The voice of transparency and CD4

Evaluation of the Cyflow CD4 Counting

2007-10-31T11:06:00.000-07:00

PROBE TEAM ON EVALUATION OF CYFLOW CD4 COUNTING MACHINE AND THE SD BIOLINE HIV RAPID TEST KITS
( Dar es Salaam, March 2007)

Members:

1. Prof. Philip R.Hiza, Retired Consultant Surgeon/Chief Medical Officer,
Ministry of Health and Social Welfare, Dar es Salaam.Tanzania.
2. Prof. Raphael A.Lema, Retired Consultant Pathologist, now Vice
Chancellor of IMTU, Dar es Salaam. Tanzania.
3. Dr. Jumah P. Madati, Retired Chief Government Chemist,
Ministry of Health and Social Welfare, Dar es Salaam. Tanzania.

Rapporteur: Dr. Jumah P. Madati

Secretariat: Dr. Jumah P. Madati

REPORT OF THE PROBE TEAM CONCERNING THE CYFLOW CD4 COUNTING MACHINE AND
SD BIOLINE HIV RAPID ANTIBODY TEST KIT

INTRODUCTION
This Investigation stems from a serious concern about how MUCHS (Muhimbili University College of Health Sciences), Dar es Salaam, and MoHSW (Ministry of Health and Social Welfare) officials handled the issue of the evaluation of a new CD4-counting machine known as the CyFlow® SL Blue which is manufactured by Partec Essential Healthcare company of Germany. The only CD4-counting machine which has been monopolizing the market in Tanzania is the FACSCount which is manufactured by the Becton-Dickinson company of USA.
Blood CD4 cells testing is considered by clinicians to be the essential element of monitoring HIV infected patients receiving ART (antiretroviral therapy/treatment). According to current regulations, an infected patient must have a count of less than 200 CD4 cells per microlitre (µl) of blood, before doctors prescribe for that patient to take ARVs (antiretroviral drugs). Above this cut-off point, the patient is not eligible to start ART. Therefore, if a CD4 counter registers a CD4 count for an HIV/AIDS patient above this cut-off point of 200 cells/μl even though his/her true CD4 count is less than 200 cells/μl, then that patient will not be started on ART; and without ART that patient will continue lowering his/her immunity and die prematurely. A CD4 counting machine which gives false CD4 count like this will therefore be a killer, and should never be used in any HIV/AIDS treatment monitoring center under any circumstances. So, the question we are addressing here is whether that CyFlow® machine is truly such a killer or not.
There are many CD4 counting technologies nowadays (see Annex 2.23), and the availability of the lowest-cost technology is essential for diagnosing HIV infection and for monitoring ART. Significant progress has been made in reducing both the cost and training required for HIV diagnostic testing. Competition among manufacturers of CD4 counters, and production of rapid HIV tests has culminated into costs as low as US$ 1.6 to US$ 2.1 per test. So far, CyFlow technology has reached this limit, while the cost of say the FACSCount is US$ 5-20 (Annex 2.23).

The "CyFlow saga" had disappointed so many people that a lot of news media began voicing their chorus of disapproval of unfair play, especially when the Partec’s CyFlow® SL Blue CD4 counting machine was evaluated and disqualified by MUCHS, which led to the MoHSW ordering to rid Tanzania of all models of Partec CyFlow machines which are already in Tanzania, and ban further importations of them. At the same time the MoHSW ordered to replace all the CyFlow machines with the FACSCount CD4 counting machines manufactured by BD (Becton Dickinson) company of USA which, through its local agent Mr. Bharat Rajani, has been the sole supplier of these FACSCounts for many years.
A question to ask here is whether these FACSCount machines have really undergone the rigorous evaluation by the latest appropriate analytical methods or SOP which the CyFlow machine underwent at MUCHS in 2005? Yet another question is whether any one or more persons are responsible for perpetuating this lengthy monopoly of Mr. Bharat Rajani in any possible way, e.g. by frustrating or delaying the evaluation exercise? And if there people who do this, do they do so free of charge or they do so in exchange for something or some favour?
One of the first chorus of disapproval came from the Rai newspaper whose issue dated 31/08/2006 blazed a front page headline: "Corruption of MoHSW is Shaking the World–Muhimbili is Involved in This." (see Annex 2.60.1). This Rai article quoted Dr.Roland Godhe, an International Director of Partec as having informed the scientific world and the international public at large how Partec is considering taking legal action against the Tanzanian MoHSW for the corruption that led to the disqualification of the CyFlow® CD4 counting machine and subsequent banning of all versions of CyFlow machines in Tanzania. He said that the MoHSW said that this action was taken because the CyFlow® did not meet the standard requirements.
One of the medical experts from Canada, after hearing this "news too shameful for the scientific community", said that MoHSW had been too rash to ban the CyFlow machines without looking at the myriad publications from all over the world on the CyFlow. The internet is full of them. When asked by another Rai reporter about what was now termed the "CyFlow saga", the former Minister for Health, Hon. Mrs. Anna Abdallah, M.P. said simply that, she told the MoHSW officials of the imprudence of using only one kind of important machines for monitoring human life. She said that, banning of the CyFlow machine by the MoHSW was due to the results of its evaluation by MUCHS which found the CyFlow® to be imprecise when determining low CD4 count samples of < 200 cells/μl (see Annex 2.60.2). But when the former Hon. Minister for Health searched the internet, she found a number of reports on the CyFlow machines which contradict the MUCHS findings of faults existing in the particular CyFlow® machine which MUCHS evaluated. So she said that she was flabbergasted to see that other world scientists were extolling the good performance of the CyFlow, while we in Tanzania maintain that the CyFlow performance is bad.
She said she thought it is often prudent to seek a second opinion whenever a controversy like this arises.
There are quite a few CD4 techniques nowadays to choose from and evaluate before putting it in the national list. The following table summarizes the recent CD4 monitoring tests and technologies:
1. Flow Based Assays
Guava Easy CD4 System
Partec CyFlow
PointCARE
Panleukogating Technology
2. Manual Assays
Dynal Immune Bead-Based Assay (Microscopy)
Coulter Immune Bead-Based Assay
3. Technologies Which are In the Pipeline
LabNow Microchip Technologies
SemiBio Slide Test (Microscopy)
SuPAR (Soluble Urokinase Plasminogen Activator Receptor)
CD4 Dipstick for Remote Care
The following are amongst the important aspects of Laboratory monitoring:
►Cost of ARV in developing countries is potentially exceeded by the cost of Laboratory monitoring.
►Sophisticated assays often established as part of clinical trial infrastructure, paid for by international grants.
►HIV+ individuals outside trials must find fiunds to pay for their own monitoring.
►Monitoring HIV treatment is a rather complex undertaking comprising:
CD4 and VL
Drug Toxicity
Adherence
Drug Resistance
All this prompted the Hon. Minister for Health and Social Welfare of the United Republic of Tanzania, Professor David Mwakyusa, M.P. to appoint a three man Probe Team to look into the allegations of corruption leveled against some officials of the MoHSW, as well as some researchers and technicians of the Microbiology/Immunology Department of the Muhimbili University College of Health Sciences (MUCHS).

The second saga of the SD Bioline concerns the local company called SD (AFRICA) Ltd. of Dar es Salaam, a South Korean based company which markets the SD Bioline HIV 1/2 3.0 Rapid Antibody Test, which SD (AFRICA) submitted to the PHLB (Private Health Laboratories Board) to evaluate and register, presumably with the ultimate aim of entering their Kit into the Tanzanian market.
SD Africa were frustrated when, in spite of passing successfully both Phase I and Phase II of the mandatory evaluations stipulated by PHLB, and in spite of being registered by PHLB, and satisfying all the five conditions according to the Sub-Section 2.5.2, GN No. 226 of the "Private Health Laboratory (Conditions Pre-Requisite to Registration and Management of Private Health Laboratories), of the Private Health Laboratory Regulations Act 1997", the MoHSW kept on delaying entering their Kit into the National Algorithm, which is a pre-requisite for being invited to tender for the supply of HIV Test Kits.
When finally the MoHSW insisted on inviting discriminatory Tenders using trade names of the unregistered HIV Test Kits of Capillus and Determine and excluding SD Bioline which possess full PHLB Registration, although the MoHSW itself announced in a Press Release (see Annex 2.64) that thenceforth SD Bioline would be the front-line HIV Test Kit, the SD Bioline promoters and news media including some unnamed senior MoHSW officials cried foul. Ultimately the PPRA (Public Procurement Regulatory Authority) and the State House had to intervene and stop MoHSW Tender Board allowing Capillus and Determine win the Tender without being registered. Naturally, SD (AFRICA) Ltd. kept on purporting that some MUCHS and some MoHSW officials must have been influenced by suppliers of the HIV Test Kits Capillus and Determine whose local marketing company happens to be the same Biocare Health Products Ltd. owned by the famous Mr. Bharat Rajani, who has been for many years the sole suppliers of the BD FACSCount and BD FACSCalibur CD4 cell counting machines too (see the details of the "CyFlow saga" in the preceding sections of this Report.
In this (SD Bioline) saga too, the news media were even more vocal and sided squarely with the SD Bioline suppliers in their allegations of corruption, and condemned the MoHSW and its affiliates for openly opting to "kill" prematurely HIV infected persons by insisting on testing them with the Capillus Test Kits which even MoHSW itself admitted in a Press Release of 10/11/2006 (see Annex 2.64) that it is not registered, and it is prone to giving wrong HIV test results. The SD Bioline promoters and news media also alleged that the Hon. Minister for Health was being constantly misinformed or not informed at all about all this.
All this prompted the Hon. Minister for Health and Social Welfare to appoint a team of independent, experienced professionals to investigate these and related allegations and find out how, if at all, any corruption or bribery has played a role in these two sagas in any possible manner.
The Hon. Minister for Health and Social Welfare guided the Probe Team by giving them 8 Terms of Reference, which are appended herewith as Annex 1.1, 7 of which concern the CyFlow saga, and the last one concers the SD Bioline saga.
The Probe Team comprised the following persons:
Prof. Philip R. Hiza, retired Consultant Surgeon, and once the CMO.
Prof. Raphael A. Lema, retired Consultant Pathologist and currently the Vice Chancellor of IMTU.
Dr. Jumah P. Madati, B.Sc. (Chem.), M.Sc. (Anal. Chem.), Ph.D. (Phyto.
Chem.), Fellow of the Royal Society of Chemistry (F.R.S.C); Chartered
Chemist (Ch.Chem.); who was Chief Govt. Chemist (1979-1987), retired
from civil service since 1992, and is currently a free lance Consultant.

METHODOLOGY
The Probe Team started work by deliberating on the strategies of the enquiry, and decided that it would attempt to gather as many documents as possible such as: Air Waybills, Bills of Lading, Invoices, Import Declaration Forms; Requisition, Issue, and Dispatch Vouchers/Notes, in order to establish the exact movements and transit stops made by the CyFlow machine, the SD Bioline Test Kit, and their reagents. The Probe Team endeavoured, by this way, to establish any delays that occurred, when, why, and whether the dalays were deliberate, identifying each stop over and persons who handled them, and when and how their evaluations commenced, were performed, and the Evaluation Report issued. All these documentary evidences were assigned end-note numbers and appended herewith as ANNEXes.
The Probe Team also scrutinized the letters and Reports exchanged between different stakeholders, and Minutes of the various Board and Committee Meetings, including all those letters and newsprints of complaints from the suppliers/promoters and their agents and responses to them by the various officials of MoHSW, MUCHS, AMREF and their affiliates. All the documentary evidence is assigned end-note numbers and appended at the end of this Report.
The Probe Team interviewed a number of persons who carried these items from one spot to the other, who ran samples of patients’ blood in the CyFlow machine and SD Bioline HIV Rapid Test Kit, in the course of evaluating the machine and the Kit, before submitting the evaluation results to the PHLB and subsequently sending the Final Evaluation Report to the MoHSW and thence to the suppliers/promoters. The Probe Team read through several documents given by the interviewees and some which were downloaded from the internet.
The names of the persons who were interviewed are given hereunder, and their Interview Reports are appended herewith as ANNEXES.
These Reports are not in chronological order, since many of the interviewees were too busy with their routine chores to talk to the Probe Team exactly when the Probe Team wanted to interview them. The following is the list of intrviewees.
1. The Hon. Minister for Health and Social Welfare, Professor David Mwakyusa.
2. The previous Hon. Minister for Health and Social Welfare, Mrs. Anna Abdallah
3. The Permanent Secretary Mrs. Hilda Gondwe (it wasn’t possible to consult her).
4. The previous Permanent Secretary of the MoHSW, Mrs. Mariam Mwafisi.
5 The Chief Medical Officer of MoHSW, Dr. Gabriel L. Upunda.
6. The Director of Hospital Services, Dr. Zechery A. Berege.
7. The Registrar of the Private Health Laboratories Board, Mr. Sabas Mrina.
8. The Programme Manager of National Aids Control Programme,Dr.Roland Swai
9. Mr. Hasan S. Khalid, Laboratory Technologist of NACP.
10. The former Ag. Head of the Diagnostic Section of MoH, Dr.Faustin Ndugulile.
11. Dr.Carnelia Atsyor, Ag. WHO Resident Representative.
12. Dr.Magani,WHO Representative to Tanzania (it wasn’t possible to consult him
13. Prof. Eligius F.Lyamuya,Assist. Professor and Head of Microbiology,MUCHS
14. Professor Fred Mhalu, Professor of Microbiology, MUCHS.
15. Mr. Sufi, Head Technologist, Microbiology Laboratory, MUCHS.
16. Mr. Severin Mgonja, Technologist, Microbiology Laboratory, MUCHS.
17. Mr. Charles Kagoma, formerly with MUCHS, but currently with WHO.
18. Mr. Mbena, Technologist, MUCHS (it wasn’t possible to interview him)
19. Mr. Joseph Mgaya, Director General, Medical Stores Department (MSD).
20. Ms.Lucy Nderimo, MSD Quality Assurance Manager.
21. Mr. Hezron Shayo, MSD Quality Assurance Officer (Diagnostics).
21. Mr. Msemu, Procurement Officer, MSD (It was not possible to interview him).
22. Dr. R.S. Mlinga, Chief Executive Officer, PPRA (Public Procurement
Regulatory Authority).
23. Mrs. Ndomondo-Sigonda, MD of TFDA (It was not possible to interview her).
24. Dr. Benedict P. Mbawala, Managing Director, Oysterbay Hospital, DSM.
25. Lt. Mr. Hamisi Gabriel Chifupa, Director General, Tega International, DSM.
26. Dr. Urasa, CDC (it wasn’t possible to consult him).
27. Dr. Wictor, CDC (it wasn’t possible to consult him).
28. The AMREF Country Director (it wasn’t possible to consult or his affiliates).
29. Dr. Florence Temu Mbaga, Head of Programmes, AMREF.
30. Dr. Msolla, AMREF
31. Dr. Ocheng, AMREF
32, Mr. Barhat Rajani, Managing Director, Biocare Health Products Ltd.

33. Dr.Rainer Brandl, Bulongwa Hospital (It wasn’t possible to interview him).
34. Several Technicians working in Health Facilities all over Tanzania which had
CD4 counters and HIV Rapid Test Kits were interviewed by telephone,
preferred to remain anonymous.
Unfortunately, we were unable to visit Health Facilities which possess and use CyFlow CD4+ cell counting machines in Tanzania, and in some neighbouring African countries, at least. This was a pity since some of these Health Facilities or Centers apparently are very happy with the performances of their CyFlow machines that are manufactured by Partec of Germany, and which exhibit no shortcomings – certainly not like what MUCHS observed in this one CyFlow which they evaluated in August 2005. Many proud owners of various CyFlow machines all over the world, have written several positive statements and/or scientific Reports praising CyFlows’ performances and even compared their CyFlows with other CD4 cell counting machines made by other companies like Becton-Dickinson of USA, namely FACSCount, FACSCalibur, FACScan, etc. Reports of these comparative studies do confirm that the CyFlows are just as good as or sometimes better than other CD4 counting machines.
The style of reporting of this extensive, and difficult investigation is to have a short Executive Summary which will have in the text all bibliographic references written in parentheses and whose fully annotated list will be appended at its back. To actually see part of or the whole of the reference document, one will have to go to the back of the longer main Probe Team Report which is spiral-bound seperately.

