMP-TTA) during a multi-site clinical trial

Abstract

Background

Molecular malaria diagnostic approaches present high sensitivity and detect submicroscopic parasitaemia in a patient. However, molecular techniques like polymerase chain reaction are costly, require specific equipment and the reaction read-out interpretation can require extensive experience. Hence, a simple and user-friendly loop mediated isothermal amplification molecular technique resolves limitations of the polymerase chain reaction. However, performing accurate and high-quality loop mediate isothermal amplification reactions requires appropriate training and follow up, particularly for laboratory staff who have never performed molecular methods. This study aimed to assess the potential gain in knowledge and technical skills provided by the initial training and during onsite support visits.

Methods

All laboratory technicians hired in the LAMPREG study were enrolled, consented and skills were evaluated using a questionnaire before and after training, as refresher and follow up interventions during health centre inspections. Data entry was performed using an excel table. Data analysis was performed using Prism Graphpad v8.0 for windows.

Results

From the total enrolled 15 participants, all but one participant reported no previous work experience with LAMP technology. In contrast to pre-initial training evaluations, a report during post-training showed the self-assessed technical knowledge median rating increased by four points (median score of 5/5, range 4/5–5/5), and knowledge of the LAMP chemistry itself increased by 9 points (median score of 10/10, range 6/10–10/10). Regarding assessment on follow up visits, all participants reported being self confident on their ability to run a LAMP reaction, and the self-assessment of raw results interpretation was excellent with a median score of 10/10 (range 8/10–10/10) at the first follow-up and 10/10 (range 10/10–10/10) at the second follow up assessment.

Conclusion

Clinical trials and diagnostic studies lead to the new implementation of technology in rural settings. Providing adequate training, support, and evaluation, is part of a successful technology transfer programme.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-025-05631-z.

Background

Malaria diagnostic usually relies on conventional approaches such as microscopy and rapid diagnostic tests (RDT). The performances of these approaches are limited by either the expertise required to perform the test (microscopy) and their intrinsic limited sensitivity (1–200 parasites/microliter of blood) [1, 2]. In addition, the persistence of a positive signal in malaria diagnostic tests might reflect the continued presence of HRP-2 antigen in the patient’s peripheral blood even after parasite clearance [3–5]. Molecular approaches are revolutionizing infectious diseases diagnostic because they present high sensitivity and detect lower parasite load (submicroscopic parasitaemia, as low as 1 parasite/millilitre) [6–10]. Molecular approaches detect parasitic nucleic acid (DNA and/or RNA) through enzymatic amplification of targeted genomic regions. However, the conventional polymerase chain reaction (PCR) techniques are not compatible with the diagnostic laboratory requirements: PCR reactions are costly, require specific equipment (thermal cycler) and the reaction read-out interpretation can require extensive experience.

Loop-Mediated Isothermal Amplification (LAMP) is a molecular approach that relies on isothermal amplification of a DNA target using loop primers that bind to the targeted genomic region [11]. In a LAMP assay, 4 to 6 primers guide the amplification by forming a dumbbell-like structure that has multiple sites of primer binding and self elongation. LAMP surpasses PCR for point-of-care diagnostic in remote settings. First, the LAMP reaction is isothermal, which means that the reaction can be conducted at a constant temperature, limiting the need for complex laboratory equipment. Second, LAMP read-out methods are simple, easy and inexpensive. Last, the enzyme requires in the LAMP reaction mix are robust and can perform well even with samples extracted with low-quality approaches.

In Ethiopia, malaria continues to be a major cause of morbidity and mortality. About 60% of the country’s population lives in malarious areas and 75% of the country’s landmass is favourable for malaria transmission. Plasmodium falciparum and Plasmodium vivax are the two predominant species in Ethiopia, with relative prevalence of 70% and 30%, respectively [12]. Despite the Ethiopian government aim to achieve nationwide malaria elimination by 2030, Ethiopia recorded a 32.5% increase in confirmed malaria cases between 2021 and 2022, from 1.1 million to 1.5 million, driven by the continued fallout of pandemic-related programme disruptions, armed conflict, and displacement. A similar trend was observed in 2023, with increased by 150% and 120%, respectively, compared to the same periods in 2021 and 2022 [13, 14]. Providing health facilities with sensitive, practical, and rapid options for malaria diagnostics is a key factor to successful malaria control and elimination programs. Moreover, the sensitivity and specificity of malaria RDTs targeting P. falciparum histidine-rich protein 2 (PfHRP2), are threatened by the emergence and expansion of parasites harbouring pfhrp2 gene deletion [15, 16], thus limiting the availability of rapid methods requiring limited technical expertise.