INVESTIGATIONS, OBSERVATIONS AND CONCLUSIONS
THE TERM OF REFERENCE NO.1:
To investigate if there was a deliberate delay in evaluating the Cyflow.
As stated in the Introduction of this Report, the CyFlow saga has two groups which accuse each other. On the one side you have the Partec Essential Healthcare (Partec) company of Munster, Germany which offered its CyFlow® SL Blue 5 Parameters CD4 T-cell counting machine to the Ministry of Health and Social Welfare (MoHSW) to evaluate and register. The Partec people who used to follow up this evaluation, and who, after their CyFlow machine was disqualified, leveled all sorts of allegations of irregularities against the MUCHS and MoHSW officials, include: Professor Wolfgang Gohde, his son Dr. Roland Gohde, Dr. Volker Ost, who were all based in Germany; Mr. Khisa Joseph who was based in Nairobi, and Dr. Benedict Mbawala who is based in Dar es Salaam.
The opposite side comprised the Ministry of Health and Social Welfare (MoHSW) officials who include: the previous Hon. Minister for Health and Social Welfare, Mrs.Anna M. Abdallah; the current Hon. Minister for Health and Social Welfare, Prof. David Mwakyusa; the previous Principal Secretary (PS) Mrs. Mariam Mwafisi; the current PS Mrs. Hilda Gondwe; the Chief Medical Officer (CMO) Dr. Gabriel Upunda; the Chairman of the Private Health Laboratories Board (PHLB) Dr. Zachary Berege; the then Head of Diagnostic Services of the MoHSW, Dr.Faustine Ndugulile,; the Registrar of the PHLB Mr.Sabas Mrina; the then Head of the Microbiology/Immunology Department of Muhimbili University College of Health Sciences (MUCHS), Prof. Eligius Lyamuya; and his deputy Prof. Matee, his Chief Technician Mr.Jaafari Sufi; the Director General of the Medical Stores Department (MSD) and his colleagues, and the Director of the National AIDS Control Programme (NACP), Dr. Swai; and his Technician Mr. Hasan S. Khalid.
There were two possibilities of delays: (a) during transportation, and (b) while waiting in transit spots or at the final destinations – laboratories of MUCHS and AMREF. The people whose names are written above for each camp, were the ones who were in a position to delay or expedite this evaluation exercise somehow, singly or jointly. Although this Report will mention the role each of these persons has played in this saga, it is not possible to pin point which person is fully responsible for exactly which part of which delay, if any. This Report will also deal with the malfunctioning of the CyFlow counting system compared with the other CD4 counting systems, about which several allegations have been traded between the Partec and the MUCHS camp.
A. Chronology of CyFlow’s Departure from Partec to MUCHS, and MoHSW Attempts to Contain its Officials’ Handling of the CyFlow Evaluation
1. The CyFlow Machine saga started at the XV International AIDS Conference in Bangkok, Thailand, 11-16/07/2004, at whose Exhibition, the Tanzanian Delegation led by the then MoHSW PS, Mrs. Mariam Mwafisi met Prof. Wolfgang Gohde of Partec Essential Healthcare Company of Munster, Germany, who offered to send one CyFlow SL Blue 5 Parameter CD4 T-cell counting machine to the Tanzanian Ministry of Health and Social Welfare for evaluation.
2. On 22/9/2004 Partec dispatched one CyFlow machine to Tanzania, complete with its Starter Kit (of reagents) enough for 200 tests, and 100 vacuettes, from Munster, Germany, to the MoHSW, Dar, Tanzania, vide Invoice No.04093571 dated 22/9/2004, and Air Waybill No.724/ DUS/4286 4356 dated 23/09/2004.
3. On 27/9/2004, the CyFlow SL Blue CD4 machine arrived at DIA (Dar es Salaam International Airport), vide the same Air Waybill No.724/ DUS/4286 4356 originally dated 23/09/2004, and on its arrival at DIA it was marked 27/09/2004.
4. From 10-30/10/2004, Partec and its Dar based agent Dr. Mbawala repeatedly called MoHSW PS to help locate the CyFlow machine and get it evaluated.
5. Finally, on 11/11/2004, the PS located the CyFlow machine, got MSD (Medical Stores Department) to go to DIA to clear it, which they did, vide Import Declaration Form No. TRA/477391 dated 11/11/2004.
6. This means that the CyFlow CD4 counting machine was stranded at DIA from 27/09/2004 - 11/11/2004, equivalent to the first delay of 1.5 months.
7. Then, on 12/11/2004, MSD’s Mr. Fundi delivered the CyFlow machine to Mr. Mikidadi of NACP (National AIDS Control Programme), vide MSD Delivery Note No.00014193 dated 12/11/2004.
8. Mr. Khisa Joseph, Partec’s Nairobi based Partec Application Specialist Engineer, sent reports of his 1st and 2nd visits to MUCHS, by E-mails to Partec and Dr.Mbawala dated 21/10/2006 and dated 24/10/2006, which are appended herewith as ANNEX 2.5 and 2.6.
(a) Mr. Khisa visited Dar from 10-19/11/2004, for the purpose of commissioning the CyFlow machine and train Technicians. Since the CyFlow had not reached MUCHS yet, as it was still stranded at DIA (see occurrence No. 6 above), Mr. Khisa whiled away his time at Dr. Mbawala’s Oysterbay Hospital until 15/11/04.
(b) On 15/11/2004 is when Mr. Khisa, accompanied Dr. Mbawala, transported and delivered the CyFlow machine with its Starter Kit, to MUCHS, to commence his 3 days of the CyFlow installation and training duties.
(c) From 15-18/11/2004, Mr. Khisa conducted a detailed training of the following Technicians headed by Mr.J.Sufi, using the CyFlow Blue CD4 counting machine and its Starter Kit (which he and Dr. Mbawala had just brought from NACP):
J.Sufi, S.Mgonja, Doto Kalovya, Viola Msangi, Dr.Saidi Aboud, and Asha Shah.
9. On 23/09/04, the MoHSW wrote to Prof. W. Gohde in Germany (Letter Ref.No. BC/191/544/01/88 dated 23/09/04 appended herewith as ANNEX 2.7, signed by Dr.Z.Berege for PS), giving him the 5 terms and conditions under which the CyFlow machine was to undergo mandatory Evaluation:
(a) Partec will bear all costs of installation of its CyFlow.
(b) Its evaluation will last 6-12 months.
(c) Partec will provide essential reagents and supplies, including training, service,
and maintenance of the CyFlow machine.
(d) The Evaluation Results will be the property of the MoHSW.
(e) The MoHSW is not bound to purchase the CyFlow at the end of the evaluation.
10. On 28/10/2004: Prof. W.Gohde wrote back to MoHSW stating that his company Partec had already dispatched one fully equipped CyFlow machine with a Starter Kit of reagents to MoHSW in Dar since 22/09/2004, and he accepted all the 5 conditions stipulated by the MoHSW, and undertook to supply the necessary reagents for up to 2,000 CD4 tests free of charge. Prof. W.Gohde ended his letter by saying that: "I will ensure it is installed and used without further delay".
11. From this time onward, Partec and its agents, especially the Dar based Dr. B. Mbawala, kept on enquiring about the progress of the evaluation of the CyFlow machine regularly. These frequent follow ups/enquiries kept on upsetting some officials of MoHSW and especially of MUCHS so much that:
(a) The then MoHSW PS, Ms. M.Mwafisi once convened a Meeting of relevant officials, and in this Meeting and particularly in a letter she wrote to reprimand some or one of them (we did not see this letter because we were not given access to any MoHSW files) for not doing enough follow ups of the CyFlow Evaluation, and therefore slowing down its pace. She even warned some officials against keeping letters which are addressed to the PS without showing her and/or replying to some without her knowledge. (see ANNEX 1.4.4). She emphasized that MoHSW officials are there to help expedite the evaluations not to obstruct them.
(b) In one Interview, Ms.Mwafisi said that Prof. Lyamuya was so unhappy about these follow ups that he complained that she was "bullying and harassing" him.
Mr. Khisa’s E-mails also allude to this (see ANNEX 2.5 and 2.6).
(c) The anger sparked off by these regular follow ups by Partec people was so pervasive among some MoHSW and MUCHS officials that, for instance, Prof. Matee of MUCHS could not resist the urge to ban all Partec people especially Dr. B.Mbawala from going to the MUCHS campus at all. (See Mr. Khisa’s E-mails, End-Notes No. 5 & 6, appended as ANNEX 2.5 and 2.6).
(d) Mr. Khisa’s E-mails continue stating that, on 18/11/2004, the last day of the training session, the then trained Technicians led Mr. Khisa to Prof.Matee who was then the Ag. Head of MUCHS Microbiology Department. Prof. Matee was brief and categorical, that the evaluation of the CyFlow machine would not be possible without payment. This he said was due to the fact that the evaluation was not part of the routine work of the Technicians. He also stated that they were busy with exams and only "extra time" would be allocated, and this should go with "extra payment". Prof. Matee further said that nobody from Partec should follow up the evaluation progress. He especially cautioned Dr. B.Mbawala to keep off the MUCHS campus, without elaborating.
(e) Mr.Khisa’s E-mail said that, it is important to note that such payment was not provided for (in the conditions of evaluation stipulated by MoHSW). What was provided for is that, Partec was to provide enough reagents while the MoHSW was to provide Technical staff. Other forms of payments, if any, would be only internal arrangement by MoHSW. Mr. Khisa believes that, since this payment was not forthcoming, evaluation took the official stand (of no payment no evaluation), and was thus not done until 24/7/05, instead of commencing the evaluation immediately after Mr. Khisa completed the CyFlow demonstration/Training of Technicians on 18/11/2004, thus causing a further 8.5 months delay, over and above the 1.5 months delay when the CyFlow was stranded at DIA.
(f) When Mr. Khisa was requested and visited MUCHS for the 2nd time on 24/7/05 to solve a technical problem, which turned out to be the result of fungal growth in the tubing (due to negligence and lack of cleaning during the 8.5 months’ waiting), he met the Head of Microbiology Department (Prof. Lyamuya) who complained of harassment over the CyFlow Evaluation progress although he said it was the MoHSW to blame for not buying reagents for the BD FACSCount, a Becton Dickinson (CD4 counting) Machine to be used for comparison. (The procurement of these BD machines’ reagents took from 15/11/2004 (when the CyFlow arrived at MUCHS) to 24/6/2005 (when the MoHSW delivered the BD reagents to MUCHS, thus causing a delay of 7 months).
(g) Mr. Khisa’s E-mail continues to state that, due to this scenario, he gathered from the staff that old samples from a certain VCT were collected and analyzed on the CyFlow. Mr.Khisa stressed that no fresh samples were compared, as required by the procedure, and that the exercise was carried out in protest.
12. As the Introduction hinted, the suppliers of the CyFlow Blue CD4 T-cell counting machine were disappointed when MUCHS’s Final Evaluation Report disqualified their CyFlow machine. This sparked off myriads of bitter complaints from Partec officials and agents. Since I did not have access to the MoHSW files in order to read exactly what their letters to the Hon. Ministers and to their PSs and other senior officials alleged, I can only go by the responses which Prof. E.F. Lyamuya wrote after the MoHSW handed all Partec’s complaints to him to reply.
According to the 6 pages letter Ref.No.MIM/022/01/06 dated 30/01/06 appended as ANNEX 2.12, written by Prof Lyamuya to the MoHSW PS, in response to the PS’s letter Ref.No. HA.209/270 /01/100 dated 16/01/2006 (which the Probe Team did not see) which was rebutting the complaints of Partec on MUCHS’s Evaluation Report of their CyFlow machine, it said the following:
(a) The CyFlow CD4 Easy Count "machine" was delivered to MUCHS by Mr. Khalid, a Laboratory Technician of the NACP, on 24/12/2004.
(b) And to prove that the CyFlow was delivered on 24/12/2004 and by Mr. Khalid, Prof.Lyamuya attached a copy of the NACP Local Stores Requisition and Issue Voucher dated 24/12/2004, appended herewith as ANNEX 2.13, pertaining to the delivery of the CyFlow by Mr. Khalid on 24/12/2004.
(c) Evaluation of the CyFlow could not start immediately because MUCHS had no reagents for Flow Cytometry (the Reference Methods using BD FACSCount and BD FACSCalibur); and it was agreed that MoH would be responsible for providing them. Due to well known difficulties in the procurement of these reagents, it took quite sometime (24/12/2004 – 24/6/2005, i.e. 6 months if one assumes the CyFlow reached MUCHS on 24/12/2004; or 7.5 months if we take the date given by Partec’s Engineer Mr. Khisa and Dr. Mbawala of CyFlow’s arrival at MUCHS to be 15/11/2004 as stated above) before MoHSW could get the reagents for the Reference Methods which were finally delivered to MUCHS on 24/06/2005, 7 months after the CyFlow was submitted to MUCHS.
(d) Prof. Lyamuya’s letter says that MUCHS then embarked on the process of evaluating the CyFlow, but noted that Calibrating Beads were missing. These were provided by Mr.Mrina (the PHLB Registrar) on 12/07/2005.
(e) MUCHS continued with the familiarization process, and on 19/7/2005, the CyFlow system was observed not to give a display on the screen. They immediately communicated the problem to Mr. Mrina, who arranged for a CyFlow engineer from Nairobi (Mr. Khisa Joseph), to help solve the problem. Mr. Khisa arrived on 23/7/2005, and resolved the problem which, according to him was a simple one. He informed them that there was nothing wrong with the instrument and directed the Technicians on how to operate the CyFlow correctly.
(f) MUCHS subsequently continued with the evaluation process until late August 2005, analyzed the data, and provided the final Evaluation Report on 06/10/2005.
(g) From the description of events, Ptof. Lyamuya’s letter said, it is not true that the CyFlow was received at MUCHS in September 2004, and it is not true that the CyFlow was kept at MUCHS for 14 months before performing the evaluation.
The process of evaluating the CyFlow started 7 months after MUCHS had received the CyFlow, and the delay was due to logistical problems encountered by MoHSW in procuring the reagents for the Reference Methods.
(h) Even going by Partec’s claimed dates of delivery of the CyFlow machine, Prof. Lyamuya’s letter says, the period September 2004 (claimed date of delivery of CyFlow to MUCHS, which is not true), to August 2005 (when CyFlow evaluation was complete) this is not 14 months (as Partec claims).
(i) The letter says that MUCHS is not a BD (Becton Dickinson) Reference Center, as purported in the letter from Partec. MUCHS happens to have CD4 counting systems manufactured by Becton Dickinson (BD FACSCounter and BD FACSCalibur). But this does not amount to it being a Reference Center for the Company.
13. Unfortunately, Prof. Lyamuya’s letter has some rather obvious flaws, the main one of which is his mistaken and oft repeated contention that the CyFlow had been delivered to MUCHS on 24/12/2004 and that the CyFlow wasdelivered by Mr.Khalid of NACP. To do justice to this important point, let us go through all the above 9 points one by one:
(a) (i) The truth appears to be that the CyFlow machine was not delivered to MUCHS on 24/12/2004 – and even Prof.Lyamuya and Mr.Khalid would have found it easy to remember if the CyFlow was really delivered to MUCHS one day or 1.5 months (if it was delivered on 15/11/2004 as proven below) before Christmas. Mistaking so distant dates like these cannot be an oversight.
(ii) Furthermore, the CyFlow was never at any time delivered by Mr. Khalid, but it was delivered to MUCHS by the Nairobi based Partec’s engineer, Mr. Joseph Khisa, accompanied by Dr. Mbawala on 15/11/2004, after which Mr. Khisa used this same CyFlow machine and the Starter (Easy Count) Kit of reagents that came with it, to train Technicians for 3 solid days, from 15-18/11/2004. There can be no oversight at all on these training dates. Accepting Prof. Lyamuya’s theory that the CyFlow was not delivered to MUCHS until 24/12/2004, is tantamount to presuming that these Technicians were not trained on these dates 15-18/11/2004 (so when were they trained?), or presuming that they were trained on those dates but without using the CyFlow which, according to Prof.Lyamuya, did not reach MUCHS until 24/12/2004, 1.5 months later!
Both these notions are absurd and untenable, as further evidence adduced by the same letter of Prof. Lyamuya shows hereunder:
(b)i As clearly shown in the NACP Requisition & Issue Voucher, which is appended herewith as ANNEX 2.10, which Prof. Lyamuya himself attached to his own letter as evidence, what Mr.Khalid delivered to MUCHS on 24/12/2004 was not the CyFlow machine at all, but Mr. Khalid delivered to MUCHS only 10 Starter (Easy Count) Kits of its reagents. The Issue Voucher is clearly written:
"Quantity Required=10 KITS, and Quantity Issued=10 KITS (not 10 CyFlows)".
(b)ii Prof. Lyamuya’s letter, paragraph 3, first sentence was incorrect to state that:
"The CyFlow CD4 Easy Count machine (CyTecs GmbH Ser.No.040814517) was delivered to MUCHS by Mr. Khalid of NACP on 24/12/2004 (copy of NACP Local Stores Requisition and Issue Voucher attached)."
First of all, "CyFlow Easy Count (strips)" is a ‘Kit’ of reagents, and not a ‘machine’ as written above. Secondly, "CyTecs" is the name of the company marketing the CyFlow machine’s software, and its Easy Count Kit of reagents, as the Delivery Note and two pages of Packing List of the CyFlow CD4 Starter Kit (not of CyFlow machine itself) clearly shows that the Kit contained all reagents and supplies including "Calibrating Beads" which Prof Lyamuya’s letter reported that they were missing.
(b)iii Prof. Lyamuya claimed that: (1) what Mr. Khalid delivered to MUCHS, was the CyFlow ‘machine’, and that: (2) this CyFlow ‘machine’ was delivered on 24/12/04. But the NACP Issue Voucher’s Item Description writes: "CyTecs CD4 Easy Count", of unit ’10 Kits’, and it is not written of unit ’10 machines’ because ‘CD4 Easy Count’ is a Kit of strip reagents used in the CyFlow machine. Therefore this NACP Issue Voucher is not evidence of the issue of the CyFlow machine by Mr. Khalid at all as Prof. Lyamuya’s letter claims. It is the evidence of the issue of the 10 Easy Count Starter Kit of reagents, enough to make 2 x 100 tests. This destroys all evidence and reference of the date when the CyFlow machine was delivered to MUCHS being 24/12/2004, and of the deliverer of the CyFlow machine being Mr.Khalid.
(c)i The question of the provision of the reagents for Reference Methods (which use BD FACSCount and BD FACSCalibur CD4 counting machines), and the "Calibrating Beads" which Prof. Lyamuya reported they were missing, and which delayed the CyFlow Evaluation for a further 6 months (or 7.5 months’ delay if we take the true date of arrival of the CyFlow at MUCHS to be 15/11/04), is perplexing, to say the least. For whatever reason there may be, Prof. Lyamuya’s letter has erred on the date of arrival of the CyFlow machine to his Laboratory at MUCHS.

(c)ii Since Dr. Z.Berege, on behalf of MoHSW wrote back to Prof. W.Gohde the letter Ref.No. BC/191/544/01/88 dated 23/09/2004 which is appended herewith as ANNEX 1.1, to accept Partec’s offer of the CyFlow for evaluation, and set the 5 conditions for its evaluation, MUCHS must have known that the CyFlow evaluation would definitely need to be compared to the BD CD4 counters which would definitely need those BD reagents. Therefore MUCHS should have ensured that it has all the supplies necessary to conduct a full and proper evaluation before accepting to evaluate the CyFlow and set conditions for its evaluation (which did not include the 7.5 months’ waiting for BD CD4 Counters’ reagents). Indeed Partec say that they would have provided even the BD CD4 Counters’ reagents much earlier had they been requested to do so.
(d)i The question of MUCHS noting that Calibrating Beads were ‘missing’ is confounding, since Mr. Khisa must have used only small amounts of all the CyFlow complete Starter Kit reagents which were delivered to MUCHS together with the CyFlow machine on 15/11/2004 as aforesaid. It might have been understandable if Ptof. Lyamuya’s notified Partec that the remaining Calibrating Beads were accidentally lost during Mr. Khisa’s training session. The absence of such a notification is not an oversight.
(d)ii Another probability may be that reporting any supplies to be missing while knowing that it might take some time to replenish them, may have been part of the plan to delay the CyFlow evaluation, for purposes of frustrating Partec’s goal.
(e) The blockage of tubes by fungus which was discovered and cleared by the Nairobi engineer Mr.Khisa who ultimately instructed the Technicians how to clean and use the CyFlow correctly imply that the attitudes of the evaluators of the CyFlow were too nonchalant if not outright unwilling to evaluate it, as the facts mentioned in No. 11(g) above show – i.e. a deliberate non use of fresh samples by the evaluators who performed the whole CyFlow evaluation exercise "in protest".
(f) The fact that MUCHS was able to complete the Evaluation of the CyFlow in 2.5 months, once all the reagents were in place and the CyFlow was kept clean, shows that, had MUCHS been serious and willing to evaluate it, and planned their work well in advance, the whole CyFlow evaluation exercise should not have taken them the 12 months (from the time it arrived at DIA on 27/09/2004, to the time the Evaluation Report was released on 06/10/2005).
In other words, regardless of who in Tanzania’s MoHSW, MSD, NACP, and/or MUCHS was responsible, there was a delay of 9.5 months before the CyFlow evaluation was performed, which lasted 2.5 months only.
(g) From the above sequence of events and explanations, it is untrue of Partec to speak of "the CyFlow was kept at MUCHS for 14 months before performing the evaluation". But it appears true that there was a total delay of about 12 months.
(h) And the correct rebuttal of Partec’s allegation of "the 14 months’ delay" by MUCHS would be to invoke the condition No.2 which was stipulated by Dr. Berege’s letter Ref.No. BC/191/544/01/88 dated 23/9/2004 (which is appended herewith as ANNEX 1.1), which states that:
"The equipment shall be subjected to trial/evaluation for a period of 6-12 months to assess its performance in Tanzania."
Since the overall period of 12 months had not been exceeded yet, Partec was not quite right to shout so loudly about the delay.
(i) But this above mentioned "6-12 months’ period" condition does not justifiably exonerate MUCHS and MoHSW from unwarranted delays caused by e.g. the late clearance of the CyFlow from DIA, the late procurement of reagents for the BD FACSCount and FACSCalibur, procurement of Calibration Beads, and leaving the CyFlow uncared for to the point of its tubes growing fungus and jamming the display of its screen, etc. If MUCHS made proper planning e.g. by keeping reagents for BD reference CD4 counting machines handy all the time, these delays would have been minimized drastically, as would be the complaints. And since these delays in fact were not really beyond the control of MUCHS and MoHSW, the use of the phrase "deliberate delay" cannot be said to be far fetched, bearing in mind the above discourse and its documentary evidence herewith attached.
(j) Partec’s complaint that MUCHS is acting as a Reference Center of the USA suppliers, Becton Dickinson company, of the CD4 counting machines such as the FACSCount and FACSCalibur, is out of place only in so far as MUCHS is a Reference Center for the whole Republic of Tanzania to which evaluations of health laboratories’ supplies are referred. I think this was a reference to the over 40 BD FACS machines scattered all over Tanzania, and Dar es Salaam alone could have about 10 such BD machines. If this assumption is correct, then it should not have been impossible to borrow enough FACS machine reagents from the owners of these 10 machines with which to test about 240 samples, and replace these reagents when the MoHSW procures these reagents for MUCHS a little later. Alternatively MUCHS should have anticipated and order these reagents as early as when the MoHSW was notified that one CyFlow machine was sent on 22/9/2004.
This talk of "MUCHS being a Reference Center for BD machines" may have been triggered by Partec’s belief that all those 40 or so BD FACS machines have not undergone the rigorous evaluation which the CyFlow underwent, for no tangible reason. This state of affairs is prone to be made an excuse to disqualify any other CD4 counting machine like the CyFlow which will leave the BD CD4 counting machines without any competition, which is a rather precarios set up.
B. Different Treatment of Various CD4 Counting Machines
1. Let us quote a few examples of how different officials of MoHSW gave different orders concerning the evaluation and registration of some CD4 cell counting machines. The CyFlow CD4 counting machine alone was subjected to rigorous evaluation for 12 months under the 5 tough conditions. But other CD4 counting machines were exempted from evaluation altogether and so did not get the mandatory PHLB Registration stipulated by the PHLB Act of 1997 and "Private Health Laboratories (Conditions Pre-Requisite to Registration and Management of Private Health Laboratories)", Government Notice No. 226, sub-section No.2.5.2 (i) – (v). The pretext for others not observing this legal stipulation is that those old CD4 counting machines were evaluated before the PHLB Act was promulgated in 1997, but they do not show their Evaluation Report nor their Registration Certificate which they were give then (by who?), nor do they say why those CD4 machines were not evaluated properly and issued proper Registration by PHLB once this Board was established in 1997 after which the PHLB Act was to apply to all health laboratories supplies without exception. But the 40 or so FACSCount machines being currently used in Tanzania are not PHLB registered.
(a) As stated earlier, the CyFlow CD4 counting machine which Partec offered to MoHSW and meticulously evaluated for 12 months, complied with the 5 conditions stipulated by MoHSW’s Dr. Z.Berege’s letter to Prof. W.Gohde Ref.No. BC/191/544/01/88 dated 23/9/2004, and it was eventually disqualified.
(b) Since 1966 or earlier until now, when anyone wishes to possess a CD4 counting machine, all one needs to do is send for a Proforma Invoice to Mr. Bharat V.Rajani, the Managing Director of Biocare Health Products, who guarantees delivery in 4 weeks ex Dar es Salaam of a BD FACScount System Complete, on payment of US$ 66.379.00, as the letter Ref.No. GA.134/209/07/0350 dated 05/05/2006 written by Dr. R.O.Swai, NACP Programme Manager and copied to the MoHSW PS, Attention of Dr.F.Ndugulile shows. And Tanzania currently has over 40 such CD4 counting machines, procured by this direct way or through "one sided Tenders". The disqualification of CyFlow, which possess several advantages more relevant to the resource limited settings of a developing country like Tanzania, ensured that the market for CD4 counting machines in Tanzania was left to FACSCount to monopolize.
(c) When Dr. B.Mbawala of Oysterbay Hospital applied to PHLB to import a CyFlow CD4 machine, he was given different conditions for its evaluation, by a letter signed by Dr.F.Ndugulile Ref.No. BC.19/544/01/89 dated 5/10/2004, which is appended herewith as ANNEX 2.13. These conditions were:
(i) The CyFlow will be evaluated at the Reference Laboratory for 6 months.
Since its technology is new, it shouldn’t be used in public/private health facilities.
(ii) You will be required to facilitate orientation training on the use of the machine
(iii) During the evaluation you will be required to ensure availability of the
reagents and necessary other supplies to run the equipment.
(iv) Outcome of the evaluation will be, the basis decision on its use.
After asking a few questions such as why other CD4 machines like BD ones were not evaluated, though their "technology" was the same as that of CyFlow machines, Dr.Mbawala immediately got his Clearance Certificate from PHLB, cleared his CyFlow machine which he is using satisfactorily until now.
(d) There happens to be quite a few other CyFlow CD4 counting machines in Tanzania, some examples of which are shown hereunder, none of which is evaluated, and all of them have all this time been used to test HIV/AIDS patients, with full knowledge of MoHSW and its PHLB with no worry nor fuss whatsoever:
(1) Oysterbay Hospital, Dar es Salaam.
(2) Consolata Hospital, Ikonda.
(3) Lutheran Hospital, Bulongwa.
(4) PIUMA, Makete.
(5) Hope Village,Dodoma,whose CyFlow was launched by the Prime Minister.
(6) Consolata Hospital, Iringa.
(7) Aids Working Group, Tanga.
(8) D.D.Hospital, Muheza.
(9) RDTC, KCMC Hospital, Moshi.
(i) It is simply inconceivable that the CyFlow machine such as the one which was inaugurated by the Hon. Prime Minister in Dodoma, and the one at a big Referral Hospital like KCMC, and the other 7, some of which do have facilities to check their performances, have not discovered that all or some of them have faults.
(ii) It is strange that the PHLB cannot follow up all these CyFlow machines, evaluate them, discover their faults, and get them rectified, failing which close them up to avoid causing HIV/AIDS patients any further damage.
(iii) If the powers that be were serious, couldn’t someone all this time have tested a few samples having low CD4 counts (<200 cells/µl), in one or more of these other CyFlow CD4 counting machines e.g. the one at the Oysterbay Hospital, or at KCMC Hospital, etc., to confirm once for all whether the accuracy and precision of these machines’ assays are faulty and why.
(iv) Especially after the Partec’s CyFlow SL Blue CD4 counting machine evaluation results were reported to be imprecise and Partec raised bitter complaints, someone should have tried any of the many tactics of proving this imprecision even by seeking second and third opinions and/or by requesting the Nairobi based Partec Application Specialist Mr. Khisa to come to MUCHS to investigate the CyFlow’s imprecision and other faults and rectify them. But all this did not happen.

C. The CyFlow Evaluation Report of 2410/2005 Raised a Lot of Complaints
1. The Evaluation Report of the CyFlow CD4 cell counting machine was made public by the letter Ref.No. HC.49/421/Vol.IV/132 dated 24/10/2005, which is appended herewith as ANNEX 2.12, signed by MoHSW’s Dr.Z.Berege for PS, and addressed to Prof. W.Gohde. The following are excerpts from this Report:
"(a)The results showed unequal distribution of CD4 T-cells counts among the three categories for counts of less than 200 T-cells while there was a good comparison for 200-500 and above.
(b) This means that Partec CyFlow machine has low accuracy and low precision with low CD4 count (less than 200) which amounted to about 48%.
(c) Since counts of less than 200 CD4 T-cells is one of the criteria for determining eligibility for initiation of ART in Tanzania, the use of the machine will exclude individuals who are eligible for ART leading to denial of treatment.
(d) Conclusion: The Report showed that the Partec CyFlow machine system has a lower precision than FACSCount machine for counting CD4 T-cell categorized under less than 200 counts, but fairly with good comparison results for counting CD4 T cell categorized under count 200-500 and above 500.
(e) Deliberations: After discussions the Board decided that:
(i) The Partec CyFlow machine needs to be improved by the manufacturer in order to rectify the identified shortcomings.
(ii) Due to aforementioned shortcomings, it is not advisable to use the CyFlow in lower hospital settings (Dispensaries, Health Centers, or District Hopitals).
(iii) The CyFlow machine can only be used in Referral Hospitals where good quality assurance can be conducted and monitored."
(f) It is not clear whether the last sentence of Dr. Berege’s letter, No. 2(d)(iii) above, was meant to merely placate Partec people or it seriously meant to allow the CyFlow CD4 machine to be used in Referral Hospitals only (as do the BD FACS machines which are too intricate for ordinary Lab Technicians to operate).
(g). It is noteworthy at this juncture to hear what the Nairobi based Partec Application Specialist had to say about monocytes interference, in his E-mails:
"I wish to comment about the issue of the monocytes vs T-lymphocytes using Partec Flow Cytometers. The software used in CyFlow clearly distinguishes monocytes from lymphocytes based on natural immunology of these cells. Monocytes are known to have approximately 10% of CD4 markers found on CD4-positive T-lymphocytes! From the attached protocol, you can see from fig. 1, CD4 counting with CyFlow, that the population of monocytes, found to the left of CD4 positive T-Lymphocytes (RN1) can easily be separated by the region gates defined as RN1 in the Flomax software . The count in RN1 will be delivered to the programmed report template. The users at MUCHS are very much aware of this operation. The System will also perform CD4 % among lymphocytes. This is important in pediatric cases.
Such capability is non existent in FACSCount machines. Obviously the FACSCalibur despite being very expensive, can only derive CD4% from separate hematology instrument that uses a completely different technique.
Comparison between BD FACSCount/FACSCalibur and CyFlows has been done at several Universities e.g. the attached CDC study from Zimbabwe."
(i) Partec’s Application Note entitled: "Counting of CD4+ T-Cells using CyFlow SL_3 machine with Partec CD4 Easy Count Kit", the Package Insert gives instructions on how to adjust the CD4+ T-Cell Peaks in the FL2 Histograms with three decades logarithmic scale (log 3), and given in fig.1 of the Application Note which is appended as ANNEX 2.14 herewith. This way even low count samples (of range <200µl) can be assayed accurately as you can see also from histograms obtained from Dr. B. Mbawala’s CyFlow SL Green counting machine samples of print outs appended as ANNEX 2.15 herewith, of Analysis of whole blood specimens using the CyFlow SL Green CD4 counting machine and the CD4 Easy Count Kit (of reagents), which showed good correlation with reference CD4 counters at Muhimbili (MUCHS) on assaying the same blood specimens.
(ii) The last sentence of Mr. Khisa’s E-mail comes from an article in the Journal of Translational Medicine 2006, 4:33 dated 14/08/2006, which states that:
"A Zimbabwe-Stanford University comparative study in which CD4+ T-lymphocyte counts were enumerated using a CyFlow counting machine and BD FACSCount. Using linear regression analysis, they found a very strong correlation (R = 0.991) between the overall CD4+ T-lymphocyte counts obtained by the CyFlow and those which were obtained by FACSCount, even when data analysis was stratified according to the ranges: 0-250; 251-500; and 501-1200 cells/µl of absolute CD4+ T-lymphocyte counts.
CyFlow cytometry was found to be much more affordable, easier to use technology which is useful not only in identifying HIV seropositive individuals who require ART (Antiretroviral therapy), but also for monitoring immunological responses to ART, and capability to perform CD4% among lymphocytes of children.
Although the purchasing price of FACSCount and CyFlow counting machines are comparable (US$ 30,000 – 50,000), the reagents for FacsCount are much more expensive than the reagents for CyFlow. The cost of CD4+ T-lymphocyte counts is US$56 for FACSCount and for CyFlow it is only US$ 2.5. Also the CyFlow has a high throughput and as many as 200 specimens can be run per day, making it ideal for use in Zimbabwe, a country with one of the highest prevalence of HIV globally."
(ii) The price of reagents of FACSCount machine is far too expensive. In order to compete with Partec CyFlow counters, the Becton-Dickinson (suppliers of FACSCount counters) in Kenya tried to lower the price of its reagents, only to raise it many time over after a short while. This makes CyFlow the low-cost method for enumerating CD4+ T-lymphocytes.
(h)(i) On 14-15/03/2005, Dr. Volker Ost, Partec’s Chief Engineer, spent what he later termes two solid uneventful day in Dar. Accompanied by Dr. Mbawala, Dr.Ost visited MUCHS, after paying courtesy call to senior Ministry of Health and Social Welfare’s senior officials including the then Principal Secretary, Ms. Miriam Mwafisi, and the then Chief Medical Officer, Dr. Gabriel Upunda. When Dr. Ost informed the PS and the CHO that he is sent round by Partec to conduct regular maintenance and technical services for all Partec’s equipment, he was given permission to conduct these services for Partec’s CyFlow which was being evaluated at MUCHS Microbiology Department.
Let us remember that this visit was coming after the Partec’s Nairobi based Engineer Mr. Khisa Joseph’s first visit to MUCHS (15/11/2004), in which he was told by MUCHS’s Prof. Matee before Dr. Mbawala in no uncertain terms that:
"Prof. Matee further said that, nobody from Partec should follow up the progress (of the CyFlow evaluation). He especially cautioned that Dr. Mbawala should keep off MUCHS, without elaborating."
(see Mr. Khisa’s E-mails appended herewith as ANNEX 2.5 and 2.6
N.B. In spite of this outburst, soon afterwards when MUCHS failed to trouble-shoot the CyFlow, MUCHS asked Dr. Mbawala to summon Mr.Khisa, who then paid a second visit to MUCHS on 24/7/2005 and rectified the CyFlow problem which was caused by fungal growth in the CyFlow tubes due to lengthy storage of the unused machine without cleaning.)
One expected that after Mr. Khisa installed and demonstrated the CyFlow to the Technicians, work on evaluation would start right away. But this was not to be.
(ii) Dr. Ost’s Technical Service Report conducted on 14-15/03/2005, which is written in German and is rather technical, emphasize that:
~ The CyFlow SL Blue, 5 Parameter machine No. 040814517, which he serviced,
arrived at DIA with a complete CD4 Starter Kit (of reagents – CyTecs CD4
Easy Count Kit), enough to perform 2 x 100 tests.
~ He found that all items on the Packing List including Calibration Beads present
~ He changed tubings and Sheath.
~ He checked the settings and Flomax (which ensures separation of monocytes).
~ He found out that until this time (14-15/03/2005), the whole CyFlow instrument was completely untouched. That means that its evaluation had not started at all, despite most senior MoHSW officials repeatedly repeatedly telling Dr.Ost and Dr.Mbawala: "Evaluation of your CyFlow is right on track, and it would be ready in a matter of days not weeks." This shocked Dr.Ost very much.
D. After the CyFlow Returned to Germany, Its Data Showed Manipulations
(i) Finally, after the supplier of CyFlow, Partec, decided "to go for the carotid", its Dr.V.Ost wrote the following letter on 19/09/2006 to the MoHSW PS:
"Return of Partec CyFlow instrument from MUCHS through Mr. Masuki:
Dear Madam/Sir, As you promised in your letter to us dated 11/07/2006, to release the CyFlow machine after its evaluation, I understand you are in a position to help me to get the CyFlow® instrument through Mr. Gerald G. Masuki of Action Medeor International Healthcare Branch, Tanzania. There will be no cost to your Ministry for this action. In addition, I would like to thank you for your cooperation in this matter. Best regards, Dr. Volker Ost."
(1) And after MoHSW’s Dr.Z.Berege scribbled a note saying: "NSCP, ‘Tafadhali wape mashine hiyo’ meaning "NACP, please give them that machine", the CyFlow and all its accessories were air freighted to Munster, Germany.
What followed was an E-mail captioned "PROOF OF CYFLOW DATA MANIPULATION AT MUCHS" (appended herewith as ANNEX 2.19), addressed to Dr.B.Mbawala in Dar from Partec’s Dr.Roland Gohde in Germany dated 30/11/2006, with promises to send more detailed letters to the Government:
"Dear Dr. Mbawala, Under the presence and notification of an Attorney-at-Law, the CyFlow SL air freighted from Dar to Munster, it was opened at PATREC’s premises in Munster, Germany. The CyFlow unit and its accompanying computer (PC) hard disk were unpacked and immediately connected to the power plug and switched on. The PC hard disk and the data it contained were then carefully checked and documented. Then the hardware including the hard disk of the PC was directly handed over to the Attorney-at-Law for securing the existing documentary evidence.
Results: From the revealed data and the facts preserved in the CyFlow equipment, it can be indisputably confirmed that MUCHS personnel intentionally manipulated the instrument setting so that the measurement for CD4 counting could not yield correct values. Furthermore, despite knowing the existence and the full availability of the manuals, the application notes, and the CD4 counting protocol procedures, the MUCHS personnel deliberately opted not to use the predefined correct settings, which have been stored in the CyFlow as a ‘File’ which is automatically preloaded whenever the software is started. But they performed ‘measurements’ using the wrong manipulated settings which they concocted themselves, which led to completely wrong detection channel of the CyFlow machine used, which in turn gave wrong values. Any operator with minimum knowledge of flow cytometry and CD4 counting would have immediately recognized this after seeing the very first histogram from a sample run.
Judging from the manipulated data retrieved from this CyFlow machine, it now becomes very clear why MUCHS banned all Partec people from visiting the MUCHS campus and why they refuse all support and technical assistance offers from visiting Partec personnel, because they had targeted from the very beginning to manipulate the ‘comparison studies’ by changing the settings on the CyFlow machine.
Details: Only a brief report is being given hereunder. We shall send a detailed Report directly to the MoHSW and the Tanzanian Presidency, as well as issue a Press Release:
(a) Present on the desktop is a formatted document for short instructions on how to run CD4 counts (File name: CD4 PE Counting Procedure). This File describes the few steps for successfully performing CD4 tests on the CyFlow unit. It also shows the steps on how to load the predefined correct settings. Once loaded, these settings remain always ready for use as long as no one changes the settings deliberately. But even when someone changes these settings, the correct settings could be easily reloaded using the short written instruction procedure.
(b) The predefined correct settings (C:/FloMax/CD4Count.INST) which are automatically loaded are clearly located and mentioned by the instructions which have been clearly and easily visible as Word File on the Desktop (Word File mentioned under (a) above – CD4 PE Counting Procedure).
(c) The QC (Quality Control) runs performed by Partec Service Engineer from this CyFlow unit are well stored as are all the subsequent analysis data from MUCHS. It can be shown that the QC use the correct predefined settings and therefore the correct detection channel of the unit, leading to excellent QC run results.
(d) The analysis data from MUCHS for the CyFlow unit clearly shows that suddenly the settings were changed manually, leading to their use of the wrong detection channel. The histogram of all MUCHS measurements would have easily shown to any Laboratory Technician that the wrong detection channel was used. Nonetheless MUCHS personnel continued to perform all the measurements using the wrong settings. This can only happen when one purposefully and intentionally with willful intent decides to create manipulatively wrong results/data which may not be detected or identified as being incorrect by unsuspecting individuals like the MoHSW officials when studying the Report.
The data which are now safely in the hands of Attorney-at-Law are serving as indisputable material evidence for the manipulation of the CyFlow unit by MUCHS personnel, the intended use of wrong settings and therefore the use of wrong detection channels leading to incorrect results for particular purpose. This is more significant as MUCHS personnel did act in this way despite better knowledge and despite the fully available, entirely acknowledged, and clearly written CD4 counting procedures.
In addition to this, MUCHS accountable scientists did not only avoid any communications with Partec people who could have easily sorted out any unwarranted errors in the use of the CyFlow machine, but also blocke all numerous offers for assistance and support from Partec.
Kind regards, Roland Gohde."
(2) As soon as I see Partec’s final Investigation Report with all the damning evidence of MUCHS’s manipulations which the above letter promised to send to the Hon. Minister for Health and Social Welfare, to the State House, and to the scientific community at large, I shall review it and report it "verbatim".
(3) This issue has reached a magnitude far greater than we all anticipated. If Partec goes public by distributing press releases to the public as well as to the scientific community at large, it will seriously jeopardize the reputation of not only MUCHS but of various related Tanzanian Higher Education Institutions, Ministries and the whole Government of Tanzania. Scientifically what Partec claims did occur during MUCHS’s evaluation of their CyFlow machine in 2005 is feasible, and so it is gravely serious. The computer hard disk is similar to an aeroplane’s "black box", in the sense that everything that it recorded can be retrieved intact even after several years and reproduce print outs which would show the time the tests were done and what setting were done under. MUCHS should try to rebut these technical allegations scientifically as soon as practicable, for the sake of everyone.
(4) In the mean time, we should look critically other aspects of this data manipulation allegations such as:
(a) Whether MUCHS personnel is computer literate enough to manage to fiddle with the CyFlows electronics to the point of making it read what MUCHS wants? (b) Try to identify these or any other computer literate people, and quiz them on how this manipulation can be effected, and get them to tell us exactly how Partec too could have made this returned CyFlow read the data which Partec claims is proof of MUCHS’s manipulation of their evaluation results.
(c) Even if MUCHS itself is found to possess no computer wizard capable of fiddling with the CyFlow electronics like we surmise here, is it probable that rival CD4 suppliers like Becton-Dickinson or their agents could avail MUCHS such computer expertise and enable them to do such tricks of manipulating data?
(d) However, if the answer is "No, MUCHS is not that much computer literate", then the next question we should ask is whether MUCHS personnel are computer illiterate enough not to recognize when the CyFlow’s correct predefined settings (which are loaded automatically by the act of switching on its software) have changed accidentally or have been altered deliberately by someone, such that MUCHS would not know what happened or how to reload the correct settings?
(5) Other aspects to consider with detachment should be the following:
(a) Could the reason why some officials of MoHSW and especially of MUCHS banned Partec people from following up the evaluation by going up to the MUCHS campus be so as not to be caught red handed manipulating the CyFlow or being visited by other non-MUCHS people, as some unconfirmed rumours said?
(b) The feeble complaint of some of the MoHSW camp that Partec had no right to withdraw their CyFlow or that MoHSW should have refused to release the CyFlow is baseless, since MoHSW had promised, as one of its conditions, to return the CyFlow machine to Partec once they completed its evaluation.
This was made clear by the letter to Prof. Wolfgang Gohde, Ref.No. EPS/01/17/80 dated 11/07/2006, signed by Dr.Z.Berege on behalf of the MoHSW PS, with a copy to Dr.Mbawala, appended as ANNEX 2.20 herewith.
(c) MUCHS should explore the possibility of being allowed to reexamine the CyFlow with the aim of discovering if Partec has ‘doctored’ the CyFlow.
(d) In fact, in retrospect, it would have been prudent for Partec to leave the CyFlow at MUCHS, and bring a Partec engineer here so that he/she may check the CyFlow here, or take one MUCHS representative to Germany with the CyFlow, so that the CyFlow checking could be done in front of both MUCHS and Partec representatives. Alternatively, even now, Partec could allow a MUCHS representative to witness a rechecking of their CyFlow machine, either here or in G ermany, and settle this saga amicably and out of court, once for all.
(6) Some members of the MoHSW camp have gone as far asking why Partec is fussing so much about selling Tanzania one CyFlow machine, instead of being
content with the large market which they claim to have established for their CyFlow machines worldwide? The answer is, selling one or more CyFlow machines to Tanzania is not the crux of the issue. The reputation of a company that currently sells over 40% of CD4 counting machines worldwide runs into too great a danger of being jeopardized, if MUCHS or anyone else would spread proven accusations that their CyFlow machine is faulty when they believe that such accusations are based on false manipulative data and/or mischievousness. If they keep silent in front of such grave accusations, they will not only lose their big market, but it will tarnish the good standing or image of their country, government, and the people of Germany. They are bound to leave no stone unturned until they get to the bottom of this saga. And the same goes for MUCHS vis-à-vis the MoHSW, the Government and people of Tanzania if MUCHS will be proven to have been devious or manipulative with the data that resulted into discrediting the CyFlow machine. We should all bear all this in mind in a detached and unbiased manner.
(7) I hope I shall be able to see the print-outs done on this same Partec CyFlow before the machine was returned to Germany (if MUCHS could provide a few print outs), and after it was returned to Germany – both with the allegedly manipulated settings and with the correct settings, for all three CD4 count levels of 0-200, 201-500, and 501-1200 cells/µl. All these should be compared with the QC runs which the Chief Engineer of Partec did on this CyFlow machine on 14-15/03/2005 (see Dr. Volker Ost’s Technical Service Report of the CyFlow machine, appended herewith as ANNEX 2.17). I have requested Partec to avail me these and any other evidence of manipulations they possess. I hope they will oblige me this much before I complete my Report..

THE TERM OF REFERENCE NO. 2:
To investigate if the reagents used to evaluate the CyFlow had expired.
To avoid the semantics based complications and misunderstandings, we shall discuss, under this term of reference, both "Expiry date" and "Shelf life" of these reagents. Technically, if you consider expiry date per se, the reagents were used for the CyFlow evaluation at least 2 months before their expiry dates. But what about the Shelf Life of the reagents which MUCHS claims to know nothing about? Let us play the game in MUCHS’ own court.
(a) The following are the expiry dates shown on the reagent containers (bottles) labels, as given in Prof.Lyamuya’s letter of 30/01/2006, page 2 (ANNEX 2.9) :
EXPIRY DATES OF REAGENTS USED FOR THE CYFLOW MACHINE
NAME OF THE REAGENT WRITTEN
ON THE CONTAINER LABEL
EXPIRY DATE
WRITTEN ON THE
CONTAINER LABEL
TIME USED
BEFORE
EXPIRY DATE*
CyTecs CD4 Easy Count Dilution Buffer
Code No. CY-R-1004; Lot No. 041020wd
December 2005
Four
Months
CD4 Easy Count CD4 PE
Code No. CY-R-104; Lot No. X27008
February 2006
Five
Months
Calibration Beads
Code No. 9544000
October 2005
Two
Months
* Assume that the expiry date given as October 2005 means the reagent expired on 30/10/ 2005.
According to Prof.Lyamuya’s letter of 30/01/2006, page 2, the CyFlow evaluation started on 24/07/2005, after Partec’s engineer Mr. Khisa arrived at MUCHS and repaired the CyFlow, and ended on 30/08/2005. According to the the returned CyFlow the last CD4 count was recorded (in the "black box" i.e. harddisk) on 03/09/2005 (see page 4 of ANNEX 2.54). Both dates for the completion of the CyFlow evaluation are moreorless the same. Thus, even the Calibration Beads, which were the first to expire, were used about 2 months before their technical expiry date of 30/10/2005. Therefore Partec’s allegation that MUCHS used the Partec Reagents after their Expiry Dates had elapsed, may be technically untrue.
(b) But is it true that these types of reagents do not have a "Shelf Life" apart from the "Expiry dates"as MUCHS implies? Partec says no, these Partec reagents, the same as BD reagents, do have a "Shelf Life" of about 6 months. Let us look at the BD reagents with which MUCHS is more familiar:
(i) A quick glance at the BD FACSCount CD4 Machine Logistics Fact Sheets (appended herewith as ANNEX 2.21.1), page 2, under the heading SHELF LIFE of REAGENTS, the Fact Sheets states that:
"-15 months from manufacture: Reagents are guaranteed to have 6 months shelf life when leaving San Jose, Puerto Rico, and 5 months when arriving in Africa."
Therefore, as Partec said, these Partec reagents do have a Shelf Life of about 6 months, which had certainly elapsed by 24/07/2005 when the CyFlow evaluation commenced, by which time the reagents had spent about 10 months in the tropical Dar heat (4 months after expiry of Shelf Life), having arrived at DIA on 27/09/2004. Clearly, those CyFlow reagents were unfit for use after 24/04/2005.
MUCHS forgot this , or decided to ignore it, for reasons best known to them.
(ii) Be that as it may, apart from Partec reagents’ inserts, instrument manual and other instructions, Partec reagent containers carry Labels which have precise storage and other instructions as shown in the label sample herewith appended as ANNEX 2.21.2. The label mentions that it is part of the Partec Easy Count Kit of reagents, and it would state its function e.g. "no lyse buffer" or "CD4 mAb PE" or "CD4%". Then it would give its storage temperature as 2-8oC, which means its temperature should never be allowed to reach freezing nor hotter that 8oC. Now even if these CyFlow reagents were not frozen, it cannot be denied that they were left in temperatures above 20oC for most of its 10 months’ waiting. This definitely would render any such rreagents unfit for use in the CyFlow evaluation.
(iii) This CyFlow evaluation did use reference instruments namely FACSCount and FACSCalibur whose reagents were newly procured and used fresh in this CyFlow evaluation against the 10 months OLD CyFlow reagents which have been overheated well past their shelf life.
(iv) There were no compelling or convincing reasons for that much delay and negligence in using the Partec reagents well past their Shelf Life, even if MUCHS would insist on pleading ignorance of shelf life, for ignorance is no defence.
~ An important evaluation exercise like that should have been planned well in advance, as soon as the MoHSW set the conditions for the evaluation on 23/09/2004 (see ANNEX 2.7), and Partec had dispatched the CyFlow instrument on 22/09/2004.
~ Not ordering the reference method reagents which did not reach MUCHS until 24/06/2004, nearly 9 months later is not excusable under any circumstances.
~ Not requesting Partec to supply yet another fresher Easy Count Kit of reagents once MUCHS put their act together, again, it is inexcusable.
~ Not asking or better still not accepting Partec’s efforts to try to assist in trouble shooting to find out what caused those CyFlow imprecissions and other faults reported by MUCHS, when all the problems may have been sorted out, is strange and inexcusable too.
~ Not reading the enormous literature on CyFlow studies of comparing it with all the other CD4 counters, and finding out that they all showed excellent correlation, which would have made MUCHS consider the possibilities of MUCHS being wrong somehow after all, is ununderstandable and inexcusable.

THE TERM OF REFERENCE NO. 3:
To investigate the types of CyFlow machines which have and are being used in Tanzania, in which Hospitals, and how they entered Tanzania.
(a) This kind of information should be on the fingertips of PHLB. But answers to a long questionnaire we had to send to its Registrar showed that PHLB does not know the exact number CyFlows which are in Tanzania, in which health facilities they are, nor how they entered Tanzania and by whose permit, or how they are performing wherever they are. And of course none of them have been evaluated, approved, nor registered by PHLB, though all of them are being used all this time; and if PHLB knows, they do not want to admit nor act.
Therefore the only means by which we could answer the above questions of this Term of Reference pro[perly, was to visit all the Health Facilities which possess these CyFlow machines, but we were not enabled to do this.
(b) The following are the few Health Facilities about which we were able to find out, which possess and use CyFlow CD4 counting machines are:
(1) Oysterbay Hospital,Dar es Salaam,which uses the CyFlow SL Green model.
(2) Consolata Hospital, Ikonda.
(3) Lutheran Hospital, Bulongwa.
(4) PIUMA, Makete.
(5) Village of Hope, Dodoma, where the Hon. Prime Minister Lowassa, M.P.,
personally inaugurated their CyFlow CD4 cell counting machine.
(6) Consolata Hospital, Iringa.
(7) Aids Working Group, Tanga.
(8) D.D.Hospital, Muheza.
(9) RDTC, KCMC Hospital, Moshi.
Information we tried to gather by telephone calls indicated that some of these centers possess and use more than one CyFlow counters, and they cross check their CD4 cell counts at nearest referral Hospitals which possess reference CD4 counters, which they and their blood specimens can reach within 3 hours and be still fresh enough for CD4 cell counting. For instance Bulongwa Hospital specimens are driven to Mbeya Referral Hospital in 3 hours, after telephoning Mbeya to be ready, and get their specimens cross checked as soon as they arrive.
Dr. Rainer Brandl of Bulongwa Hospital said in one of his short Reports that there are over 18 CyFlow machines currently in use in Tanzania. Most likely these are of different models or versions of CyFlow CD4 cell counting machines.
(c) And none of these CyFlow machines scattered all over Tanzania have ever been evaluated, approved, nor given a clearance certificate or Registration by PHLB until now, although they are all being used to count CD4 cells. In answer to the questionnaire we gave him, the Registrar of PHLB says the following:
"Our records show that only 3 machines passed through PHLB – one for Bulongwa, another for Muheza, and another for Oysterbay Hiospital. The machine for Oysterbay was released on the condition that it should be used for demonstration purposes only. The other machines could have passed through TFDA. The Board agreed with NACP that the existing CyFlow machines be replaced with be replaced by FACSCount machines. It has been impossible for the Board to take strong measures to Laboratory Centers with these machines, because replacement has not yet been implemented. Only Bulongwa Hospital has been replaced by a new FACSCount machine."
This THLB answer does not tell how many CyFlow machines are in use in Tanzania, in which Hospitals, what types, whether they are evaluated/registered or not, nor how each of them entered Tanzania. Indeed the information we gathered show that Bulongwa imported two CyFlows, a Green model and the bigger Blue model like the one Partec offered the MoHSW in September 2004 to evaluate. It also shows that Bulongwa travels to Mbeya Referral Hospital, 3 hours’ drive, to cross check their CD4 counts by a FACSCount machine there, if and when that machine was functioning – which is certainly not all the time.
This THLB answer also shows the inherent confusion of some of the Acts which established PHLB, TFDA (Tanzania Food and Drugs Authority), GCL (Government Chemist Laboratory), and the like. Instead of being dealt with by PHLB, some Laboratory supplies may be dealt with (issued permit for importation, registration, approval to use as laboratory equipment) by TFDA if or when these CyFlow machines were treated as a medical devises; or by the GLC if or when their reagents were treated as industrial chemicals.
But to the best of my knowledge – confirmed by a telephone call to TDFA and GCL – TFDA is mandated to deal with machines or devices and drugs which are made to enter into a human body somehow, and CD4 counting machines only assay fluids like blood specimens which are outside the body. Therefore these CyFlow CD4 cell counting machines were not given Importation or Registration Certificates by TFDA. And it is only by physically visiting these centers that we could have learnt first hand which types of CyFlow were being used by them, and how they were imported into Tanzania. Similarly GCL felt that they could not deal with the CyFlow reagents even if they were separated from the CyFlow machine.
(d) The same PHLB answer to our questionnaire stated that:
"The CyFlow machine for Dr. Mbawala was imported for demonstration purpose only. It was not to be used for routine laboratory work. A programme of the MoHSW under QASI is sending Quality Assurance samples to assess the machine."
This kind of answer is typical of most PHLB officials’ answers – they announce what is not occurring, and things which occur are not announced by MoHSW nor PHLB.
To the best of our knowledge, Dr.Mbawala’s CyFlow SL Green machine is being used satisfactorily at his Oysterbay Hospital ever since it was imported in October 2004, through PHLB Importation Certificate. On the other hand, all the MoHSW orders issued by Dr.F.Ndugulile on behalf of the PS and PHLB – that the equipment be placed at the Reference Laboratory to evaluate its performance for at least 6 months (see ANNEX 2.13) – were never implemented, and one fails to know why the PHLB kept quiet since then! Nor is it known why the conditions of evaluation are different and the Regulations of the Private Health Laboratories Regulations Act, 1997 (No. 10 of 1997), made under Section 18 and came into operation on 01/07/1998, are observed only when it suits PHLB. For instance, all the FACSCount machines which ere being imported into Tanzania directly (mostly without going through public Tenders system), not only haven’t the authorities concerned not shown us their Evaluation Reports and Registration Certificates, but these machines which must have undergone several alterations since the early sixties when they started entering Tanzania, should have undergone evaluations regularly and issued fresh Registration by PHLB, as Drugs do after every 5 years.
(e) Since rough estimates indicate that there are over 18 CyFlow CD4 cell counting machines in use in Tanzania, it is safe to assume that they are not all the same, but there are different versions. Therefore it is safe to give the following summary of CD4 counting CyFlow data and compared this to other CD4 counters like FACSCount, as compiled by UNICEF/UNAIDS/WHO/MSF in June 2005.
SOURCES AND PRICES OF SELECTED MEDICINES AND
DIAGNOSTICS FOR PEOPLE LIVING WITH HIV/AIDS
Summary of CD4+ T-cell enumeration technologies
Instrument
FACSCount CD4 Counting Machine
CyFlow SL CD4 Counting Machine
Manufacturer
Becton-Dickinson, CA, USA
Partec GmbH (Munster, Germany)
Assay principle
Flow cytometry
Flow cytometry
Instrumentation
Dedicated CD4 counter
Dedicated CD4 & CD4% counter
Detection system
Fluorchrome labeled anti-CD3,
CD4 and CD8
Fluorchrome labeled anti-CD4/ anti-CD45,MAbs,(CD3/CD4), (CD3/CD8), CD4/CD8
Specimen
Whole blood
Whole blood
Results
Absolute CD4&CD8 count, CD4/CD8, ratio,CD4% , andCD8% among T-cells
Absolute CD4 and CD45 count, Absolute lymphocyte count,CD4% among lymphocytes, CD4% among T-lymphocytes
Correlation with flow cytometry
r value = 0.93 – 0.98
r value = 0.95 – 0.99
Cost of the CD4 instrument, US$
27,000
26,975
Cost of reagents
US$/test 5 – 20
US$/test 2.26 - 3.23
Advantages
Automated, fewer steps, less human error, low biohazard risk, Absolute CD4 and CD8 counts, Quick results, EQA (External Quality Assessment) available
Reagents available at low cost, Equipment includes reagents for 200 CD4% tests, Quick results, EQA (External Quality Assessment) available
Disadvantages
Reagent prices vary widely, CD4% among lymphocytes not reported, can be calculated from hematology data
Limited data available
More details of characteristics of the various CyFlow CD4 counting machines as well as other makes of CD4 counting machines are given the document compiled by a Joint UNICEF/UNAIDS/WHO/MSF Project entitled: "Sources and Prices of Selected Medicines and Diagnostics for People Living With HIV/AIDS" dated June 2005.
(f) Partec company of Germany supplies double platform CyFlow CD4/CD8 machines as well as single platform volumetric CyFlow CD4/CD8 machines. All double platform flow cytometers in column 1 above including CyFlow machines can measure absolute counts by combining its results with those from hematology to provide absolute counts. Volumetric instruments in column 2 above have the capability of measuring the volume of the sample, and provide direct absolute counts without the use of hematological analysers or beads. Both these two types do give Absolute CD4 and CD8 counts, CD4% and CD% among the lymphocytes, and they can give CD4/CD8 ratios. Protocols for aged samples for volumetric CyFlow machines are available as are EQA (External Quality Assessment).