LAMP methods gained popularity for malaria diagnostics due to their high sensitivity, rapid turnover, and limited equipment; however, in malaria endemic area, laboratory technicians are rarely familiar with the technique. Performing accurate and high-quality LAMP reactions requires appropriate training, particularly for laboratory staff who have never performed molecular methods. This study is ancillary to a multi site trial measuring the implementation of LAMP technology for malaria diagnostics during antenatal care (protocol available in [17], and evaluated the impact at the short and long term on laboratory staff undertaking LAMP training ((HumaLoop M instrument [Human DE, Germany] and the LoopampTM Malaria Pan, Pf, Pv Detection Kit [Eiken Chemical Company, Japan])) for malaria diagnostics as part of their laboratory duties. The implementation of laboratory training during clinical trials is an excellent opportunity for technology transfer and expanding laboratory staff's skill set. The specific objectives of this study were (1) to assess the potential gain in knowledge provided by the initial training, (2) to longitudinally monitor the technical skills and measure the during onsite support visits.

Methods

Study location

All laboratory technicians hired in the LAMPREG study [18] (a diagnostic outcome clinical trial in three study sites (Chisabay, Andasa, and Hamusit health centre) (Fig. 1) and centrally coordinating site Amhara Public Health Institute, Bahir Dar were eligible for the study. The Amhara region is endemic for malaria which accounts for 33% of Ethiopia's malaria burden and is targeted for malaria elimination by the Federal ministry of health (unpublished FMOH data). Amhara public health institute is a technical arm of the Amhara Regional Health Bureau, serve as a research centre for the region, managing public health emergencies in the region and centre for laboratory confirmation of different tests that have been referred from peripheral heath facilities in the Amhara region. Staff who were trained (from all the institutions, from the coordinating centre APHI and the health centres) were consented for the study. All data were de-identified before analysis.

Fig. 1.

Map showing location of three study sites. (Andasa Health Centre, Chisabay Health Centre and Hamusit Health Centre)

Questionnaires for participants

The questionnaires were worded in English and requested self-reported assessment of the participants knowledge and competency for LAMP technology. Participants were invited to rate their knowledge regarding LAMP technique itself (rating 1–5, one the lowest and 5 the highest), LAMP chemistry (rating 1–10, one the lowest and 10 the highest), ability to run a LAMP reaction independently (Yes/No/Unsure), and their ability to interpret LAMP raw results in the laboratory (rating 1–10, one the lowest and 10 the highest).

Initial LAMP training

The initial technical training for the staff was organized by APHI at Bahir Dar, Ethiopia. Training was provided by certified experts at the institution, who followed a manufacturer’s specific training (HumanDE, Wiesbaden, Germany) provided through the LAMPREG trial training in the Armauer Hansen Research Institute at Addis Ababa, Ethiopia. The staff training encompassed theoretical and practical parts, including an orientation about LAMP technology and techniques, and practical laboratory training under supervision. The specific Malaria Pan/Pf and Pv kits were used (HumanDE, Wiesbaden, Germany).

Data collection

Laboratory staff skills were evaluated using a questionnaire before and after training, and as refresher and follow up interventions during health centre inspections. Data collection was performed through a questionnaire before and after training and through laboratory evaluation (in-person inspection). Data were collected before and after the initial training, and during two follow up visits (1 month and 6 months post training), the questionnaire was administered as a paper form, and data were entered in an excel sheet.