THE TERM OF REFERENCE NO. 4:
To investigate which type of CyFlow machine was tested in the special HIV/AIDS Laboratory at MUCHS.
(a) In the Partec Invoice No. 04093571 dated 22/09/2004, (appended herewith as ANNEX 2.1), the Item Description of the instrument which MUCHS evaluated, is written as: "CyFlowR SL, Blue, 5 Parameters". It is equipped with a blue solid state laser (power 20mw, wavelength 48nm); and it has five optical parameters: forward scatter, side scatter, fluorescence channel 1, fluorescence channel 2, and fluorescence channel 3.
The back of the instrument is written the date of manufacture as 2004, Serial Number as 040814517, and CyTecs GmbH, Am Flugplatz 13, D-02828 Görlitz. CyTecs is the name of the section of the company which manufactures the CyFlow machines which is in Görlitz, East Germany, while Partec is the research and administration section which is located in Munster, West Germany. CyFlow is the registered trade mark of CyTecs.
(b) This CyFlow unstument which was at MUCHS is named "CyFlowR SL. It is equipped with a blue solid state laser (power: 20mW, wavelength: 48nm); and it fitted with 5 optical parameters (forward scatter, side scatter, fluorescence channel 1, fluorescence channel 2, and fluorescence channel 3)."
(c) This CyFlow counting machine differs in its configuration from the dedicated CD4 counting machines also manufactured by Partec, such as: CyFlowR Counter and CyFlowR SL_3. Unfortunately, these two CyFlow machines were banned by MoHSW from being imported into Tanzania, despite the fact that they were never evaluated at all in Tanzania. This appears to imply the ban on CyFlow SL Blue on MUCHS instigation has been translated into a total ban of all CyFlow instruments – a case of judgment without trial!
It is particularly pitiful donations of CyFlow units dedicated for humanitarian support of NGOswho treat children, have been banned from importation, notwithstanding all competitive instruments like BD FACSCount (which has reigned without competition for the past 15 years, and of which there are over 40 units in Tanzania), are incapable of performing the vital VD4% analysis which is a must in the treatment of AIDS infected children below 7 years of age. This causes hundreds of children to remain without essential reliable monitoring/treatment.
(d) The CyFlow Blue 5 Parameters machine is one of the many versions of CyFlow multipurpose CD4+ T-cell counter, comparable to other CD4 counters which use the assay principle of "flow cytometry", whose characteristics are summarized in the following table compiled by a joint UNICEF-UNAIDS-WHO-MSF Project in June 2005, and acknowledged as being comparable or as good as the reference counters such as FACSCount, FACSCalibur, etc.
SOURCES AND PRICES OF SELECTED MEDICINES AND
DIAGNOSTICS FOR PEOPLE LIVING WITH HIV/AIDS
Summary of CD4+ T-cell enumeration technologies
Instrument
FACSCount CD4 Counting Machine
CyFlow SL CD4 Counting Machine
Manufacturer
Becton-Dickinson, CA, USA
Partec GmbH (Munster, Germany)
Assay principle
Flow cytometry
Flow cytometry
Instrumentation
Dedicated CD4 counter
Dedicated CD4 & CD4% counter
Detection system
Fluorchrome labeled anti-CD3,
CD4 and CD8
Fluorchrome labeled anti-CD4/ anti-CD45,MAbs,(CD3/CD4), (CD3/CD8), CD4/CD8
Specimen
Whole blood
Whole blood
Results
Absolute CD4&CD8 count, CD4/CD8, ratio,CD4% , andCD8% among T-cells
Absolute CD4 and CD45 count, Absolute lymphocyte count,CD4% among lymphocytes, CD4% among T-lymphocytes
Correlation with flow cytometry
r value = 0.93 – 0.98
r value = 0.95 – 0.99
Cost of the CD4 instrument, US$
27,000
26,975
Cost of reagents
US$/test 5 – 20
US$/test 2.26 - 3.23
Advantages
Automated, fewer steps, less human error, low biohazard risk, Absolute CD4 and CD8 counts, Quick results, EQA (External Quality Assessment) available
Reagents available at low cost, Equipment includes reagents for 200 CD4% tests, Quick results, EQA (External Quality Assessment) available
Disadvantages
Reagent prices vary widely, CD4% among lymphocytes not reported, can be calculated from haematology data
Limited data available
N.B. Partec claims that some of the characteristics of their CyFlow machines in the above table of June 2005 are erroneous and/or missing, and WHO corrected these in the August 2005 version which I have not seen yet. (see ANNEX 2.23, and 2.40 and 2.41).
(c) The CyFlow SL Blue 5 Parameters is a relatively big yet compact machine, which is versatile, easier and faster to operate, affordable, and an ideal reliable medical technology for developing countries with resource limited settings.
THE TERM OF REFERENCE NO. 5:
To investigate if the procedures used in evaluating the CyFlow machine tested in the special HIV/AIDS Laboratory at MUCHS was really scientific, and was accurate, and is capable of producing correct results.
(a) Analytical or assay procedures are not, as a rule, improvised as the whim of the analyst takes him/her, or as he/she proceeds with the analysis of any substance. Even if that analyst is the originator of a particular method of analysis, he/she must have experimented with his/her methodology thoroughly, and once he/she had perfected an/d standardized that method, he/she would publish it. And henceforth he/she or any other analyst who wants to use that methodology in analyzing something, would follow every step of it exactly as the methodology directs. This is especially so when a machine is supplied with a manual or instructions on how to use that machine to analyze or evaluate a particular substance using a prescribed method of analysis. If the instructions are not followed to the letter, the manufacturer does not bear any responsibility for the
malfunctioning of the machine and/or the incorrectness of the analytical results. Even when a reagent or a particular type of water is missing, or an apparatus is not cleaned in the prescribed manner, or the temperature stipulated is not available, the analyst has to halt the analysis until all requirements and the SOP (Standard Operating Procedure) are fully met. And ordinarily, an analyst collects and prepares all the requirements well before embarking upon the analysis in question.
(b) Now Partec has leveled several allegations against MUCHS, including those concerning the test or analytical procedures of using the CyFlow machine and the CyFlow CD4 reagents, some of which have some evidence and some have no tangible evidence. For example:
(i) The Nairobi based Partec Application Specialist (Mr. Khisa Joseph) who installed the CyFlow, came to MUCHS twice to rectify and/or check it, as did Dr. Volker Ost, Partec Chief Engineer. Technical Service Reports of both these Partec Engineers, appended herewith as ANNEX 2.6 (Mr. Khisa’s) and appended as ANNEX 2.17 (Dr. Ost’s), mentioned the bad manner in which the CyFlow was kept, during many months of waiting, which caused fungi to grow in its tubes and jam the CyFlow machine. This negligence was contrary to SOP given by the instructions of the instrument manual. The evidence of this is in MUCHS having to request help from Mr. Khisa, and he came on 24/97/2005, removed the fungi, cleaned and checked the machine thoroughly as it should have been done regularly by MUCHS, and instructed the technicians on keeping it clean and well. This magnitude of negligence was certainly uncalled for, unscientific, and are likely to give incorrect results, and confirms the alleged carefree attitude which Mr. Khisa (see ANNEX 2.6) expressed in the following manner:
"The evaluation of the CyFlow would not be possible without payment. … Since payment was not arranged, evaluation took the official stand and was therefore not done until 24/07/2005."
(iii) Further evidence of the CyFlow lying dormant and unused for months was given by Dr. Volker Ost, Partec’s Chief Engineer whose Technical Service Report (appended herewith as ANNEX 2.17) talked of the two "empty" days he spent at MUCHS checking the CyFlow on 14-15/03/2005 being most disappointing since the CyFlow machine had, until then, not even been touched!
(iv) Keeping particularly the Kits of reagents for about 8 months, in the tropical room temperature well above 4oC, and then use them for the evaluation analyses, using freshly procured reference machine’s reagents, was also unwarranted and a contravention of the SOP, which was bound to affect the evaluation analyses one way or another.
(v) What MUCHS technicians told Mr. Khisa and his E-mail quoted them (see ANNEX 2.6),had the following mind-boggling unscientific and unpatriotic saying:
"Due to this scenario (of refusing to use the reference method BD machines’ reagents for the CyFlow evaluation) I understand from the staff that old samples from a certain VCT were collected and analyzed on the CyFlow. I want to point out that no fresh samples were compared as required by the procedures, and that the (evaluation) exercise was carried out in protest."
Most certainly alleged use of blood samples which are not fresh (older than 8 hours) was a ready recipe for unscientific, inaccurate and unreliable results. And the mere thought that the evaluators could allegedly stoop so low as to use old blood samples contrary to the prescribed procedure, as a form of protest is amazingly unjust, especially since the whole evaluating exercise is a "fight (jihad)" against HIV/AIDS and for saving precious Tanzanian lives.
(vi) In the CyFlow Evaluation Report and other letters of Prof. Lyamuya:
(1) MUCHS hasn’t given details of blood preparation protocols,reagents,& mABS.
(2) MUCHS has not given result sheets nor print outs which could have made the evaluators detect, during the evaluation, and made Partec, after the MUCHS evaluation, realize if the CyFlow instrument settings were wrong.
(3) MUCHS has based their disqualification of the CyFlow on wrong information which is readily available in manuals, inserts, and immunological literature, e.g.: (i) amount of blood for testing (20µl) (ii) blood to be kept in a fridge (iii) time/test (70 seconds) (iv) sheath fluid for testing (available) (v) daily internal QC (available daily) (vi) external QC (QASI and NEQAS available) (vii) can determine CD4% in children (but FACSCount cannot) (viii) detection limit is better than that of FACSCount and FACSCalibur – down to 5 cells/µl) (ix) CyFlow’s thoroghput is 250 samples/day (250 samples) (ix) cost per test is US$ 2 - with a 10 year warranty on this price level), FACSCount is 5-20 times more (x) sample preparation time/test = 15 minutes (for FACSCount = 90 minutes) (xi) far easier to operate than FACSCount (xii) technical support available from the Nairobi based engineer, Mr. J.Khisa. Not knowing all this must have led to incorrect evaluation.
THE TERM OF REFERENCE NO. 6:
To investigate if there is any evidence of bribery so as to pressurize the experts who performed the evaluation to give the results which they eventually gave to MoHSW and ultimately to Partec.
(a) It goes without saying that to catch a person giving a bribe or receiving a bribe, or to get a briber or a bribed person to admit or confess to the act, is virtually impossible. Even the professional, far better equipped officials of an anti-bribery organization like PCB, have to resort to laying a trap with tagged paper money, long before the bribery act takes place, in order to catch the bribery pair red handed. For our probe team selected long after this CyFlow saga took place, and being so illequipped, all that it can find as "evidence of bribery" are implications, inclinations, insinuations, allegations, allusions, connotations, and the like, which may not be admitted in the cheapest court of law as proof beyond reasonable doubt. Let us recap acts of frustrating the evaluation which culminated into the final Report which disqualified this CyFlow and banned all other CyFlows.
(b) Ever since the CyFlow SL Blue, Five Parameters CD4 T-cells counting machine complete with its Starter Kit of reagents was dispatched from Partec Essential Healthcare company (Partec) of Munster, Germany, to the MoHSW (Ministry of Health and Social Welfare), Dar es Salaam on 22/09/2004, various Partec people regularly used to enquire about its arrival in Dar and the progress of its evaluation. Most of the few MoHSW officials who welcomed these enquiries, always said the CyFlow had reached MUCHS, and its evaluation was well advanced. When they started enquiring from the then PS (Permanent Secretary) of the MoHSW, Mrs. M.Mwafisi, and telling her that the CyFlow has not even left DIA (Dar es Salaam International Airport) since it arrived there on 27/09/2004, she would telephone her officials who would tell her the evaluation is well on schedule. When these enquiries became persistent, she convened meetings of relevant MoHSW officials, reprimanded some for not telling her the truth nor showing her the correspondence concerning the CyFlow, and ordered MSD (Medical Stores Department) to immediately clear the CyFlow from DIA, and get it delivered to its destination, MUCHS Microbiology/Immunology Department, for its urgent evaluation. Evidence of these chronological movements of the CyFlow machine and its reagents, are detailed on pages 9-16 of this Report.
(b) On 11/11/2004 MSD cleared the CyFlow machine from DIA, where it was stranded for 1.5 months, and delivered it to NACP (National AIDS Control Project), from where Partec’s Nairobi based Application Specialist Engineer, Mr. Khisa Joseph accompanied by the Dar es Salaam based Partec agent Dr. Benedict Mbawala transported it to MUCHS on 15/11/2004. For details of the movements of the CyFlow with its reagent Kits and documentary evidence, please see page 8. We thus far observe the following:
(i) Several senior and junior MoHSW officials had been misleading the then PS, Mrs. M.Mwafisi, which caused a delay of 1.5 months for the CyFlow to reach MUCHS. This was not simple forgetfulness or laziness. This seems to have been one of the calculated moves to delay the commencement of its evaluation. And one does not calculate a delay (which may spoil the efficacy of the machine and its reagents, which will in turn give incorrect results) for such an urgent life and death exercise, unless that delay works to the advantage of the delayers themselves or people they represent, expecting to be rewarded for the delay. People responsible for this first delay include the CMO (Chief Medical Officer), Chairman of the PHLB (Private Health Laboratories Board), the PHLB Registrar, the then Head of Diagnostic Services, MSD Director-General, NACP Manger, and their affiliates.
(ii) As soon as the Nairobi based Partec’s Application Specialist Engineer, Mr. Khisa Joseph and Dr. Mbawala delivered the long awaited CyFlow machine, Mr. Khisa installed it, and started a three days training session of Technicians at MUCHS, using the complete Kits of reagents that accompanied the CyFlow instrument. One assumed that soon after this training, MUCHS should have commenced evaluation of the machine.
(iii) But the evaluation of the CyFlow suffered another 6.5 months delay, because MUCHS claimed that Calibrating Beads for the CyFlow were missing, which cannot be true because the CyFlow came with complete set of reagents which were sufficient for 200 tests (see the Partec Delivery Note and Packing List of Kits, ANNEX 2.11) of which Mr. Khisa’s training session used a small part only. MUCHS also claimed that it had to wait for about 6 months for the MoHSW to order and deliver to MUCHS reagents for the reference methods. Since we were not shown MUCHS’ letters requesting these reference reagents, it is difficult to believe it takes all that long to order the special reagents, and it is difficult to understand why MUCHS’ special reagents (which she possessed) could not be borrowed for CyFlow evaluation with the view to return the special reagents once the MoHSW delivered the ones they ordered for the CyFlow evaluation and save a further 6.5 months of the CyFlow evaluation duration.
(iv) Indeed, there is no tangible reason why MUCHS could not order the special reagents as early as September 2004 when the MoHSW was told the CyFlow had been dispatched to the MoHSW on 22/09/2004, or as soon as the CyFlow machine was delivered to MUCHS on 15/11/2004 by Mr. Khisa and Dr. Mbawala. For details and documentary evidence of this, please see page 9-12. This appears to have been another calculated continuation of the unwarranted delay, whereby the evaluation of the CyFlow machine had to start as late as on 24/07/2005.

(v) Even if Partec’s instructions to MUCHS to ensure that they use the CyFlow reagents before their 6 months shelf-life had elapsed were misunderstood or were not given at all, using those reagents 8 months after they arrived in Tanzania (at DIA), and compare the assay results with those of the reference method which used fresh reagents, is not a feat which a professional analyst would be proud of. Take the example of Calibration Beads, which Prof. Lyamuya had reported missing, and yet he gives their Expiry Date as 10/2005. One cannot be proud of using the beads up until October 2005 (given that the evaluation was concluded and reported by 06/10/2005), only a few days before the expiry date of "October, 2005". If MUCHS was that late to use those reagents for such a comparative evaluation, why didn’t they order fresh reagents? What were the compelling and tangible reasons for waiting until the end of the expiry dates? Isn’t it prudent to use any substance with an expiry date immediately or during the first or second quarter of its expiry date duration? Is this an exhibition of seriousness and zeal to perform that CyFlow evaluation perfectly really?
(vi) Now, out of all these unjustifiable delays and their pretexts emerges one or two indications. One of the allegations leveled by news media especially is that, the evaluators are used to receiving large rewards from the suppliers of the rival CD4 counters like BD FACSCounts, Becton-Dickinson, for each effort they make in frustrating, delaying, or better still discrediting the whole evaluation exercise and so disqualifying the CyFlow machine. This is because, any delay and particularly an outright disqualification of the CyFlow would perpetuate the over 10 years of the monopoly of the BD FACS machines that much longer. And whatwith the versatility, lower reagent cost, ease of operation, ability to determine CD4% without resorting to hematology and other such advantages over the FACS machines would certainly give the CyFlow the upper hand in supplanting the FACS machines. BD simply could not envisage such a competition which CyFlows would bring if they passed evaluation and get PHLB Registration, and any means of stopping competition would be appreciated and rewarded, so say the allegations. To reverse this trend, Partec has to give counter rewards many times bigger than the reward which the evaluators receive from the predominating BD company. Either way the evaluators stand to be rewarded, as the people who level such allegations against BD would say.
(vii) Perhaps those who were playing the delaying or frustrating tactics felt sure that Partec might not be able or wish to engage in such a dirty game, and that was why from the very start, the evaluators and their many supporters never took this evaluation exercise seriously, so goes another theory.
They dillydallied over clearing the CyFlow from DIA for 1.5 months, and waited for reagents for the reference method for 6.5 months before starting the CyFlow machine evaluation, although these special reagents were available from other Projects and could be easily lent for the CyFlow evaluation and returned soon afterwards.
(vii) And more importantly, said another theory, where the funds used for these HIV/AIDS Projects have anything to do with USA e.g. Global Funds or Clinton Foundation Funds, and thanks to the assisting attitude of PHLB, of course the CD4 counter of choice would be USA made CD4 counters, viz BD FACSCount, FACSCalibur, and FACScan CD4 counters alone.
(viii) As it was made clear earlier on, these may be termed mere speculations because they are very difficult to prove, although a few ‘insiders’ who wanted to remain anonymous leaked this information of rewards, and the above mentioned indications tend to support these "speculations".
(ix) So as not to be seen to be overdoing these uncalled for delays and/or victimization of the CyFlow suppliers, so goes another allegation, Prof. E.Lyamuya of MUCHS supported by NACP persistently claimed that the CyFlow machine and its 10 reagents Kits were delivered by Mr. Khalid of NACP as late as on 24/12/2004 (see Prof. Lyamuya’s letter of 30/01/2006 appended herewith as ANNEX 2.9), whereas in fact it was delivered by Mr. Khisa accompanied by Dr.Mbawala obout one month back, on 15/11/2004 (see ANNEX 2.5, and ANNEX 2.6). MUCHS and NACP went as far as submitting as proof of the delivery of the CyFlow on 24/12/2004, a NACP Local Stores Requisition and Issue Voucher dated 24/12/2004. But this issue voucher turned out to be the proof of delivery of the Starter Kit reagents only. The items delivered on 24/12/2004 were not the CyFlow machine at all (see ANNEX 2.10).
(x) Not remembering whether it was the CyFlow machine or the Starter Kit (of reagents only) which came on a popular date like 24/12/2004 (Christmas Eve), is certainly not mere forgetfulness, but it is a nonchalance lack of seriousness and/or a calculated move intended to show that the CyFlow came to MUCHS as late as 24/12/2004, and so lessen the duration of the delays, and so lessen the justification of Partec complaining about the delays in evaluating the CyFlow machine being too long.
(xi) However, later on, after being prompted somehow, Professor Lyamuya retracted some of his claims by offering a fresh additional submission on 4/1/2007 (see ANNEX 2.22), which stated, amongst other things, that:

"The CyFlow machine was received in the Department on 15/11/2004 (which is now true), and saying that the CyFlow was handed in by Mr. Khalid of NACP (which is still untrue, because Mr. Khalid handed in the 10 Kits of Kits of reagents only, without the CyFlow machine, and these Kits were handed in on 24/12/2004, not on 15/11/2004 (see ANNEX 2.10). The CyFlow reagents were enough for testing the system only and the Calibration Beads were not included (which is again untrue because the Starter Kit always had all the reagents including the Calibration Beads, and they are enough for 200 tests (as seen in the Delivery Note and Packing List of the reagent Kits (see ANNEX 2.11) enough to start the evaluation with (and remember the total number of samples MUCHS tested throughout the CyFlow evaluation was 240 only)."
Why all this barrage of obvious abnormalities and untruths, one may ask?

7. DID WHO EVER DO AN EVALUATION OR MULTICENTER STUDY OF THE CYFLOW MACHINE? WHAT RESULTS DID THEY GET?
(a) The short answer is no, WHO never did any evaluation or multicenter study of the CyFlow® CD4 machine, and so WHO did not get any results. As a matter of fact, WHO has never done any evaluation or multicenter study of the FACSCount, FACSCalibur, nor any other CD4 machine, simply because that is not one of its duties and WHO has no laboratories for doing any solo or multi-center study or evaluation itself. All that WHO can do and often does, is to coordinate different laboratories who opt to do some studies, or recognize good studies done by them. WHO can recommend and/or procure equipment and reagents for various laboratories and/or occasionally fund portions of studies, and disseminate scientific data and information on any medico-technological topic which can help advance medical knowledge and/or improve the health of man anywhere any time. If WHO were evaluating CD4 counting machines, we would all wish to entrust WHO as a reputable international health organization, and avoid all these headaches of establishing expensive laboratories and policing them to keep bribery out of one organization only.
(b) The implications behind the above stated question presumably is, whether WHO recognizes Partec’s CyFlow technology or not. Indeed some adversaries of Partec and its CyFlow systems put that question this way: "Has WHO ‘validated’ ‘approved’ ‘certified’ the CyFlow systems or not?" The answer to this question too is no CD4 counting system has ever been given a certificate/approval – not Partec’s CyFlow nor BD FACSCount systems. It is simply not their responsibility right now. But WHO has done a lot which show that it fully recognizes the Partec CyFlow CD4 enumeration technology just as it recognizes BD FACSCount technology and other technologies as demonstrated by the following table which was compiled jointly by WHO, UNICEF, UNAIDS, and MSF (Medecins sans Frontieres) in June 2005, and revised in August 2005 (see Annex 2.23).
A SUMMARY OF CD4+ ENUMERATION TECHNOLOGIES
COMPILED BY A JOINT UNICEF/UNAIDS/WHO/MSF PROJECT, JUNE 2005
Parameter
Double - Platform
S I n g l e - P l a t f o r m
Volumetric Bead-based
Instrument
Flow cytometer
Flow cytometer
Flow cytometer
Manufacturer
Partec GmbH (Germany)
Becton-Dickinson (USA)
Coulter Corporation (US
PartecGmbH Germany)
GuavaTechnology(USA
Becton-Dickinson(USA
CoulterCorporation(US)
Cost in US$
20 – 95,000
20 – 70,000
20 – 95,000
Cost Reagent
per test US$
2 – 11
1 - 10
3 – 25
Specimen
Whole blood
Whole blood
Whole blood
Results
AbsoluteCD4/CD8 count CD4%/CD8% in lymphcts
CD4/CD8 ratio. B and NK cells are possible
AbsoluteCD4/CD8 cont
CD4%/CD8% in lymph
CD4/CD8 ratio. B and NK cells are possible
AbsoluteCD4/CD8 cont
CD4%/CD8% in lymph
CD4/CD8 ratio. B and
NK cells are possible
Samples/day
Up to 250
Up to 250
Up to 250
Advantages
One tube assay possible
without QC problems
EQA (External Quality Assessment) available
No need for extra beads or hematology analyzer.
Protocols for aged
samples available
EQA available
No need of hematology analyzer. Protocols for aged samples available
EQA available
Disadvantages
Needs use of hematology
Analyzer. More prone to clerical errors. Fresh samples needed in order to obtain absolute counts
Internal QC for pipetting needs 2 tubes assay. Instruments not yet proven in an independent multi center study
Internal QC for pipetting needs 2 tubes assay. Beads are expensive and require careful handling
N.B. Partec claims that some of the characteristics of their CyFlow machines on this table were erroneous and/or missing, and WHO corrected those errors in the August 2005 Revision.
The above table, in whose compilation WHO fully participated, shows that:
(i) WHO fully recognizes the Partec CyFlow technology, or else WHO would not be a party to this compilation which has included CyFlow technology. I do not think this can be termed WHO validation or certification or approval of the Partec CyFlow technology though.
(ii) Such honest compilations by reputable organizations like these, could not possibly hide any shortcoming of any one of the technologies they have listed, or better still those technologies having any flaw would not be included in these lists.
(iii) So the alleged shortcoming such as: "less precision when assaying low CD4 count specimens of <200 cells/μl)”, if they were exhibited by any of the flow cytometers in column one of the table shown above, it would have been recorded in the “Disadvantages row”. Since there is no shortcoming recorded in the Disadvantage column, then it is correct to assume that none of the flow cytometers shown in this table, including the CyFlow machines, possess such a disadvantage.
Bunching together all those CD4 enumeration technologies above ostensibly means that each technology listed is as good as the other, amnd all of them have faults worthy of note.
(c) Because of this joint recognition, WHO and many other International Aid Agencies have, been willingly purchasing CyFlow CD4 cell counting machines many times, something they would never do had CyFlow machines been proven to have any grave faults. The following are a few of the examples of such purchases:
(1) WHO, Supply Division, Geneva, Requisitioner: WHO, AFRO-BRAZZAVILLE, CONGO, date of approval of order 29/06/2006, ordered 2 units, as WHO donation to Harare, ZIMBABWE (see Annex 2.28).
(1) UNICEF: Supply Division of UNICEF, Copenhagen, Denmark,ordered one unit on 11/10/2006 for Sanaa,YEMEN, a Portable Desk Top CyFlow SL-3. (see Annex 2.25)
(2) WHO: Supply Division, WHO, Geneva, ordered three units of CyFlow FL-1, on 01/05/2006, for Khartoum, SUDAN (see ANNEX 2.26).
(3) WHO: Supply Division, WHO, Geneva, ordered two units of Cyn Fl;ow FL-1, on 25/11/2005, for Cairo, EGYPT (see ANNEX 2.27).
(4) WHO: Supply Division, WHO, Geneva, ordered one unit of CyFlow FL-1, on 14/02/2006, for Brazzaville, CONGO (see ANNEX 2.28).
(d) As it was stated clearly in (a) above, since WHO itself has no laboratories with which to do studies. Therefore WHO has never done any multi-center studies of CyFlow or any other CD4 machine by itself. For the same reason, any multi-center study does not lose the right to be called a "multicenter study" simply because WHO has not physically entered a laboratory to participate in that joint study with one or more of the other laboratories. Therefore, the question to address is whether there are any multi-center or international studies done involving the Partec CyFlow machines. And the answer is yes, there are hundreds multi-center and international studies, in some of which famous international research centers like USA based CDC (Center for Disease Control), or famous Universities like Stanford or Havard of USA, have participated (see Annex 2.58; 2.44; 2.29-40). WHO cannot go round participating in, supporting, or coordinating all such multicenter studies. But for the same reason, WHO cannot possibly disown Partec CyFlow or any of its partners in the joint studies, or indeed deny recognition to its international multi-center studies on the pretext that "WHO has not done a multi-center study of CyFlow". Therefore, CyFlow did participate and is still participating in several multi-center studies whose results are compared with the results of other CD4 counting machines such as those which are manufactured by BD (Becton-Dickinson), and researchers often found that there was good correlations of results between them.
► And the Stanford University/Zimbabwe University Study (see Annex 2.29) had this to report:
"Objective: To evaluate CyFlow cytometry using CyFlow SL machine of Partec,
Munster, Germany for enumeration of Absolute CD4+ T-lymhocytes in subtype C HIV-1 seropositive subjects, and using FACSCount of Becton-Dickinson, San Jose, CA, USA, as ‘predicate method’.
- Results: Using linear regression analysis, there was a very strong correlation
(R = 0.991), between the overall CD4+ T-lymphocyte counts obtained by FACSCount and those obtained by CyFlow.

- Conclusion: The CyFlow counter is as accurate as the FACSCount in
enumerating Absolute CD4+ T-lymphocytes in the range 1–1,200 cells/µl. CyFlow cytometry is relatively affordable, easy to use technology that is useful not only in identifying HIV seropositive individual who require ART, but also for monitoring immunologic responses to ART.
- Data analysis was also stratified according to the range 0 - 250 (in developed
countries the cut off point is not 200 as in Tanzania, bur 250 or even 300);
251 – 500; and 501 – 1,200 cells/µl of absolute CD4+ T-lymphocyte counts,
to determine any range-dependent differences between the two methods.
- Cost- currently in Zimbabwe, the cost of CD4+ T-lymphocyte count is US$56.
This cost is revised upward quarterly. According to the manufacturer of CyFlow, a CD4+ T-lymphocyte count using their machine and reagents should cost only US$2.50 (2 Euros). Although the purchasing price of FACSCount and CyFlow machines are comparable (US$30,000 – 50,000), the FACSCount reagents are more expensive than those for the CyFlow. The CyFlow counter also has a higher throughput, and as many as 200 specimens can be run per day, making it ideal for use in Zimbabwe, a country with one of the highest prevalence of HIV globally."
► The Results, Observations, and Conclusions of these Multi-Center Studies were similar in extolling the close correlations between the CyFlow and the FACS machines, as shown by the following example of a Joint Senegal and Belgium Study (see Annex 2.30):
"Conclusion: Direct volumetric and bead-based single platform measurement on the CyFlow showed good correlations with gold standards cytometers. The precision of volumetric measurements on the CyFlow can be improved by including a time versus fluorescence and a time versus total cell count plot as an additional internal quality control measure."
► Rwanda/Luxemburg Study is yet another International Multi Centre Study with a lot of user satisfaction and praises. However, its summary points to the challenges facing vulnerable MoH officials (allowing some machines while banning others for no scientific reasons) in some countries including Tanzania:
"Summary: The scientific evidence shows that the CyFlow has been validated without any doubt by independent international experts, published in worldwide leading scientific journals under peer-review from renown experts in this science…Nevertheless, without any, the MoH in Rwanda forbade to use CyFlow in the country, and refused all requests to give reasons and data on which they based the ban. The only evidence existing is the two scientific studies both of whichshow that the CyFlow performance is superb."
► Joint Cambodia/Belgium Study, in Intrnational AIDS Society, 12/07/2004.
► Joint Italy/Italy Study, published in International AIDS Society, 12/07/2004.
► Joint Thailand/Atlanta Study, published in International AIDS Society, 12/07/2004.
► Joint Germany/Bukirna Faso/Cameroon/Cambodia Study, published in
Antiviral Therapy, 9:395405.
► Joint Havard/Boston/Nigeria Study, published in Clinical and Diagnostic
Laboratory Immunology, Jan 2005, p. 224-227.
► Joint Luxemburg/Belgium/Malawi Study, published in Royal Society of Tropical Medicine and Hygiene, 09/04/2006.
► Multicentre Studies, Senegal, in J.Acquir ImmuneDefic Syndr, May 2005.
► Joint CDC (Centre for Disease Control/Zimbabwe, published in Clinical Vaccine Immunology, 31/01/2007.
► Let us now quote the latest study: "Evaluation of the CyFlow SL_3 system against the FACSCalibur system in the determination of CD4 absolute counts and percentages in the immune monitoring of HIV infected patients in Zimbabwe", published in Clin Vaccine Immunol, 31/1/2007, by Manasa, J., et al, of National Microbiology Reference Laboratory (NMRL), Zimbabwe; African Institute of Biomedical Science and Technology; Connaught Clinic; CDC, Zimbabwe:
"A single platform volumetric flow cytometer, the Partec CyFlow SL_3 was evaluated against a BD FACSCalibur/Sysmex XT1800i dual platform, in the measurement of CD4+ lymphocytes, total lymphocytes, and CD4% in whole blood samples monitoring the immune system of HIV/AIDS patients. Statistical analysis for precision, correlation, and agreement were performed. Coefficient of Variations (CVs) of 5.8, 4.6, and 3.9% were obtained for low, medium, and high CD4 cell counts, respectively, using the CyFlow SL_3; and the CVs of 3.7, 4.0, and 0.94 were obtained for the same categories using the BD FACSCalibur. Significant correlations (p<0.005) between the two assays for CD4 counts, total counts, and CD4% were obtained, correlation coefficients (R(2) of 0.99, 0.96, and 0.95, respectively (n=229. USING THE Bland Altman plot, mean bias of -18; cell/µl (95% CI:-91 to 54 cells/µl), -0.85% (95% CI: -3.6 to 2 cells/µl), -36.8 cells/µl (95% CI: -477 to 404 cells/µl), were obtained in comparing CD4 counts, CD4%, and total lymphocyte count respectively.
Effects of sample age on the three parameters were also analysed by comparing results from the same samples analyzed at 6, 24, and 48 hours after sample collection, and the composition between different time points, for the same machine, and across machines for all the time points, had R(2) values greater than 0.90. This data showed that the Partec CyFlow SL_3 assay method is comparable to the BD FACSCalibur/Sysmex XT 1800i dual platform method, in the measurement of CD4+ cells, total lymphocytes, and CD4%, for the purposes of monitoring of HIV/AIDS patients."
► Multicenter Studies in Thailand, in International AIDS Society, 15/08/2006.
(f) Yet another study which compared the CyFlow FCM (Flow Cytometer) and the Guava PCA (Personal Cell Analysis), captioned as: "Evaluation of two volumetric flow cytometers for the quantitation of CD4+ T cells in Thai HIV-1 infected patients", by Phuang-ngem, Y., et al, published by International AIDS Society, on 15th August 2006 (see Annex 2.40).
This joint study determined blood samples of Thai patients in parallel by four methods: the new single platform volumetric methods, CyFlow Green FCM, the Guava PCA system, and the two standard Single Platform bead-based method, TriTEST/TruCOUNT tube using a FACSCalibur FCM and two colour FACSCount system. Correlation and Agreement were analyzed using linear regression and Bland-Altman analysis.
Conclusion: The volumetric CyFlow Green FCM and the Guava PCA system performed well relative to the two standard bead-based systems. Use of these new technologies could make CD4+ T cell enumeration more affordable in Thailand and other resource-poor settings."
Sources of the Theory of "Imprecision" of the the CyFlow® and Its Spreading
(g) At this juncture, this Report wishes to show how some of the reputable International Organizations’ officials can and do take sides and extol or criticize certain equipment willy-nilly, without any scientific basis. For example:
In the Interview with Dr.Faustine Ndugulile, the then Tanzanian MoHSW Head of Diagnostic Services (see Annex 1.3.10), told the Probe Team about WHO’s "low" opinion of CyFlow machines, and promised to show us confidential E-mails concerning this CyFlow issue, on condition that we did not quote them nor disclose their source!
Shown hereunder, are the excerpts from these revealing E-mails (appended herewith as ANNEX 2.40) exchanged between Dr.Gaby Vercauteren of WHO Essential Health Technologies (EHT) Division, Geneva, and Dr. Faustine Ndugulile of the MoHSW Diagnostic Services Department. Earlier, in a limited circulation E-mail, Dr. F.Ndugulile had leaked the information to Dr.Vercauteren that Partec’s CyFlow has less precision when assaying low CD4 cell count samples (of < 200 cells/µl). These E-mails make very interesting and revealing reading (the highlighting of its portions is my own emphasis of the treacherous untruths):
"To Dr. Ndugulile, thank you for your message which provides useful information regarding the performance of the CyFlow instrument. I will check with our procurement services what is happening. When asked for advice on the CyFlow instrument, I have always mentioned that data are conflicting. And as the company (Partec) has not been willing to participate in an independent WHO validation, we are not in a position to buy their equipment (CyFlow machines). Early 2006 WHO will again officially contact the manufacturers of the CyFlow counter and offer them the opportunity to participate in such a comparative study. Most probably you are aware of the letter Dr.Rainer Brandl from the Evangelical Lutheran Church in Tanzania, Bulongwa Lutheran Hospital sent to Dr. Willy Urassa, which I am attaching the letter and related correspondence….
I would like to suggest that you may wish to discuss the importance of quality assurance programmes of HIV testing and CD4 measurements…. with the WR (WHO) office (there was/is an HIV/AIDS country officer) and the CDC office (Dr. Stefan Wiktor). Please accept my best wishes 2006. Dr.Gaby Vercauteren."
~ When this WHO’s Dr Vercauteren was E-mailed twice to clarify these points, he never responded. Nor did a WHO officer in the Dar office respond to a similar request of clarification as to whether Partec is still declining the offer to participate in a comparative study, and to tell me if it is true that WHO was not procuring any CyFlow machines at all and why. Also we were not able to see Dr. S. Wiktor of CDC nor Dr. Will Urassa mentioned herein.
~ Of course this WHO EHT senior official’s E-mail to Dr. F.Ndugulile of MoHSW has quite a few flabbergasting untruths, including:
(i) If the CyFlow technology was giving "conflicting data" as Dr.Vercauteren said, WHO (with UNICEF, UNAIDS, and MSF) would never have selected and compiled those tables of "CD4+ Cell Enumeration Technologies" including the CyFlow technology, shown in No. (a) above as "Sources and Prices of Selected Diagnostics - Summary of CD4+ T-cell Enumeration Technologies" (see ANNEX 2.23 appended herewith).
WHO would have at least mentioned CyFlow’s "conflicting data" in the "Disadvantages" row of those tables.But it had no shortcoming worthy of mention.
(ii) This "Summary of CD4+ T cell Enumeration Technologies" is proof that WHO and other International Organizations not only do recognized CyFlow technology, but also confirmed that the Partec CyFlow machines are comparable to the FDA recognized USA made BD FACSCounter, FACSCalibur and FACScan machines, as numerous conclusions from various multi-center evaluations show.
~ For example in the Zimbabwe studies which deeply involved the USA University of Stanford conclude that:
"Comparative studies between the Partec CyFlow SL_3 using CD4% reagents and the BD FACSCalibur/Sysmex dual platform using the Multi Test, for the determination of absolute CD4 counts and CD4% for immune monitoring of HIV/AIDS patients, demonstrated very good correlation and agreement between the two methods. The CyFlow can also safely and confidently be used for the same purpose. … These findings confirm other results published from the studies in South America, Asia, and West Africa. (see papers appended herewith as ANNEX 2.29.1, 2.29.2, and 2.39)."
~ Another example is the Rwanda-Luxemburg joint studies (See ANNEX 2.31) which conclude as follows:
"CD4 determination using volumetric counting on the CyFlow and bead based measurements on the FACSCount showed correlation on this cohort (R2=0.914). Two samples did not yield any results with the FACSCount (CyFlow count=69 and 711/mm3)."
~ Another example is the Senegal-Belgium studies on "Evaluation of an affordable instrument for absolute CD4 counting in resource-poor settings against two reference clinical flow cytometers" which conclude that:
"Direct volumetric CD4 T cell measurements on the CyFlow correlated very well with the CD4 counts obtained by gold standard cytometers like FACSCount (R2=0.953) and TruCount analysis on FACScan (R2=0.961). In addition , bead-baseda absolute CD4 measurement on the CyFlow correlated highly with those obtained on FACScount (R2=994)."
~ The following conclusion of the Stanford University – Zimbabwe joint studies goes as far as puncturing the balloon being flown around by Dr.Ndugulile /Dr.Vercauteren that CyFlow machines fail to separate the lymphocytes from the monocytes and therefore give erroneous inflated CD4 counts.The studies say that:
"Using linear regression analysis, there was a strong correlation (R=0.991) between the overall CD4 T-lymphocyte counts obtained by FACSCount and those obtained by CyFlow. When data analysis was stratified by study groups, there was a strong correlation between the FACSCount and the CyFlow CD4 T-lymphocyte counts, from subjects in the 3 independent studies. Subtype C resistance (R2=0.987), Duke ART (R2=0.980), and KS (R2=0.994).
Using the Bland-Altman plots, the overall absolute CD4+ lymphocytes obtained by the two methods were in excellent agreement (mean difference 1.21,95% Confidence Interval (CI): -2.1 to 3.3).
~ For the CD4+ lymphocyte range of 0-250, the CD4 counts obtained using FACScount were also in good agreement with those using the CyFlow machine (the mean difference = 2.6 cells/µl, 95% CI, -1.1-6.3)
~ Similarly, for the 251-500 range (the mean difference = 1.0 cell/µl, 95% CI, -3.7 to 5.6); and
~ Also, for the 501-1200 range (the mean difference = 0.29 cells/µl, 95% CI, -8.1 to 8.7), CD4 T-lymphocytes range, good agreement was observed.
Conclusion: The CyFlow counter is as accurate as the FACSCount in enumerating absolute CD4+ T-lymphocytes in the whole range of 1 – 1200. And, CyFlow counter is relatively affordable, it has easy to use technology that is useful not only in identifying HIV seropositive individuals who require ART (Anti-retroviral Therapy), but also for monitoring immunologic responses to ART."
~ This should dispose of the unsubstantiated claims of "conflicting data", once for all, and hence it would justifiably be said that:
(i) The CyFlows are not imprecise for CD4 T-lymphocyte range of <200 cells/µl.
(ii) The CyFlow data are not conflicting.
(iii) The CyFlow manufacturers, i.e. Partec, are not unwilling to participate in
independent WHO or any other validations. And, in fact:
(iv) WHO does purchase regularly various types of CyFlow machines from Partec, which they would never do were it true that CyFlow has conflicting data. And:
(v) In fact, as it will be shown hereunder that the facts on the ground are quite opposite in the sence that, it is the WHO official Dr.Vercauteren who keeps on refusing to cooperate with Partec, and even declined to recognize (validate) 27 multi-center studies involving centers in various African, Asian, and European countries like Belgium, Italy, Germany, USA, and France (See ANNEX2.50.3 and 2.50.4 appended herewith). These 27 reputable and many other research centers in Europe, Asia, and Africa cannot be lying and colluding to hide the fact that CyFlow technology gives imprecise and conflicting data.
~ In this last instance, Partec’s letter of complaint to Dr.G.Vercauteren himself (concerning his allegations against CyFlow) and copied to WHO’s ADGs (WHO Assistant Director Generals): Dr.Chow and Dr. Lapakhin), added the following conclusion made by MSF (Medicenes Sans Frontieres) (see ANNEX 2.50.1):
"Also MSF evaluated the CyFlow system very successfully. The conclusion of MSF resulting from the field evaluations state: ‘After being trained , local district laboratory staff found the CyFlow machine easy to operate and robust under field conditions. The CyFlow counter produces excellent results in a field setting, and can be installed in a District Hospital setting. It is ideal for patients’ monitoring in the context of scaling up ART in resource-limited settings.’"
It is inconceivable to even imagine that all there esteemed International Organizations like UNICEF, UNAIDS, and MSF, including WHO itself could willingly gang up to deceive everyone by saying that Partec CyFlow technology produces excellent data in field settings, and can be used in even District (small) Hospitals, of which the DB FACSCount technology for instance is incapable. And who would bribe or influence such renowned Organizations – Partec?
(e) Now, let us give some classic examples of how, for better or for worse, some MoHSW and MUCHS personnel swallowed such ‘limited circulation mails’ information hook-line-and sinker, without verifying their logic or authenticity. Some must have done it in return for rewards or promises of rewards. Some to save their faces and those of their fellow "club"-members. Yet others swallowed these propaganda because it was better that the alternative of washing laundry in public, and "collective responsibility" as the jargon goes:
A(i) Dr.Berege, the MoHSW DHS and Chairman of the PHLB, signing for the PS, sent an 18 pages "Report on Evaluation of Partec CyFlow System Machine for CD4 Cell Count" dated 24/10/05 (see ANNEX 2.14), pointing out the following:
"(1) The Board discussed and approved the Report on 20/10/2005.
(2) A total of 240 samples were tested on the Partec CyFlow machine and
FACSCount machine. FACSCalibur flow cytometry was used as a
Reference Method. The CD4 T cell counts were counted and the results categorized as less than 200 counts (low), 200-500 counts (medium), and above 500 (High)…. This means that the Partec CyFlow machine has low
accuracy and low precision with low CD4 count (less than 200) which
amount to about 48%.
(3) Other observed shortcomings regarding the equipment were:
» Sample need to be stored at 4oC overnight.
» Daily Internal Quality Control not incorporated in the machine.
» Local Technical support not available.
Conclusion: The Report showed that the Partec CyFlow machine system
has lower precision than the FACSCount machine for counting CD4 T
cells categorized under < 200 cells counts, but fairly with good comparison
results for counting CD4 cell categorized under counts 200-500 and above.
Deliberations: After discussion, the Board decided that:
» The Partec CyFlow machine needs to be improved by the manufacturer in
order to rectify the identified shortcomings.
» Due to aforementioned shortcomings, it is not advisable to use the
machine in Lower Hospital settings (Dispensaries, Clinics, Rural
Health Centres, and District Hospitals).
» The machine (CyFlow) can only be used in Referral Hospitals where
good Quality Assurance can be conducted and monitored.
» Attached please find the detailed Report.
Dr. Z.A. Berege. for Permanent Secretary"
A(ii) The above are verbatim quotations of Dr. Berege’s Report, which he signed on behalf of the PS, after chairing the PHLB which thoroughly deliberated uponthe Report on 20/10/2005. If any of the statements of this top heavy official are flawed, then the whole Board too is flawed. Unfortunately, a rapid glance shows that some of these conclusions are at best uninformed, or at worst outright incorrect. Here follow the corrections:
►The question of the imprecision of the CyFlow while assaying low CD4 count samples (of <200 cells/µl) due to its failure to differentiate between monocytes and lymphocytes has been explained many times, although its theory is simple: Either the evaluators failed to read and observe the instructions of the CyFlow Instrument Manual, Application Notes, and Inserts, and so failed to switch back to the pre-defined instrument setting and detection channel after the instrument setting was wrongly set accidentally or maliciously by someone, and so gave erroneous or fictitious data.
› In order to avoid the imprecision caused by failure to separate the monocytes
from the lymphocytes, the 4 pages Partec Application Note (appended herewith as ANNEX 2.15) instructs the following SOP (Standard Operating Procedure):
"Set an analysis range for the CD4+ T-cell peak using the cursors (and refer to CyFlow SL 3 Instrument Operating Manual) as shown in Fig. 1. There should be a clear differentiation (seperation) between the main peak of highly fluorescent CD4+ T-cells and dim fluorescent CD4+ monocyytes."
If the evaluators did exactly as instructed and increase or decrease the gain value of the FL2 parameter in order to set the CD4 T cell peak into the second decade, they should have succeeded to separate them as
›› Another possible failure to separate them is the use of wrong instrument setting which leads to the use of the wrong detection channel, which would definitely give erroneous results. This will be discussed further later on now that the Hard Disk of the returned CyFlow’s PC has had its CD4 counts reprinted – both while the instrument setting is wrong, and when the setting is correct. It was sadly pitiful MUCHS refused to include full data and print-outs of some if not all the 240 assays, which could tell everyone the root cause of the imprecision.
››› Another cause of erroneous results may be the non use (or not reading properly) of reagents inserts like CyTecs CD4 Easy Count Kit (see ANNEX 2.42 herewith appended) which instructs clearly to store these reagents in the fridge (in the dark and at 4oC) before use (which Dr. Berege criticizes and calls it a shortcoming!) may lead to erroneous results too. Many flow cytometer reagents including some FACS cytometers’ carry such a stipulation; and even if the others don’t, CyFlow cytometer’s insert instructs so.
›››› Yet another probable cause of erroneous results may be the over 8 months unattended storage of the CyFlow and its reagents at DIA and at MUCHS, in so bad condition that the CyFlow tubes grew fungus. Surely using 8 months OLD reagents in an assay that compares its assay results with reference methods whose reagents were used fresh is far from SOP (Standard Operating Procedure) and perforce it could lead to erroneous results.
››››› Finally, if Partec’s allegation is true that the MUCHS evaluators kept on using over 8 hours old blood samples on the CyFlow, in protest (!), results are likely to be like the samples, viz imperfect.
► With regards to QC (Quality Control), a glance at the Instrument Manual or other numerous literature on flow cytometry would show that Daily Internal Quality Control is a feature commonly incorporated in most if not all CyFlow machines, including the CyFlow SL Blue. MUCHS were taught how to do this by the Nairobi based Partec Engineer, Mr. Khisa Joseph, during his two visits to MUCHS and the 3 day training he held for MUCHS Technicians. When Partecs Chief Engineer Dr. Volker Ost visited MUCHS and serviced the CyFlow for 2 days amid the shock of finding out that the instrument had not as yet been touched, he carried out several Internal Quality checks. This is a case of misinformation!?
►The "shortcoming" of non-establishment of local support is very strange. Where does it stipulate that this is a prerequisite demanded by PHLB? Didn’t Mr. Khisa Joseph, the Partec Application Specialist Engineer based in Nairobi come all the way to MUCHS twice to install the CyFlow and spent 3 solid days training Technicians here and later service the instrument? Do we all remember when MUCHS left the CyFlow derelict for 1.5 months at DIA (Dar es Salaam International Airport) and a further 6.5 months at MUCHS without even cleaning it, until its tubes grew fungus and so its monitor failed to display? Who did MUCHS summon and he came immediately and rectified it immediately?
And honestly, what was the point and logic of Partec establishing a service center in Tanzania before its CyFlow was registered, and when the Nairobi and the South African service centers operate so satisfactorily? Doesn’t anyone know that of the 40 or so FACSCount machines currently scattered all over Tanzania, over half of them are non functional most of time in spite of Biocare Health Products Ltd. having been contracted to service them all the time? Admittedly some of the FACSCounts remain non-functional most of the time because of its too expensive reagents – yet another disadvantage of the FACS machines over CyFlow machines.
► It was astonishing and interesting of Dr.Berege’s Evaluation Report letter of 20/10/2005, to end up by declaring that:
"the CyFlow machine can only be used in Referral Hospitals",
despite its shortcomings which Dr.Berege’s catalogued earlier in his letter. It is interesting because the uses of FACSCounts and FACSCaliburs are also restricted to Referral Hospitals only but for a different reason of intricacy of their technology which an ordinary district or rural Technician cannot comprehend and operate them. But as MSF (Medicenes Sans Frontieres) concluded above, CyFlow machines were easy enough for even rural Technicians to operate – one of the many good characteristics of the CyFlow machines over the BD FACS machines.
► Despite all the above arguments in favour of CyFlow machines, most senior officials of MoHSW and MUCHS have been taking turns to extol FACS machines and criticize CyFlow machines bitterly, even long after its final Evaluation Report was released on 20/10/2005. Let us recap:
B(i) First Dr.Z.Berege on 24/10/2005 issues an 18 page CyFlow Evaluation Report, after which one would have thought the CyFlow case is closed, at least from MoHSW and MUCHS’ side. But it could not be left like that – not when a grave mistake was committed by the Chairman of the PHLB, Dr. Berege and his Board exempting CyFlow and allowing the CyFlow to operate in Tanzania provided that its use is restricted to Referral Hospitals only. Naturally this incensed many adversaries in the MoHSW and MUCHS, and made them to come out openly and condemn the exemption of CyFlow, and in so doing others added one or more "shortcomings" of Partec and/or their CyFlow, long after the final Evaluation Report came out:
B(ii) On 19/06/2006, 8 months after the Board (PHLB) and its Chairman had released a final CyFlow Evaluation Report on 20/10/2005, a "Special Meeting" was convened to discuss the use of CyFlow. This "Special Meeting" was "re-inventing the wheel" as it were, or other legally inclined persons would say that this was a matter of "trying the accused twice for the same offence", which is wrong legally and ethically! This special meeting said many things – repeating some and adding some which were not in the final Evaluation Report:
► "On the Special Meeting’s point No.3.1(ix) that: The actual evaluation started in July 2005. The causes of the delay include: Failure of the machine suppliers to provide the required reagents and supplies in time." The answers to this are:
› If this is imputing that on 15/11/04 the CyFlow was not del ivered by Mr.Khisa
and Dr. Mbawala together with the "Calibration Beads", we have already shown
clearly that the Packing List/Check List (see ANNEX 2.11 appended herewith)
the CyFlow instrument came with a complete set of reagents, including the
"Calibrating Beads". Thus, Prof. Lyamuya’s letter was not correct to declare emphaticaly that the CyFlow "Calibrating Beads" were missing, unless he could explain how the Nairobi based Partec Engineer Mr.Khisa was able to install the CyFlow and use it to train Technicians for 3 full days, if the calibration beads were truly missing. There is therefore no tangible excuse for the delay caused by "missing" reagents.
» And if this "failure to provide all the required supplies in time" was referring to
the reagents for reference method whose delivery caused another 6.5 months
delay, Partec did not "fail to provide" and it was certainly not Partec’s fault,
because it was agreed that MoHSW was to provide these.
›» The reason for the delay which the Special Meeting called the "break down of
the machine" had no excuse either because it was caused by MUCHS and
MoHSW carelessly leaving the CyFlow unattended and unused for 1.5 months
at DIA, plus another 6.5 months of due to waiting for reference reagents. This
carelessness caused fungi to block the CyFlow tubes and prevent its PC monitor
to display. Like all the above excuses, this was the fault of MoHSW /MUCHS
for which Partec cannot bear the blame, and therefore Partec has the right to call
these 8 months a "deliberate delay".
► "On the Special Meeting’s point No.3.1(xiv) that: The final Evaluation Report said that the results indicated for CD4 levels below 200, the CyFlow misclassified 48% of the samples." The answer is:
› If the CyFlow truly misclassified, then any of the 5 or all the causes mentioned
above, which were occasioned by some MoHSW/MUCHS officials’ negligence
and failure of the evaluators to follow the SOP (Standard Operating Procedures)
"in protest", could apply, and the fault would not be Partec’s nor CyFlow’s.
► "On the Special Meeting’s point No. 4.0 CONCLUSION AND WAY FORWARD, which stated that: The Chairman of the "Special Meeting" requested Dr. B.P.Mbawala, who was invited to attend this Special Meeting as Partec’s representative, to:
(a) Submit written evidence of the WHO Multi-Center Evaluation, and
(b) Submit a list of other countries using CyFlow CD4 machine other than Africa."
›(a) This claim which keeps on resurfacing over and over again, is strange
especially because, as we said earlier, WHO does not usually enter a laboratory
itself and do solo or multi-center studies or evaluations of CyFlow or
FACSCount or any other machine or Kit. But WHO can and does coordinate,
equip, or recognize/validate good studies conducted by one or more centers.