Data storage and ethical considerations

All hard copies were stored in APHI, and all the data were de-identified, and the results cannot be traced back to the laboratory operator. Due to the low sample size, all further analyses blend the results from the study sites to preserve the participants identity. The study was approved by the Regional Public Health Research Ethics Review Committee (approval APHI/H/R/T/T/D/5/13).

Statistical analysis

Data analysis was performed using Prism Graphpad v8.0 for windows. Due to the very low sample size, only descriptive data are presented (median, range).

Results

Technical staff included

Fifteen individuals completed the initial training, of which three were from Health Centre 1, three from Health Centre 2, three form Health Centre 3, and six from the regional institution coordinating the trial. The average age was 32 years old (SD ± 6 years), with a sex ratio of 1:4 (F/M). The years of professional experience varied widely, from 1 year to more than 10 years (average 8 years and 7 months (SD ± 5 years). Most of the participants were trained as laboratory technicians or specialist (n = 11/15, 73.3%), three (n = 3/15, 6.6%) were medical parasitologists, and one (n = 1/15, 6.6%) underwent graduate school education with a Master of Infectious Tropical Diseases. In terms of occupational activity, there were nine laboratory technicians or technologists (n = 9/15, 60.0%), one lecturer (n = 1/15, 6.6%), one research coordinator (n = 1/15, 6.6%), one medical parasitologist (n = 1/15, 6.6%), one laboratory quality officer (n = 1/15, 6.6%), one laboratory head (n = 1/15, 6.6%), and one (n = 1/15, 6.6%) immunology and clinical chemistry laboratory coordinator.

Evolution of LAMP knowledge through initial training

All but one participant reported no previous work experience with LAMP technology. When asked to rank their knowledge, participants reported a low awareness regarding LAMP technology (median score of 1/10, range 1/10–5/10), a low self-assessed technical knowledge rating (median score of 1/5, range 1/5–5/5), and a low self-assessed knowledge of the LAMP chemistry itself (median score of 1/10, range 1/10–5/10). When asked to provide keywords (up to five) about LAMP, 10/15 (%) of the participants reported “Nothing” (Fig. 2). After the first training, the self-assessed technical knowledge median rating increased by four points (median score of 5/5, range 4/5–5/5), and the self-assessed knowledge of the LAMP chemistry itself by 9 points (median score of 10/10, range 6/10–10/10). All participants (n = 15/15) reported that the training modified their perception of LAMP technology. When asked to provide keywords (up to five) about LAMP, all participants were able to provide three to five relevant keywords (Fig. 2).

Fig. 2.

Participants perception of LAMP. Participants were asked to provide up to five keywords that they associate with LAMP. A Results prior to the initial LAMP training. “nothing” was the most reported word. B Results post LAMP initial training

Self-perception of LAMP related competency before and after training

Before training, the vast majority of the participants were either not confident (n = 8/15, 53.3%) or unsure (n = 5/15, 33.3%) of their ability to independently run a LAMP reaction. Regarding results reading and interpretation, the self-assessment reported low confidence scores (median of 1/10, range 1/10–10/10). After the first training, almost all participants (n = 14/15, 93.3%) were confident in their ability to independently run a LAMP reaction. Participants also reported that they felt confident to interpret raw LAMP results (median score 9/10, range 9/10–10/10) (Fig. 3).

Fig. 3.

Self-assessment scoring results before and after training. Participants (n = 15 for the initial training, and n = 9 in the subsequent assessment), completed a self-assessment (ranking score from 1–5 for technical knowledge or 1–10 regarding LAMP chemistry and results interpretation). Data plotted are the median value alongside the score range

Assessment of competency and technology utilization throughout the study

Participants were assessed for their skills as part of the follow up at after 1 month and 6 months. In terms of LAMP technique knowledge self-assessment, the median score was 5/5 (range 4/5–5/5) for the first follow-up and 5/5 (range 5/5–5/5) for the second follow-up. Regarding self-assessment of LAMP chemistry knowledge, the median scores were 10/10 for both assessments, with a range of [8/10–10/10] and [9/10–10-/10] for follow-up assessments one and two, respectively (Fig. 3). All participants reported being self confident on their ability to run a LAMP reaction independently at both follow-up visits, and the self-assessment of raw results interpretation was excellent with a median score of 10/10 (range 8/10–10/10) at the first follow-up and 10/10 (range 10/10–10/10) at the second follow up assessment (Fig. 3). All participants reported using LAMP daily in their work and that their LAMP knowledge improved during the study period.