»(a) In order to obtain WHO validation/recognition, Partec sent to the same Dr.G.
Vercauteren of EHT Department, WHO, Geneva, 27 such multi-center studies
(see ANNEX 2.45.4 appended herewith), which use CyFlow and other machines
but Dr.Vercauteren declined even to reply (see Dr.R.Godhe’s letters to Dr.
Vercauteren copied to WHO ADGs, ANNEX 2.45.1, 2.45.2, and 2.45.3).
›»(b) As for enumerating non-African countries which use the CyFlow machines,
earlier in this Report, we gave a list and documents of 11 multi center studies
(see ANNEX 2.29 - 2.40 appended herewith). I am herewith now giving a
further list of multi-center clinical validations/studies on the CyFlow, which
covered centers in and out of Africa, e.g. Europe (Germany, Belgium,
Luxemburg, France, and Italy), and Far East and Middle East (Thailand, and
Cambodia), and USA, as well as in Africa (Cameroon, Nigeria, Burkina Faso,
Uganda, Malawi, and Rwanda). Papers for these studies were read in all the
International Conferences on Aids, and published in Scientific Journals of
repute. (see ANNEX 2.44 herewith appended).
››››(b) The Special Meeting’s demand that Partec should "supply a list of other
countries which use CyFlow CD4 machines other than Africa" is too petty to say
the least. So, once this list is produced, what then? Would the CyFlow final
Evaluation Report being contested be withdrawn and/or rewritten? Besides, what
if Partec has opted to sell its CyFlows to Africa only (where Nigeria alone has so
far procured over 140 CyFlow machines) – would that be a sin, or is it not
possible? Why not ask why FACS machines are not so common in USA and in
some countries "friendly" to USA too?
More importantly, hasn’t it dawned on anyone that Africa is a developing
country, and it is in developing countries where the prevalence of the HIV/
AIDS pandemic is highest globally, and so it is not surprising to find most
of HIV/AIDS machines and Kits in Africa than in developed countries.
►All this notwithstanding, the simple and obvious answer is that, Partec’s CyFlows have been in use in and outside Africa for many years. Partec and its CyFlows have done several multi-center studies with countries in Africa and outside, which possess and use CyFlow machines, in: USA, Europe (France, Germany, Belgium, Italy, Luxemburg), as well as in Asia, the Far and Middle East (Cambodia, Thailand, Yemen), etc, all using CyFlow machines in comparison with large flow cytometry systems like BD FACSCalibur, Coulter EPICS, Partec PAS, etc. In fact, in contrast to FACSCount, CyFlow has been tested against all flow cytometry techniques ever established in the scientific field.
C(i) As if the final CyFlow Evaluation Report of 20/10/2005 was not actually final, some people deemed it fit to continue debating the CyFlow long after its final Evaluation Report was given. For instance, some MoHSW officials convened a "Special Meeting" on 19/06/2006 (8 months after the CyFlow Report was out) to put the even more final nail in the CyFlow coffin in Tanzania.

But even that was not enough. ~ On 03/07/2006 (half a month after the ‘Special Meeting’), another meeting termed the "Emergency Board Meeting" was held in the MoHSW Library, chaired by Prof. Fred Mhalu, a member of MUCHS staff, because the Board Chairman had to go to Morogoro (and the Meeting could not be held later, in his presence, nor could he reschedule his Morogoro trip for another day), to deliberate on what the newspapers of "This Day" and "Kulikoni" alleged against MUCHS. After discussing the HIV Rapid Test Kits, this "Emergency Board Meeting" made the following decisions concerning the "dead and buried" CyFlow machine:
► "With regards to the Emergency Board Meeting Item No.4.0 ANY OTHER BUSINESS: 4.1 CYFLOW (PARTEC) stating that:
(a) Members revisited the arguments of the Board’s Budget Meeting of 26/06/2006 which deliberated on the use of CyFlow machines, and
(b) Members realized that this machine (CyFlow) is unreliable in counting CD4 below 200.
(c) It was also realized that, centers which possessed CyFlow machines, which were involved in the evaluation of CD4 machines’ performance, have shown poor results,
(d) And in other areas centers have not been able to participate accordingly. After some deliberations, the Board members further agreed that:
(e) The Board should "stop (isitishe)" its decision of 26/06/2006 (which was also the ruling of the Board Chairman’s letter of 20/10/2005 – on the final CyFlow Evaluation Report) that CyFlow should be allowed to be used, but its use is to be restricted to Referral Hospital Laboratories only.
(f) The CyFlow (Partec) machine is not suitable as it is now,
(g) It should be banned immediately, so as to avoid any adverse effects which may befall the patients, because the evaluation which was performed by the MUCHS experts showed that it is unsuitable.
(h) The Board should advise the MoHSW, through AIDS CONTROL PROJECT, to remove all the CyFlow machines, but before their removal, the MoHSW should replace them with alternatives, namely FACSCount!
(i) It was suggested and agreed that "guidance" for performing evaluations of machines (CD4) and Test Kits (HIV) in the country should be completed as soon as possible." coup
»Phew! What substantive accomplishment! What a feat of far reaching achievement these are! And one wonders why the same Board could not come up with all these epic decisions, which was the main goal of convening this many Meetings 8.5 months after releasing the final CyFlow Evaluation Report on 20/10/2005! And what a more convenient way of increasing even further the sale of FACSCount machines and the sale Capillus and Determine Test Kits! And what a coincidence that the supplier of all these is the same Mr. Bharat Rajani of Health Biocare Ltd. of Dar es Salaam who represents Becton Dinkinson of USA!
Obviously this is precisely what the adversaries of Partec’s CyFlow always wanted – they abolished the permission for CyFlow to be used in Referral Hospitals, and banned/removed all CyFlow machines, and of course replace them with FACSCount machines. What could be better than this unchallengeable monopoly of the FACS machines! Bulongwa Hospital which possessed two CyFlows (which were working perfectly) was the first to get a FACSCount to replace their CyFlows! I am not sure if they stopped using their 2 CyFlows which are far more user friendly, cheaper, versatile, robust than the FACSCounts. Let us peep at the mighty belated Emergency Board Meeting decisions, one by one:
›(a) To the conveners of that "Emergency Board Meeting", the total damnation
of the CyFlow must have been so important that they had to squeeze it in the
Budget Meeting, although it was finalized 8 months back by the final CyFlow
Evaluation Report of 20/10/2005, and in the "Special Meeting" of 19/06/2006.
Could this be result of the "pressurization" mentioned in the Term of Reference
No. 6? Or was it the promise of "reward/s" or both?
›(b) The unreliability of the CyFlow when determining samples of low CD4 counts
of <200/μl has been answered too often. It is either fictitious or a disregard of
SOP (Standard Operating Procedure) which led to a wrong instrument settings
/wrong detection channel and ultimately wrong results.
›(c & d) What is said in (c) and (d) above is untrue, for no CyFlow Evaluation
other than that of the CyFlow Blue os 20/10/05 has ever been done in Tanzania.
›(e, f, g, and h) This unfortunate decision of the "Emergency Board Meeting" of
"withdrawing (isitishe/isimamishe)" the earlier Board’s decision "to permit the
CyFlow machines to be used in Tanzania’s Referral Hospitals only", and
especially the decision to ban and remove all the CyFlows from Tanzania, so as to give sole monopoly to FACSCounts is stupendous to say the least.
As the former Hon. Minister of MoHSW Mrs. A.Abdallah rightly cautioned about giving monopoly to a single person or firm to supply a vital item, the monopolizing firm will end up reneging on even the few simplest commitments it first made. True enough, well over 50% of the FACSCount machines in Tanzania are non-functioning all the time due to lack of the contract services promised, and/or too expensive reagents.
► The stopping (withdrawal) of one of the decisions of the PHLB (which allowed the CyFlow machine to be used in the Tanzanian Referral Hospitals) was rather bizarre and an astute tactic of effectively allowing Partec to supply only about 20 CyFlow machines (in the 20 regions of Tanzania) which are affordable, versatile, easy to use and service, and robust, while letting Biocare Health Products Ltd./Becton-Dickinson company supply over 200 expensive, not easy to use and service, FACSCount machines to District Hospitals and Health Centers in the country. A Board that one day makes up one decision, and 8.5 months later alters that decision and replaces it with an even more flawed decision, is no Board at all.

›› As if to confirm that the current Board is weak, I do not think it has published that "guidance" for the equal systematic evaluations of all HIV/ AIDS hospital supplies, without fear or favour, and of course no other CD4 cell counting machines, including all these 40 or so FACS machines have been given the stringent evaluation such as the CyFlow Blue underwent. If any of them passed any evaluation in any Reference Center in Tanzania, MoHSW/PHLB would not hesitate to give anyone their PLHB Registration number and even their final Evaluation Report as it did for the CyFlow Blue.
► (2) Let us now recapitulate:
(a)The final CyFlow Evaluation Report was given on 20/10/05. This was not final.
(b) On 12/6/06, the CMO, Dr.Gabriel Upunda, instructed the PHLBoard to
advise MoHSW on how it should treat these CyFlow machines(ANNEX 2.46).
(c) The PHLB Registrar sent the CMO PHLB’s reply (ANNEX 2.47) that:
› (1) The decision of the 27th Board Meeting (and the Board Chairman’s final
CyFlow Evaluation Report letter) is still correct that, the CyFlow machines
should be used in Referral Hospitals.
› We should follow up all the CyFlows in Tanzania, and the results should be
analyed by 27/09/2006, and the MoHSW be informed.
› The Board ordered that no more importation of CyFlows should be allowed.
(d) On 19/6/06, a "Special Meeting" on the CyFlow issue sat (see ANNEX 2.42).
This was not final, perhaps because it did not withdraw the earlier Board
order to allow CyFlow to be used in Referral Hospitals, and didn’t order a
total ban on CyFlows.
(e) On 26/06/06, the Board Budget Meeting discussed the CyFlow. It was not final
(f) On 3/7/06 the Emergency Meeting discussed CyFlow. This too was not final,
although it ordered the withdrawal of the earlier Board order to allow CyFlow to
be used in Referral Hospitals, ordered the removal of all CyFlows in the land, and it banned importations of any more CyFlows.
Clearly this Emergency Meeting’s tough decisions coming over 8 months after
the final CyFlow Evaluation Report, must have pleased MUCHS and some
MoHSW officials very much. Therefore:
D(i) On 17/7/06, the Ag. DHS (Director of Hospital Services), Dr.E.Mung’ong’o wrote a long Minute to the MoHSW PS (see ANNEX 2.48), notifying her that:
►"1.0, Basing on the ‘Emergency Meeting’ of 3/7/06 the Ag. DHS agreed that the
CyFlow machines be banned because experts say they have poor performance."
› If the poor performance is due to inflation of CD4 values for samples of low
CD4 counts (of less than 200cells/μl), the answer has been given many
times that it is likely the evaluators used wrong instrument settings and/or
due to not observing SOP (Standard Operation Procedures).
► "2.0 With regards to expiry dates of the CyFlow reagents having not elapsed:

› We have already said that for reagents which were stored unattended for 8
months and used for evaluation, without refrigerating them at 4oC overnight, in
comparison with reference reagents which were fresh, is definitely not an SOP
and against the instructions of the instrument manuals and reagent inserts.
►"3.0 With regards to other CyFlow machines having entered Tanzania before
the evaluation of the CyFlow SL Blue:"
› If this was an excuse for PHLB not ensuring these too are evaluated, the answer
is PHLB gave the Clearance Certificate for Dr. B.Mbawala’s CyFlow SL Green
to be cleared from DIA and since then he is using it quite satisfactorily although
it has never been evaluated. Furthermore, nothing has been done so far to
evaluate the other 8 or so Cyflow machines located in various parts of Tanzania.
►"4.0 As far as the experience of using CyFlow machines in Tanzania and outside is concerned, the Ag. DHS said that the technology of CyFlow is cheap but it has shortcomings in its performance, and quoted an article published by one researcher Luc Kestens in JAIDS, Vol. 39(1), 1 May 2005, pp 32-37 saying that:
‘Single parameter CD4 gating using a single monoclonal antibody is indisputably
more affordable than any multi-parameter CD4 measurement. But accuracy and
precision may be seriously affected as a result of the interference of monocytes,
particularly in samples with low CD4 counts (<200 cells/μl). Monocytes express
CD4 molecules at their cell surface, and they are not always well separated from
CD4+ T cells in single-parameter CD4 analyses by flow cytometry.’
The Ag. DHS continued his Minute to the PS by saying that:
‘Results of this research (Luc Kestens’) resemble the results of the evaluation which was carried out here in Tanzania (by MUCHS)’."
› I don’t know why the Ag. DHS did not continue to quote the next relevant
sentence on the same page 37 of that article (which is the same as the article authored by Tandaka Ndiaye Dieye, et al, which was co-authored by Luc Kestens captioned: ‘Absolute CD4 T-Cell Counting in Resource-Poor Settings, published in J. Acquir Immune Defic Syndr, Vol. 39, Number 1, May 1 2005 (see ANNEX 2.49) which goes on to say that:
"Nevertheless, single-parameter flow cytometry instrument like CyFlow Counter and even the more complicated CyFlow SL Green may easily out-compete any currently available manual CD4 counting method in terms of accuracy, precision, and cost per test, and certainly in sample throughput (samples/day)15. Data from a recent multi-center evaluation of different CyFlow instrument types in the field look promising16. But other multi-center field studies independent of the manufacturer are urgently needed to validate the robustness of CD4 counting by single parameter flow cytometry in clinical settings in developing countries. In addition, such field evaluation should address issue like instrument down time, troubleshooting, and service and repair efficiency in the field, because these are at least as important as the instrument accuracy and precision performance."
›› Furthermore, contrary to MUCHS’ Report, this article actually praises the
CyFlow’s simple affordable gating technique which removes any possible interference of monocytes, and clearly says that the CyFlows may easily outcompete any currently available manual CD4 counting methods, and says that different CyFlow types look promising in the field. Perhaps Luc Kestens and Tandakha Ndiaye have not seen or have decided to ignore the several recent published data and characteruistics of the CyFlow machines with facilities for removing any possible monocytes interference. Besides, this article says the accuracy and precission MAY be interfered – the use of the word MAY implies that it may or it may not interfere. Thus, the Ag. DHS’s contention that MUCHS definitive conclusion of interference resembles Luc Kestens’ uncertain statement of interference is untrue. The following publications instruct on how to use the CyFlow’s current software to distinguish the monocytes from the lymphocytes:
(a) The E-mail from the Partec Nairobi based Application Specialist Engineer,
Mr. Khisa Joseph (see ANNEX 2.5 and Application Note 2.15) saying that:
›The software in CyFlow machines clearly distinguishes monocytes from
lymphocytes based on the natural immunology of these cells. Monocytes are
know to have approximately 10% of CD4 markers found on CD4 + T-
lymphocytes. From the attached protocol it can be seen from fig. 1, CD4
counting with CyFlow machine that the population of monocytes, found to
the left of CD4+ T-lymphocytes (RN1), can be easily separated by the region
gates defined as RN1 in the Flomax software. The count in RN1will be
delivered to the programmed Report template. The users at MUCHS are very
much aware of this operation. MUCHS did not give all essential protocol and
and print outs, which would show if they followed SOP or not. If SOP
were not followed, interference would remain, and results would be wrong.
(b) Partec Application Note (ANNEX 2.15): which shows diagrammatically how
to differentiate the highly fluorescent CD4+ T-cells, and the dim fluorescent
CD4+ monocytes.
(c) The CyFlow Green print outs (ANNEX 2.16) of all 3 categories of CD4 cell
counts – low (<200 cells/µl), medium and high, using FACSCount as control.
As anyone can see, there appears to be no problem with assays of low CD4 count samples of <200 cells/μl, nor medium nor high level at all.
(d) A Joint Project of WHO-UNICEF-UNAIDS-MSF in June 2005 compiled some tables of characteristics of selected HIV/AIDS machines and Test Kits captioned:
"Sources and Prices of Selected Diagnostics….Summary of selected CD4+ T-cell Enumeration Technologies", including the Partec CyFlow technology (see ANNEX 2.23), which show high correlations between Partec CyFlow CD4 machines and other flow cytometry machines like FACSCount and FACSCalibur. These tables also show a ‘Disadvantages’ row which describes the shortcomings of any of those compared machines. It is in that row where imperfections of the CyFlow machines such as the inaccuracy and imprecision mentioned by MUCHS,
if they had any, would be shown.
(e) In a Joint Zimbabwe-CDC multi-center study, published in a paper by Manasa,
J., et al, in Clin. Vaccine Immunol., 2007 Jan 31, captioned: "Evaluation of
Partec CyFlow SL_3 assay against the BD FACSCalibur assay system in the
determination of CD4 absolute counts and percentages in the immune
monitoring of HIV infected patients in Zimbabwe", it explains how to avoid
interferences and determine absolute CD4 counts like this:
►"A single platform volumetric flow cytometer, the Partec CyFlow SL_3 was evaluated against a BD FACSCalibur/Sysmex XT1800i dual platform in the measurement of CD4+ lymphocytes, total lymphocytes, and CD4% in whole blood samples. Statistical analysis for precision, correlation and agreement were performed…"
If MUCHS did evaluate the CyFlow Blue against FACSCalibur and FACSCount, as they say they did, they should give full results – protocol details, print outs, statistical analyses for precision, correlation, and agreement, Coefficients of Variation, etc., for everyone to see and verify this CyFlow’s imprecision and inaccuracy MUCHS talks so repeatedly about. It is perfectly normal to give all such details, as this Joint Zimbabwe-CDC study gives (see ANNEX 2.28), especially if and when MUCHS decides to publish this CyFlow Evaluation Report in any scientific paper, which had better be done soon to clear the air.
(f) The Ag. DHS Minute appears to base the MoHSW’s repeated conclusion that "WHO has not done any CyFlow Evaluation" on a paper entitled:
"WHO Consultation on Technical and Operational Recommendations for Scale-Up of Laboratory Services and Monitoring HIV Anti-Retroviral Therapy (ART) in Resource-Limited Settings, Geneva, 13-15 December, 2004.".
» This paper published by WHO is only a preliminary collection of the views of a few scientists convened by WHO, who met in the WHO Headquarters in Geneva from 13-15/12/2004 to brain-storm about operational Recommendations on "CD4 Enumeration Technologies". This paper has not given even the list of participating scientists nor bibliography of the works to which they referred. That is why they have used the word "may" many times indicating that the final proof of their Recommendations was yet to come, after crystallization of these rough views. Indeed, this final proof came in June 2005 and published by a Joint WHO-UNICEF-UNAIDS-MSF Project, captioned as: "Sources and Prices of Selected Medicines and Diagnostics for People Living With HIV/AIDS" whose Annex 1A has a "Summary of CD4+ T-cell Enumeration Technologies" (see ANNEX 2.23 appended herewith.). This WHO, et al publication gives detailed tabulated summary of the CD4 technologies, including the CyFlow CD4 technology, which WHO, et al recognized and selected, giving the vital characteristics of them all. It even has a row of ‘Advantages’ in which it gives the good qualities of the technologies, and the row of ‘Disadvantages’ in which it gives the weaknesses or bad qualities of those technologies, if they have any.

Since CyFlow machines feature in all those tables prominently, it means that WHO and the other 3 International Organizations fully recognize Partec and its CyFlow machines. Therefore WHO doing or not having done CyFlow evaluation has nothing to do with the paper of Consultation on Technical and Operational Recommendations.
» The Ag. DHS’s Minute to the PS quotes the WHO Consultants on Technical and Operational Recommendations as saying that:
"Field experience has shown that the CyFlow systems MAY not YET have overcome technical challenges related to robustness…. The one parameter CyFlow Counter MAY also be inappropriate for TB co-infected patients."
It is crystal clear, from the use of the word MAY again and again, that the WHO panel of Consultants were not sure if CyFlow system has or has not as yet overcome its challenges of robustness or its imprecision; and the phrase ‘NOT YET’ implies that CyFlow is on the point of overcoming its challenges – which it has, if you look at all the appended papers on multi-center studies comparing CyFlow CD4 counters and other CD4 counters.
» The Ag. DHS is still insisting in para 4.2 of his advice (Minute) to the PS that:
"The CyFlow which was offered to MoHSW for evaluation is incapable of
determining CD4% for children."
This was another unfortunate obvious untruth, making his whole letter (Minutes) look and sound as if it were an attempt to catalogue CyFlow characteristics – whether true or false, certain or uncertain - which will help discredit/disqualify not only this single CyFlow SL®, but all the various types of CyFlow machines. And if by discrediting the CyFlows for their alleged incapability of doing CD4%, the Ag.DHS’s letter, mean to credit FACSCount with the capability of doing CD4%, as MUCHS’ statements say, they couldn’t be more wrong, because:
(a) Publications which say that CyFlows can and do determine CD4% are these:
~ The Zimbabwe-CDC Study published on 31/01/2007 is an "Evaluation of Partec
CyFlow SL_3 against the BD FACSCalibur assay system in the determination of CD4 absolute counts, and CD4% in the immune monitoring of HIV infected patients in Zimbabwe. (See ANNEX 2.39)."
~ WHO-UNICEF-UNAIDS-MSF Project compiled Tables in June 2005 (ANNEX 2.23) which show that both Single and Double Platform CyFlows are configured to determine CD4% counts in lymphocytes.
(b) Publications which say FACSCounts can not determine CD4% are these:
~ The WHO Department of HIV/AIDS Laboratory Technologies and Monitoring, on page 13 states that: "The FACSCount had not been configured for pediatric use, although appropriate reconfiguration is feasible (ANNEX 2.50.1)"
~ Prof. Lyamuya’s letter dated 30/01/2006 on page 5 admits that:
"In the introductory part of the Report (Prof.Lyamuya’s), it is stated clearly that FACSCount system is not an ideal system in developing countries setting because the equipment is expensive, it is a closed system that uses reagents from BD only, and cannot determine CD4%."
It is difficult to know where the Ag. DHS, Dr.Mung’ong’o got the idea that the CyFlow which MUCHS evaluated cannot determine CD4%! A glance at its Manual alone could tell him that it can, while FACSCount cannot do CD4%.
► The Ag. DHS ultimately advised the PS to agree with MUCHS’ verdict of
disqualifying the CyFlow, and therefore retain the all-CyFlow-machines ban, and
re-evaluate the CyFlow machine after its manufacturers rectify its shortcomings.
► Therefore, if what the Ag. DHS has mentioned in his Minute to the PS are the only arguments on which to base the disqualification of this CyFlow machine and to base a total ban of all CyFlow machines, and if these rebuttals, given by Partec (after I queried them through a detailed questionnaire), are as they have just been given, MoHSW and MUCHS have every reason to reconsider their disqualification of this CyFlow machine, and/or request to re-evaluate the same CyFlow quietly and dilligently, and settle these matters well outside the courts.
(h) After the Ag. DHS advised the PS to rubber-stamp the disqualification as well as the ban of the CyFlow machines imposed by MUCHS/PHLB on 20/10/2005, it was then the Hon. Minister’s turn to be advised. Therefore, on 22/07/2006, 9 months after the CyFlow was disqualified and banned, Ag. PS, who is also the CMO, Dr.Gabriel Upunda wrote the following Minute to the Hon. Minister of the MoHSW, repeating the same things more or less, but fewer, and wrote that:
"To the Hon. Minister of Health and Social Welfare, Refer to your Minute to the DHS Ref.No. WAUJ/JUN/)6/106 concerning the CYFLOW MACHINE. Together with this Minute, I am enclosing explanations and the report which made us realize that this machine is unsuitable for our country’s setting:
(a) This machine gives unreliable results CD4-200, and below this, is the cut-off point for starting ART (Anti-Retroviral Therapy).
(b) This machine is unreliable also for TB patients. This is reported by WHO. And in our country, 40% of our TB patients are HIV/AIDS positive.
(c) Studies about which the manufacturer talks a lot, are those in which he or his agents participated.
I suggest that we accept the decision of our researchers that these machines are unsuitable for our setting right now. If their manufacturer will improve them, then we shall re-evaluate them and decide on their future at that time.
Signed: Dr. Gabriel L. Upunda, Ag. Principal Secretary, 22/07/2006."
Unfortunately all these three points also have some flaws or are not quite correct:
»(a) As to the contention that below 200, the CyFlow gives unreliable results,
throughout this Report we have mentioned very many multi-center studies/
evaluations of various types of CyFlow CD4 machines against other reference
CD4 machines such as FACSCount and FACSCalibur, e.g. the most recent
Zimbabwe-CDC study dated 30/01/2007 (see ANNEX 2.39).

It says that the correlations between these two sets of CD4 counting machines have been very
high even for low CD4 count samples of <200 cells/µl mentioned by Dr.
Upunda. In any case, we have earlier in this Report given over 5 possibilities of why MUCHS got and gave those unexpected results, the main of which is MUCHS’ non observance of SOP (Standard Operating Procedures) such as use of incorrect instrument settings, use of wrong detection channel, use of old (over 8 hours old samples), and use of old (8 months old) reagents in the CyFlow and compared their assays with brand new and fresh reference reagents used in FACSCount and FACSCalibur machines. All these faults (using old specimens and samples) were not beyond the evaluators’ control.
»(b) As to the contention that CyFlow is unreliable for TB patients, we have said
in (g) above, Dr. Upunda here is referring to the paper: "WHO Consultation on
Technical and Operational Recommendations for Scale up of Laboratory
Services and Monitoring HIV Antiretroviral Therapy in Resource Limited
Settings, Geneva, 13-15/12/2004," which was a draft which culminated into
the "Summary of CD4+ T-Cell Enumeration Technologies (see ANNEX 2.23)".
Therefore these "WHO Consultations Recommendations" were neither final nor
binding, and that is why they have not given, at this stage, names of scientists
who participated in the consultations, nor names of Journals where the works
they referred to are published. One cannot base condemnation of all CyFlows on
such drafts. But even these drafts, have not been quoted appropriately.
For instance the reference to TB patients was in this following context:
"The one parameter CyFlow counter instrument may also be inapropriate for TB co-infected patients."
Once again, the Consultants were not definite about this inappropriateness, but only implied that the CyFlows may or may not be appropriate for TB-co-infected patients. Thus it is erroneous to quote WHO as stating categorically that the CyFlow is inappropriate for TB co-infected patients. Besides, MUCHS and/or Dr. Upunda well know that the CyFlow SLR which MUCHS evaluated was not a one parameter, but it was a FIVE parameter CyFlow which is known to be suitable for TB co-infected patients!
»(c) As to the contention that: "some of the studies which Partec talks a lot about
are those in which Partec themselves have participated", the answers are:
› This allegation and its answers have been repeated too often although its logic
is very flimsy. Let us look at the following examples:
› (i) The joint Zimbabwe-Stanford University (of USA) multi-center Study (see ANNEX 2.29.1 appended herewith), which is one of the many that exalt CyFlow in the following way, although no Partec personnel or its agent participated in this excellent multi-center Study:

"Conclusion: The CyFlow counter is as accurate as the FACSCount in enumerating absolute CD4+ T-lymphocytes in the whole range of 1-2000 cells/µl (including below 200 cell/µl). CyFlow cytometry is relatively affordable, easy to use technology, that is useful not only in identifying HIV seropositive individuals who require ART, but also for monitoring immunological responses to ART (Anti-Retroviral Therapy)."
Even if one or more Partec personnel were to participate in this Study, it is inconceivable that all those many scientists of 7 reputable centers/institutions including the world renown Stanford University, could stoop so low as to accept being "pressurized (bribed)" by Partec, the manufacturer of the CyFlows.
›(ii) The same applies to the following multi-center Studies in which Partec did not participate nor its agents, and involving famous research centers like CDC:
~ The Thailand-CDC (Center for Development Studies of USA), in which the CyFlow Green showed high correlation of absolute CD4 counts when compared with the bead-based three-colour TRUCount and FACSCount. (see ANNEX 2.33)
~ The Nigeria-Havard University (of USA) Study (see ANNEX 2.35) whose concluding remarks include:
"We compared two techniques for CD4 T-lymhocyte counting: flow cytometry (CyFlow) ans magnetic beads (Dynabead). Similar results with good correlation were obtained from the 40 adult blood samples counted (P=0.057, r=0.93). The CyFlow technique is more precise and cost effective than the Dynabead method ($3-5 versus $12-22 per test, respectively); since as many as 200 samples can be measured per day."
~ The latest Zimbabwe-CDC Study which was published on 31/1/2007 (see ANNEX 2.39 herewith appended) concluded thus:
"This data showed that the Partec CyFlow SL3 assay is comparable to the BD FACSCalibur/Sysmex 1800i dual platform method in the measurement of CD4+ cells, total lymphocytes, as well as CD4% for purposes of monitoring of HIV/AIDS patients. "
›(iii) Needless to say that there was no Partec personnel nor their agents in this
study which happens to be honestly praising CyFlow’s performance very
highly. In fact, this Study is also in effect defending the ‘CyFlow against Dr.G.Upunda’s allegations such as the ‘imprecission’ which MUCHS alleged the CyFlow exhibits in low CD4 count samples of < 200 cells/µl. The Study has confirmed that CyFlow’s performance is just as good as the FACSCount; and in aspects such as precision, cost effectiveness, throughput, ease of operation, time of preparation of samples and of tests, CyFlow is better than many other instruments such as FACSCount, FACSCalibur, etc.
Surely nobody will dare to insinuate that all those non-Partec scientists in Zimbabwe, and in USA (Stanford University, Havard University, CDC), etc. have been ‘pressurized (bribed)’ by Partec to give the honest results and conclusions which they gave in favour of Partec’s CyFlow?
›(iv) Common sence dictates that, if an evil person wishes to "pressurerize (bribe)" any scientist/s to lie about their Study results, that evil person does not have needle his/her way into the group of scientists in order to "pressurerize" them. He/she can "pressurize them"from any distance outside that group of scientist. But we observe that, even the few times when one or more Partec officials had participated in some joint Study, they all invariably ended up writing a statement
to disclaim any corruptive vested interests.
For instance, the multi-center Study published by International Medical Press, 2004, captioned: "Simplified volumetric flow ctometry allows feasible and accurate determination of CD4 T lymphocytes in immunodeficient patients worldwide", had 10 authors including Prof. Wolfgang Gohde of Partec. The partipating centers comprised some in: Rwanda, Burkina Faso, Cameroun, and 6 from different German Institutes. Because of their German associations, the whole Study Group deemed it fit to end their published article with the following Conflict of Interest Statement:
"The authors declare no conflict of interest or financial relationships influencing the conclusions of the work,"
Under the heading of "Sponsorship", they wrote the following:
"The work in Rwanda was carried out as part of the Lux Development cooperative with the Centre de Recherche Public Sante Luxembourg. The ‘Institut Pasteur du Cambodge’ was financially supported by the ESTHER (Ensemble Solidarite Therapeutique Hospitaliere En Reseau) network initiative and by the National AIDSAgency in France (ANRS). The National AIDS Agency in France financed a grant to Yvette Henin. The expenses incurred at the other centers were paid out of the University/Hospital Budgets."
Such is the openness of the overseas scientists we are dealing with here. In contrast, sponsors of most of our Tanzanian research projects, and indeed the doners who have constructed and equipped our research Laboratories, etc. are from outside, principally USA, from where CD4 counters like BD FACSCounts and HIV Test Kits like Capillus are imported, against all the PPRA (Public Procurement Regulatory Authority) and MoHSW’s own public procurement Regulations, and disobeying even the State House directives. Furthermore, donor institutions which fund HIV/AIDS projects are from overseas principally USA eg. Global Fund to fight AIDS, Malaria and Tuberculosis; The Bill and Melinda Gates Foundation; Clinton Foundation; and US Presidential Emergency Fund for AIDS. No one is pointing a finger at MUCHS or any other Reaseach Laboratories dealing with HIV/AIDS criticizing the many more conflicts of interest existing here.
However, our vulnerability is self created, since most funding agencies invariably advise the recipient countries to check the quality of health supplies ourselves.

(i) All this enormous information, some of which is still trickling in, has been a response to investigative questionnaires which we used to send to both sides (Partec people on the one hand and MUCHS, MSD, and MoHSW on the other), to give us clarifications of certain issues. And we have many documents containing this information which anyone is free to request to see and will be shown. But we cannot append herewith all of them as ANNEXES. We will take the liberty of quoting a few of them only hereunder:
›(1) In an effort to counter WHO’s Dr. G.Vercauteren’s allegations that:
"The CyFlow supplier is always unwilling to participate in a WHO validation", Partec has submitted the following letters to show that it is WHO’s EHT (Essential Health Technologies) official, Dr.Gaby Vercauteren himself who refused to have done an "WHO validation of the CyFlows" nor recognize/validate 27 multi-center Studies Partec asked him to validate:
›(2) Partec’s Dr. Roland Gohde wrote four letters dated 15/09/2004, 24/10/2004, and 24/05/2005 to: WHO’s Assistant Director Generals Dr. Jack C.Chow of HIV/AIDS, TB & Malaria, and Dr. Vladmir Lepakhin of Health Technologies & Pharmaceuticals; to Dr. Steffen Groth, Director of WHO’s Essential Health Technologies; Dr. David Miller, WHO Ombudsman; and the last two to Dr. Gaby Vercauteren of WHO EHT, captioned: "WHO Report June 2004: EHT Report on Diagnostics", "Correction of the Word Document", "Request for Information", and "CD4 Counting", and these letters briefly had the following to say:
Letter dated 15/09/2004 (ANNEX 2.52.1): Dear Drs. Chow, Lepakhin, Goth, and Miller, several weeks after returning from the XV International AIDS Conference in Bangkok, we would like to openly inform you on Report on Diagnostics within the WHO/MSF/UNAIDS/UNICEF publication: "Sources and Prices of Selected Drugs and Diagnostics". In order to prevent any damage to the different manufacturers sychroneously targeted by the mistakes produced in the EHT … submission of the false information given in the Report on CD4+ T-cell enumeration Technologies could be corrected by simply contacting the different manufacturers prior to publishing the Report. More than this, for a long time EHT Department was in full possession of scientific data.
Letter dated 24/10/2004 (ANNEX 2.51.2): Dear Dr. Steffen Groth, Director of EHT, WHO,
First of all the latter statement is not true as Dr. Vercauteren from EHT avoided any communication with Partec…. To be honest it is not possible to feel comfortable with your mail dated 01/10/2004 misreporting despite the well known scientific results/studies and as WHO - EHT did not communicate with Partec. … For the sake of putting records straight, we will now circulate this letter with the previous letter dated 15/09/2004 to the scientific community to correct the erroneous report from WHO - EHT on the CD4 counting/diagnostic part. Please bear in mind that even the newest available draft submitted by WHO does not remedy the main severe errors.
For the wide community of scientists, doctors, and experts in this field, we have established a special website section for scientific articles which are disapproving the specifications produced by WHO - EHT in the original ‘Sources and Prices of Selected Medicines and Diagnostics for People Living with HIV/AIDS’, compiled by a Joint UNICEF-UNAIDS-WHO-MSF Project. Yours sincerely, Dr.Roland Gohde. HIV/AIDS Director of Partec."
Letter dated 24/05/2005 (ANNEX 2.51.3): "Dear Dr.Vercauteren, We appreciate highly that for the first time WHO/EHT contacted Partec in order to take care that the document: ‘Sources and Prices of Selected Medicines and Diagnostics for People Living with HIV/AIDS’ is as accurate as possible, as well as scientifically correct. … Hence we rewnew our invitation to you and your colleagues for a detailed introduction and seminar on the performance demonstration at our University Department … also considering that our German Government is anyhow being entirely informed on this open invitation to WHO. Regarding the Word document containing the tables you have sent me on 20/05/2005, I am submitting the following comments on the Revised Word document. ….(This was followed by 4 pages of corrections suggested by Dr. R.Gohde). The letter ends with a reminder that: ‘Partec is an ISO (International Standards Organization) 9001:2000, and ISO 13485:2003 Certified Company’.
Dr.R.Gohde kept on reminding Dr. Vercauteren to respond to his letters."
Letter of 26/05/2005 (ANNEX 2.52.4): Re: CD4 Counting. Dear Dr. Vercauteren, In the past two years we have sent 27 comparison studies to the WHO. Among the institutions and research groups which evaluated CyFlow instruments in comparison with other companies’ CD4 counters. (He went on to list 27 Institutions with which Partec co-partipated, which included those in Africa (Burkina Faso, Cameroon, France, Rwanda, Senegal, Malawi, Zimbabwe), Belgium, Cambodia, Italy, France, Germany, and USA). Also MSF (Medicene Sans Frontieres) has independently evaluated the CyFlow system very successfully, and endend up with the following conclusion:
"After being trained, local District Laboratory staff found the CyFlow machine easy to handle and robust. The CyFlow counter produces excellent results in a field setting, and can be installed in a District Hospital setting. It is useful for monitoring in the context of scaling up ART (Antiretroviral Therapy) in resource-limited settings."
›(3) In a letter to Dr.B.Mbawala of Oysterbay Hospital, Dar es Salaam, Dr.Roland
Gohde said the following allegations of uncooperation of Partec with WHO:
"These are common allegations often raised by BD and its ‘friends’ (who happen to be in all sorts of strategic positions) that Partec is not willing to cooperate with WHO. The fact is that I personally, as a manager responsible for this field have offered WHO numerous times to arrange meetings, demonstrations, by E-mails sent to: Dr. Vercauteren, Dr. Groth and also Dr. Perriens. For instance I am copying you E-mails dated 03/07/2002 and 27/06/2003.
Proposals from our side for multi site (multi center) evaluations which was answered by Dr. Vercauteren only this Sepember 1st 2006, in spite of the many reminders to WHO – EHT, Geneva…. It is WHO which has not been responding to our many invitations for cooperation and collaboration in validation/evaluation exercises. … I sincerely hope that these pieces of information I am offering you will clarify that every allegation coming from Muhimbili (MUCHS) and some of the MoHSW officials (through Dr.F.Ndugulile’s correspondence with Dr. Gaby Vercauteren) have some untruths…Kind regards, Dr.Roland Gohde."
›(4) In its efforts to show that CyFlow machines are not only free from the faults from which they are alleged to suffer, its supplier mentioned many UN and other International Agencies (including WHO itself), states and individuals who have been procuring CyFlow instruments. Partec, has thus far sold over 240 CyFlow machines in the Sub-Saharan Africa alone, since it introduced the CyFlow as its accurate and affordable CD4 cells counting machine in 2003. This forms a share of 27% of CD4 counters. By September 2006, Sub-Saharan Africa had procured over 400 CyFlow machines, with Nigeria alone having procured 115 CyFlow instruments, increasing its share to about 40%, according to a Publication captioned "HIV/AIDS Capacity" from WHO Regional Office for Africa in Harare, Zimbabwe. All such information must be well known to Dr. G.Vercauteren and the like, but unfortunately they prefer not to disseminate the truth to their "friends", the scientific community, the UN and other international organizations.
(j) On 04/01/2007, Prof. Lyamuya sent by E-mail (see ANNEX 2.20) the following additional information/correction concerning the CyFlow SL Blue machine which MUCHS evaluated, after being prompted to do so:
"(i) The CyFlow machine was received in the Department (at MUCHS) on 15th November 2004 (while previously, see ANNEX 2.9, he said they received the CyFlow machine on 24/12/2004). He says the CyFlow machine was handed in by Mr. H.Khalid from NACP to Mr. Charles Kagoma who was then the Chief Department Technologist.
(ii) The CyFlow reagents accompanying the CyFlow machine during delivery to the Department were noted to be sufficient for testing the system only.
(iii) Calibration Beads were not included."
Unfortunately, even these additional corrections still contains the same flaws:
»(1) The statement in (i) above that the CyFlow was handed in by Mr.Khalid from
NACP is incorrect. The truth is that the CyFlow was transported to MUCHS from NACP by the Partec engineer Mr.Khisa and Dr.Mbawala, as stated earlier (see Mr.Khisa’s E-mail appended herewith as ANNEX 2.5 and 2.6).
›(2) The statement in (ii) and (iii) above that the CyFlow reagents that came
with the CyFlow machine was enough only for testing the system (CyFlow), and that Calibration Beads were not included, is incorrect.
A glance at the Check List of the Starter (Easy Count) Kit of reagents (see ANNEX 2.11) shows that the CyFlow machine was accompanied by all essential reagents including Calibration Beads, enough to test 200 samples. This was more than enough with which to start the evaluation, taking into consideration that by the end of the CyFlow evaluation MUCHS had tested a total of only 240 samples.
In addition to all this, Partec did send through Dr. Mbawala a further supply of 10 Kits of reagents enough to test 1,000 more samples – which Kits are the items which were delivered to MUCHS on 24/12/2004, by Dr.Mbawala (not Mr Khalid).
›(3) All these were part of MUCHS’s efforts to prove that there was definitely no delay nor premeditated aim of disqualifying Partec’s CyFlow machine in the evaluation of the CyFlow machine, especially as far as MUCHS is concerned, not even after Prof. Lyamuya did a volte face and admitted that the CyFlow machine was delivered to MUCHS on 15/11/2004 after all, whereas at first he said it was delivered on 24/12/2004.
(k) ››(i) Throughout this CyFlow saga, there have been some indications to justify
some of Partec’s complaints that, right from the word go, people who were
entrusted to expeditiously evaluate the CyFlow Blue 5 Parameters CD4 counting machine, had their minds set to disqualify the CyFlow machine, one way or anothe other, almost by hook or by crook. In other words, there appear to have existed a conspiracy which aimed at making Health Authorities and the public in Tanzania and the world at large believe that FACS machines especially FACSCounts are most superior and more ideal than any other CD4 counting machine for the developing world with resource limited settings like Tanzania.
››(ii) And if this conspiracy succeeds, it would preserve the status quo, whereby
CD4 cell counting machines manufactured by BD (Becton-Dickinson) of USA
such as FACSCount, which has been alone in the African market without any competition for about 15 years, would remain predominant like this perpetually. and without any competitor all over Tanzania. In Tanzania there are currently over 40 FACSCount machines procured directly by NACP, usually without any tendering mechanism (see ANNEX 2.12 appended herewith), contrary to the PPRA (Public Procurement Regulatory Authority) Regulation No.22 of 2005 (Disposal of Public Assets by Tender), and without undergoing rigorous evaluations by satisfying the 4 conditions set by PHLB Regulations, according to Private Health Laboratories Regulations Act, 1997.
›(iii) When asked to show the full Evaluation Report of the FACSCount and its consequent PHLB registration, MUCHS referred us to Prof.Lyamuya’s letter dated 30/01/2006 (ANNEX 2.9), page 5, containing the following revealing statements:
"MoHSW decided to acquire the FACSCount system based on its performance characteristics as reported in various evaluations including the evaluation done in Tanzania and published in J.Immunol Methods 1996; 195 (1-2):103-12, captioned ‘Evaluation of the FACSCount, TRAx CD4 and Dynabeads methods for CD4 lymphocytes determination’ by Lyamuya E.F., et al."
› No one submitted the FACSCount Evaluation Report or Registration, both before
1997 and after 1997 when the PHLBoard was established, afterwhich all the
PHLB Regulations became binding. There appears to be a belief that "old is gold" in the sence that the machines and Kits that have been used in Tanzania for many years (over 15 years for FACSCounts), must have been suitable, and remain suitable indefinitely, thus there is no need to re-evaluate them regularly. But like laboratory health supplies, the manufacture of drugs is expected to undergo some changes every 3 to 5 years after they were last tested; and thus it becomes mandatory to re-test the machines and drugs every 5 years, and register them afresh. I cannot get hold of a complete PHLB Act of 1997 in which, if such provisions of regular re-evaluations are missing, that must be a grave fault indeed.
›› Thus if this Lyamuya, et al, evaluation of FACSCount was done way back in
1996, that was before the promulgation of the "Private Health Laboratories
Regulations Act of 1997", which came into effect on 01/07/1998. This fact is reason enough to have let every CD4 counter like FACSCount be re-evaluated (if it were evaluated before 1998) as soon as the PHLB Regulations Act became operative. The "Private Health Laboratory (Conditions Pre-requisite to Registration and Management of Private Health Laboratories)" GN No226, Sub-section No. 2.5.2, i.e. The Health Laboratory Product or Supply has to undergo Phase I and Phase II evaluation and fulfil the other 3 conditions under this this sub-section. But there is no evidence that any of this has taken place, and we know not the reason for exempting these FACS machines from undergoing just as rigorous evaluation as did the CyFlow, or else this would be unjust and competitive public procurement of CD4 machines would be on un-level ground.
››› More technically speaking, the Prof. Lyamuya, et al, multi-center Evaluation of the FACSCount, TRAx CD4 and Dynabeads method for CD4 lymphocytes determination appears to be obsolete, because it compares the FACSCount with manual CD4 counting methods, but not with reference flow cytometers. Because the FACSCount did not have any competition in Africa until 2002 when the CyFlow came into the picture, practically no single international multi-center study exists for the BD FACSCount which would ascertain its accuracy and precision compared to large flow cytometry systems like BD FACSCalibur, Coulter EPICs, Partec PAS etc.
In contrast to this, several international multi-center studies for the CyFlow in fact exist, all showing excellent results for comparison of the CyFlow technique against the BD FACScan, BD FACSCalibur, Coulter EPICS, BD FACSCount. Therefore, as a matter of fact, unlike BD FACSCount the CyFlow has been tested against almost all flow cytometery techniques ever established in the scientific world. Because FACScount had remained unchallenged for about 15 years, there was no pressure to perform such studies for it too. It is vital to undertand this background in order to have a clear picture of this whole situation/saga .