Discussion

The fast development and popular gain of “point of care” or “low resources” molecular testing, particularly isothermal methods, is bringing molecular diagnostics in health facilities and laboratory that usually would otherwise not perform molecular testing [19, 20]. While “point of care” molecular tests are user friendly and practical to use, thorough training remains necessary, particularly to prevent cross contamination due to poor sample handling or laboratory workflow management, and results misinterpretation [21, 22]. The study presented in this paper is an ancillary assessment of laboratory staff knowledge and self-assessed competency regarding LAMP testing for malaria diagnostics, as part of a multi-site clinical trial.

The majority of the staff was laboratory technicians, and most did not have any knowledge of LAMP prior to the study implementation. Upon completion of the initial training, the staff self-reported skill sets improved and retained the competency throughout the study, assessed by questionnaires. Importantly, self-assessed technical knowledge median rating increased by four points and the self-assessed knowledge of the LAMP chemistry itself by 9 points. An improvement of the participant’s self-perceived skill was also noted.

While the implementation and training of the laboratory staff can be seen as a “side effect” of a high scale/high impact clinical trial, it is also a crucial component of the technology transfer that occurs during a clinical trial. Monitoring of the technology transfer is not usually part of the integrative quality improvement process in the health centres from the Amhara region, because the technology is not part of their standard of care procedures [23]; however, performing continuous monitoring of the staff competency is paramount to sustain good laboratory practices [24]. During the study, the technicians acquired new transdisciplinary knowledge regarding molecular diagnostics and point of care performance of LAMP testing. In the current uptake of molecular methods to perform malaria diagnostics, and in conjunction with the decreased efficacy of RDTs due to the expansion of hrp2 deleted parasites, particularly in Ethiopia [25–28], building good practices LAMP implementation is a critical component to continue improving patient care while providing innovative, affordable, and user-friendly diagnostic tools.

Due to the large-scale of the LAMPREG trial, LAMP technology was implemented in a total of eight study sites across the country. The analysis presented in this study, focusing on a subset (n = 3) of the study sites, shows that the impact of the trial on the study staff. Nevertheless, one limitation of this study is the short time frame for the follow up, and further technology transfer assessment studies should assess knowledge and competency retention across a longer timeframe and perform external quality control process. The questionnaire design is a limitation to this study, since no formal questionnaire validation had been performed prior to implementing it. This study is a pilot testing of a formal training effectiveness in the context of a research project implementing a new technology.

Most of the studies focusing on point-of care and LAMP diagnostics are focused either on the feasibility [29], improving the technology itself [6, 30, 31] or comparing different methods performances [32, 33]. The originality of this manuscript, despite the small sample size, is the focus on the laboratory staff performing LAMP for malaria diagnostics.

Conclusions

While the sample size limits generalizability, the observed trends are encouraging and suggest that short, focused training interventions may be sufficient to build foundational LAMP capacity among laboratory personnel. Future studies with larger cohorts and objective performance assessments are warranted to validate and expand upon these findings.

Abbreviations

DNA

Deoxyribo nucleic acid

LAMP

Loop mediated isothermal amplification

PCR

Polymerase chain reaction

RDT

Rapid diagnostic test

RNA

Ribo nucleic acid

SD

Standard deviation

TTA

Technology Transfer Assessment

Author contributions

CK and BT designed the study. CK designed the questionnaires and data collection forms. BT obtained ethical approval and collected the data. CK analysed the data. CK and BT drafted the first version of the manuscript. DP supervised the study. DP, CK and BT revised the manuscript.

Funding

No specific fund for this work. The LAMPREG trial was funded by Grand Challenge Canada (TTS), University of Calgary VPR.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

The study was approved by the APHI ethic committee under the approval APHI/H/R/T/T/D/5/13. All participants provided a signed informed consent for the study and publication of the results before answering the questionnaires.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.