(l) Partec’s Report on MUCHS’ Manipulations of CyFlow Evaluation Data
On 28/11/2006, Dr. Roland Gohde of Partec wrote a 12 pages letter (see ANNEX 2.54 appended herewith) to the President of the United Republic of Tanzania, H.E. Mr. Jakaya Mrisho Kikwete, which is captioned: "Report on the Muhimbili Evaluation for CD4 Counting". This letter alleged a lot of MUCHS’ wrongdoings as Partec’s previous letters, and included divulging more evidences of manipulations of the CyFlow settings in such a way that it gave wrong data. We shall now quote these allegations and see if they tally with results of our investigations, and so start making inferences and conclusions:
(1) Dr. Roland Gohde says in the introduction of his letter that:
"The evaluation was heavily delayed by MUCHS for unknown reasons."
» Our comment is: Yes,it was delayed, in the sence that first, the CyFlow was
carelessly left stranded at DIA (Dar es Salaam International Airport) for 1.5
months [from the date of its arrival at DIA on 27/9/2004 (see Air Waybill, ANNEX 2.2)] to the date of its clearance from DIA on 11/11/2004 (see Import Declaration Form ANNEX 2.3). Then, it was kept waiting for "missing reagents" at MUCHS for 8.5 more months (from the date of its arrival at MUCHS on 15/11/2004 (see Mr.Khisa’s E-mail, ANNEX 2.6) to the start of its evaluation on 24/7/2005 (see Prof. Lyamuya’s letter, ANNEX 2.9), making this a sub-total of 10 months’ delay. And since Dr.Z. Berege on behalf of MoHSW’s PS did not send Prof.W.Gohde of Partec the final CyFlow Evaluation Report until 24/10/2005 (see the Evaluation Report, ANNEX 2.14). This adds another 3 months, making the overall total delay of about 13 months. This 13 months duration is more than the duration of 6-12 months promised by MoHSW’s Dr.Z.Berege’s letter Ref.No.BC/191/544/01/88 (see ANNEX 2.7), one term and condition of which (for CyFlow evaluation) was:
"2. The equipment shall be subjected to trial/evaluation for 6-12 months",
to which Prof. W.Gohde’s letter of 28/10/2004 (see ANNEX 2.8) fully agreed.
This MoHSW-Partec agreement notwithstanding, if Prof. Lyamuya’s letter Ref.No.MIM022/01/06 dated 30/1/2006 (see ANNEX 9) says that:
"We (MUCHS) subsequently (24/07/2005) continued with the evaluation
until late August (30/8/2005), analyzed the data, and provided the final
Evaluation Report (to the PHLB) on 06/10/2005."
Then, it clearly means that the actual process of the CyFlow evaluation took about 1 month only. Therefore, it means that if MUCHS were seriously well prepared (which they ought to have been) the 12 months out of this 13 months’ duration (22/9/2004-24/10/2005) is technically a delay – an unwarranted or deliberate delay, at that, which MUCHS could have avoided, if it were committed enough.
(2) Still in the introduction, Dr.R.Gohde goes on to say that:
"Many letters/E-mails which Partec sent to MoHSW including offers of
help, were never answered, presumably most of them were intercepted and
kept hidden from the PS and the Hon. Minister for Health and Social
Welfare."
» This tallies well with what we were told during the interviews (e.g. with the PS,
Ms.M. Mwafisi, ANNEX 1.4) that she blamed certain MoHSW official/s
for keeping PS’s letters to themselves and never bringing them to the attention of the PS, and some officials even kept on replying to some of these letters without the knowledge of the PS for whom they were signing these letters! The PS, Mrs. M. Mwafisi reprimanded these officials for this intransigence! We could not see the letters of reprimand because we never had access to MoHSW files, in spite of our request which we sent with our questionnaires. In this regard, we thank the PHLB Registrar, Mr.Mrina, very much for being the only MoHSW official who responded to our Questionnaire by sending us a big bundle of very informative documents we have appended in this Report.
(3) Still in the introduction, Dr. Roland Godhe says that:
"A Report was released by MUCHS on 24/10/2005 signed by Dr.Z,A.
Berege (ANNEX 2.14) allegedly on behalf of the PS, copied to the CMO of
MoHSW, containing numerous severe scientific and technical errors
and mistakes despite better knowledge."
» Let us mention here a point of information first: Prof.E.Lyamuya’s letter Ref.No. MIM/022/01/06 dated 30/01/2006 (ANNEX 2.9), page 2, para 1. says:
"We (MUCHS) subsequently (24/07/2005) continued with the evaluation
until late August 2005, analyzed the data, and provided the final evaluation Report on 06/10/2005."
Next, on 24/10/2005, this MUCHS’ Report of 06/10/2005 was tabled before the Board (PHLB) and discussed, before Dr.Z.Berege wrote the 18 pages final CyFlow Evaluation Report on 24/10/2005 which was then mailed to Prof.W. Gohde. I stress this point of information because it is unclear if this Report, which had quite a few shortcomings and misinformations, including those which Dr.R.Gohde is complaining about in this and other letters, is exactly the same Report that MUCHS released on 6/10/2005 to PHLB.
As for numerous severe errors which Dr.R.Gohde mentions, this is the topic of the remaining pages of Dr.R.Gohde’s letter, i.e. the very next point (d) below.
(4) Still in the introduction, Dr. R.Gohde’s letter says that:
"The MoHSW and MUCHS, since the release of the Evaluiation Report,
did not answer all the requests for submitting the data printouts from the
measurements."
» The MUCHS evaluators did not give Partec all data including protocols used and
printouts, even after Partec repeatedly asked to be mailed all the essential
data. Partec suspected that preparation steps and/or dilution factor may have been mistaken; or the optimal/predefined CyFlow instrument settings may have been altered accidentally or deliberately by someone. This would have led to the wrong detection channel, and the CD4 values counted would obviously be wrong.
(5) Still in the introduction of his letter, Dr.Roland Gohde says that:

"After retreaving the data files from the harddisk of the returned CyFlow
instrument, it was shown that evaluation data were severely manipulated in
order to obtain wrong CD4 counts for that CyFlow."
» As we hinted earlier on, the harddisk of any PC is like an aircraft’s "black-box" in the sense that it retains permanently every bit of data or information ever printed on it, unless someone erases them deliberately, when even that erasure may be legible. Dr. R.Gohde goes as far as implying that MUCHS must have had a pre-meditated plan of falsifying the CyFlow Evaluation results, after seeing that the joint delaying of the evaluation (or call it go slow strike), or even using old reagents and old samples "in protest", were not enough to frustrate CyFlow out of competition with the FACS machines.
(6) Under the heading of "Background", Dr. Roland Gohde mentions that Partec’s goal, agreed upon by the former MoHSW PS, Mrs. M.Mwafisi during her two meetings with Prof. Dr. Wolfgang Gohde of Partec in March and in July 2004, was to use the CyFlow SL after its evaluation for long time support of the Tanzania AIDS patients. In spite of many letters of enquiring about the evaluation, and despite several requests of scientists of University of Munster and Partec’s application specialists, they were never allowed to enter MUCHS laboratory to even at least check the status of the CyFlow instrument and help in case help was needed. He says, many letters sent to MoHSW, including one which was sent to the former Minister for Health Hon. Mrs.Anna Abdallah through the Ambassador of the Federal Republic of Germany, H.E. Mr. Wolfgang Ringe, remain unanswered implying that some of them at least did not reach the Ministry leadership, due to the interception of some of them and hiding them from the Ministry leadership.
(7) Under the heading of manipulation of evaluation data by MUCHS, Dr.Roland Gohde relates how Partec airfreighted the CyFlow unit with its PC back to Munster University from MUCHS, connected it to electricity and its harddisk carefully checked and documented in the presence of an attorney-at-law. The instrument’s PC and its harddisk were then handed over to the attorney-at-law for safely securing the existing evidences for legal documentation and further use.
The fully retrieved original data files and printouts from this returned CyFlow SL unit shows that MUCHS had manipulated the instrument’s settings so that the counting measurements could give anything but correct CD4 count values.
The MUCHS evaluators deliberately ignored to use the CyFlow instrument manuals, application notes and inserts, and CD4 counting protocol procedutes, as well as ignoring to use the predefined correct settings (which exist as files which are automatically preloaded as soon as the analysis software is switched on. They purposely used the wrong manipulated settings which led to the wrong detection channel, FL1 (instead of the correct predefined channel FL2) which in turn gave wrong results, which MUCHS conveniently dubbed as a fault of the CyFlow instrument failing to differentiate the monocytes from the lymphocytes.
Therefore, the CD4 count values obtained by MUCHS have been systematically wrong, as any analyst with minimum knowledge of flow cytometry and CD4 counting would detect as soon as he/she glances at the first histogram from a sample run performed at MUCHS (see Fig. 6 on page 9 of Dr.R.Gohde’s letter, ANNEX 2.54 appended herewith), as compared to a quality check (QC) run (see Fig. 5 on page 8 of ANNEX 2.54 appended herewith ) using the same instrument.
(8) Dr. R.Gohde continues to say that, the files retrieved from the returned CyFlow SL instrument clearly show even the dates when all the samples were analysed – the first was analysed on 27/07/12006 (see Fig. 1 on page 4 of Dr.R.Gohde’s letter ANNEX 2.54 appended herewith), while tha last one on 03/09/2005 (see Fig. 2 on page 5of Dr.R.Gohde’s letter ANNEX 2.54 appended herewith).
A Word file, called "CD4 PE Counting PROCEDURE", present on the PC desk top gives the procedure of loading the correct predefined instrument settings, and also gives short and easy instructions on how to run CD4 counts (see Fig. 3 on page 6 of Dr.R.Gohde’s letter ANNEX 2.54 appended herewith). Once loaded these settings remain in use unless and until they are changed purposely. This means that, even if a "child" alters the settings "unintentionally", the correct settings can be easily reloaded by following these easy, briefly written instructions /procedures, unless someone deliberately wishes to ignore the procedures (SOP).
The predefined correct settings which are stored in the PC at C:/Flomax/CD4 Count.IST, are automatically loaded when launching the software. As shown in Fig.4 on page 7 of Dr.R.Gohde’s letter (see ANNEX 2.54 appended herewith), clear and easy instructions for loading this special software are given. As we stated earlier on, the population of monocytes can be easily separated by the region gates defined as RN1 in the Flomax software. Then the count in RN1 will be delivered to the programmed report template. This, Dr. R. Gohde and the Partec Application Specialists say that MUCHS technicians were definitely aware of, after being taught by the Nairobi based Partec Application Specialist Engineer, Mr. Khisa Joseph. Yet it appears none of them wished to use their knowledge or follow the easy precise instructions or standard operation procedures (SOP).
(9) The data retrieved from the QC runs performed by the Partec Service Engineers for this returned CyFlow SL unit, Dr. R.Gohde says, are still stored as well as all subsequent CyFlow analysis data performed by MUCHS technicians. The print outs for the QC runs use the correct predefined instrument setting, and therefore use the correct detection channel too, "FL2" of the CyFlow unit, leading to excellent QC run CD4 results, as clearly shown in Fig. 5 (see Fig. 5 of Dr.R.Gohde’s letter, appended herewith as page 8 of ANNEX 2.54). This Fig. 5 shows clearly that the QC run uses the correct predefined setting and the correct fluorescent detection fluorescent channel FL2 which is displayed under the large graph on the left, as well as on the small lower graph on the right – both discerned and marked as "FL2 CD4 PE".
The mark "RN1" on the graph indicates that the region gates in the "Flomax" software are in operation, makling the CyFlow capable of differentiating the monocytes population from the lymphocytes, and so preventing the true CD4 count values even for low samples of <200 cells/µl from being wrongly inflated, which MUCHS claimed was the major flaw of this CyFlow SL machine. This is why Partec asked to be sent all the data including such printouts which would definitely show the detection channel that was used. And MUCHS did not deem it fit to give all the data and print outs to clarify Partec’s doubts.
(10) Dr. Roland Gohde’s letter continues to state that, the retreaved analysis data of the retutned CyFlow SL clearly shows that, just before starting to analyse the samples, the MUCHS Technicians abruptly altered manually the correct stored
redefined setting, which suddenly made the CyFlow to switch to the wrong manipulated detection channel, "FL1". This naturally made the CyFlow SL give the wrong CD4 count values (see Fig. 6 of Dr.R.Gohde’s letter, appended herewith as page 9 of ANNEX 2.54). Fig. 6 is the screenshot of one of MUCHS’ sample run taken on 30/07/2005, while using the wrong detection channel "FL1" CD4 PE. A first cursory glance at the first histogram of the MUCHS’ measurements would have easily shown to any Technician that the wrong detection channel "FL1" was bneing used, and so they were required to change the settings immediately.
But pathetically enough, MUCHS Technicians carelessly continued to use the manipulated wrong settings which gave them wrong CD4 counting values. That is why, perhaps, MUCHS refused to send Partec all the data including such printouts which would clearly show that the detection channel used, "FL1", was the wrong one. The correct detection channel should have been "FL2" (see Fig. 7, 6, and 5 of Dr.R.Gohde’s letter, appended herewith as ANNEX 2.53). And even if MUCHS could give these data and printouts to the MoHSW decision makers or anyone else lacking in the interpretation of data from conventional CD4 counting instruments, they would not off hand detect that they were wrong and/or why.
Clearly, MUCHS at no time ever anticipated that the problems they maliciously created in order to disqualify the CyFlow SL would blow up to such proportions that would justify the intervention of persons who can detect such manipulations.
That was a pathetic risk indeed to take. It was pathetic and sad because it clearly shows that MUCHS knew exactly what they were doing (deliberately not following easy instructions and SOP) and why.
It was similarly pathetic and poignant of MUCHS to ban all Partec personnel and agents from entering the MUCHS campus and to avoid any helpful communications which might have clarified cause of these unwarranted errors.
It was sad because MUCHS’ Report was calculated to damage the reputation of the first and internationally well acknowledged manufacturer of flow cytometric equipment since 1968. This unwarranted damage may lead Partec to resort to legal means of settling this, which would damage the reputation of not only MUCHS, but the MoHSW and many related institutions and indeed the whole United Republic of Tanzania.
It is sad still to see that this saga has jeopardized the important discussions for close cooperation and support for Tanzanian HIV/AIDS infected people, attended by H.E. President J.M.Kikwete during the ceremony for handing over one donated CyFlow instrument to PIUMA. This saga has led to the MoHSW banning any further importation of CyFlow units, and to replace all the existing CyFlows with FACSCount machines which simply cannot determine CD4%.
This in turn will let the children of the "Village of Hope" and others in Tanzania will have to continue suffering severely from non availability of the urgently needed CD4% testing which CyFlow is capable of performing but FACSCount is incapable of performing.
(11) Dr. Roland Gohde’s letter ends with the following conciliatory remarks:
"With today more than 400 placed CyFlow units in the developing world – Nigeria alone having over 115 units – offering CD4 testing to everyone at a constant cost of Euro 1.75 (= US$ 2.2) per patient test, Partec is already supporting about 275,000 AIDS patients due to successful use of the CyFlow technique in Government, private, and NGO treatment programmes’projects. Hence, it is our sincere hope that, based on the above given scientific evidence and facts, the situation created by manipulations from some MUCHS’ and MoHSW officials, will be clarified, in order to concentrate again on what is really essential, viz: urgent patient support in Tanzania by increasing healthcare services at wide scale within a long lasting close and confident partnership and scientific cooperation.
For this aim, we are completely open for working closely together with the government of the United Republic of Tanzania, aiming to cover the specific needs of patients in the country.
Sincerely yours,
Roland Gohde
International Project Manager
Partec Essential Healthcare
For HIV/AIDS – TB – Malaria"
Additional Rebuttals of Doubts of Some of MUCHS’ and MoHSW Officials, and Some Positive Statements From Users of the CyFlow Systems
(m) Some of the documents which keep trickling in from both camps (Partec on one side, and MoHSW and MUCHS on the other) have additional information which throw more light on this saga, which I wish to add to this Report:
›› As to MUCHS’ pet question why the CyFlows are reflecting a big market in Africa, and whether CyFlow is recognized and used in countries such as Europe, the answer is simply that Africa is one of the poorest countries globally, and has one of the highest HIV infection rate and largest number of infected persons. Therefore, African countries needed the use of CD4 counting systems more than the first world countries. But in Africa, the use of CD4 and CD4% counting technologies other than CyFlow failed because of the following:
Prohibitive prices for the hardware and the reagents, the after-sales-service costs of about US$ 6,000 per annum, too small throughput (samples per day), too difficult and time consuming sample preparation, and technical issues, including ease of operation of the technologies . Whether CyFlows are used or not used in Europe or USA as much or more than in Africa, is really immaterial. What matters is whether CyFlow techonology works effectively or not in adult and pediatric infected persons monitoring in Africa’s poor settings.This is why when it seems the MUCHS/MoHSW camp is keen to discredit CyFlows only and praise FACSCounts only, Partec submits a lot of documents written by centres mainly in Africa which have experienced first hand the efficacy of the CyFlow systems. Besides, the first world countries (Europe and USA), unlike Africa, is where other CD4 enumerating technologies are manufactured, and naturally such countries would concentrate on extolling other CD4 technologies. And Africa’s experience of the other CD4 counting technologies would be minimal, restricted to only those very expensive technologies which they use occasionally as control or reference methods. And Africa would praise those characteristics of CyFlow minimize costs and yet perform an excellent job - the same as or better than the other technologies. For example:
› Benin: This country which is amongst the poorest countries globally has
procured 20 CyFlow units in operation, which Benin says is due to their
reliable performance and very low cost per CD4 test. This is why Benin has able to start offering CD4 testing to all Beninois free of charge, and CyFlows have positively changed the national Benin treatment programme.
› Zimbabwe: During the year 2006, two evaluations were performed in Zimbabwe
to assess the performance of the CyFlow. One was done at the Dapartment
of Immunology of the University of Zimbabwe. The other one was done at the National Microbiology Reference Laboratory in collaboration with CDC Zimbabwe, Connaught Clinic, and the African Institute of Biomedical Science & Technology. The later was a comparative performance study of a CyFlow SL_3 with a Becton-Dickinson FACSCalibur/Sysmexdual platform method. As in the previous ones, in both these studies showed that the CyFlow performance was at least the same if not better than the FACSCalibur/Sysmex system. This impressively shows that the CyFlow is at least as good as the 5-times more expensive, large, and complicated FACSCalibur reference flow cytometer.
›› Most of the Centers which posses and use CyFlow instruments perform multicenter studies which at the same time compare the CyFlow and mostly the more expensive FACSCount and the FACSCalibur and invariably end up giving positive CyFlow performance statements as the ones above and below. But like most MUCHS’ questions, they more ofen than not level criticisms of the CyFlows, and Partec submitts numerous detailed positive CyFlow statements, while hardly any are submitted for FACS systems, even in a country like Tanzania where these instruments have monopolized the CD4 counters market for the past 15 years.
For instance, Nigeria, which prides herself on possessing and using over 115 CyFlow units, offers the following "To Whom It May Concern" statements such as this one hereunder given by APIN (AIDS Prevention Initiative in Nigeria), and PEPFAR (President’s Emergency Plan for AIDS Relief), two of Nigeria’s many HIV/AIDS centers:
› APIN Centre (Annex 2.55) of Jos University Teaching Hospital, in collaboration with the Havard School of Public Health, of Boston, USA, gave the following statements:
"To whom it may concern: We have been using Partec flow cytometers (CyFlow) since 2003 at APIN/PEPFAR Laboratory. We are currently monitoring over 4,000 HIV positive patients on antiretroviral therapy. We also support a PMTCT/Paediatric programme covering about 10,000 women annually. We are very satisfied with Partec CyFlow technology because it is reliable, easy to use, and cost effective for the enumeration of CD4 T-cells and CD4%. Please find below our publication to support this claim:
Imade, G.E., et al, "Comparison of a new, affordable flow cytometric method and the manual magnetic bead technique for CD4 T-lymphocyte counting in northern Nigerian setting", published in Clin Diagn Lab Immunol. 2005 Jan; 2(1):224-7.
Partec Engineers respond promptly to help us on phone when we call them in times of difficulties. The Partec Engineer resident in Nigeria provides on-site servicing and maintainance of our CyFlow instrument at regular intervals. We are also able to purchase CD4 and CD4% reagents for the CyFlow instruments from the Partec Representative/Distributor in Nigeria.
The CyFlow instruments are user friendly and cost effective. The presence of local technical support, and a supplier of reagents for the instrument is a major advantage. We found Partec CyFlow technology very reliable for use in our setting, a developing country, for monitoring HIV/AIDS infected patients.
Sincerely yours,
Godwin E. Imade. 23/03/2006."
The statement continues to say that:
"Since our CyFlow instrument was installed in October 2003, apart from providing support for APIN/PEPFAR projects, we offer community service and deal with referrals from Plateau and neighbouring states. The cost per CD4 count for referral is Naira600.00 (US$ 4.00) by CyFlow technique, compared to Naira3,500 (US$22.00) by manual technique. They have so far done over 5430 CD4 counts – currently doing an average of 30-50 CD4 counts per day using the CyFlow instrument.
The instrument is robust and rugged, and they assay as many as 70 samples par analyst per day, and it has a capacity to do up to 200 samples per day, without instrument fatigue and errors. The settings of the instrument are very stable.
The reagents have long shelf life and are stable. The CD4 measurements are accurate and precise, with consistency in reproducibility of results. The instrument is very user friendly, simple to operate, and requires a short training session."
"The protocol for CD4 counts is simple and it requires only three pipetting steps of blood, anti-CD4 antibody and buffer. Incubation time is 10 minutes for CD4 counting. The whole test procedure from pipetting, incubation, and counting to obtain CD4 results, takes about 15 minutes. Reagents for CD4 count can be purchased locally from designated Representatives of Partec, at reasonable price of about US$2-3 per test. Other supplies such as calibration beads and measuring tubes can also be obtained from the same Sales/Maintainance Representative who is a Nigerian, and lives within Nigeria. They use locally bottled water to prepare shealth fluid for running the CyFlow instrument, unlike otherflow cytometers whose Shealth fluid is imported from overseas, and sometimes delay in obtaining supplies is a major problem in developing countries. The local Partec Representative /Service Engineer visits the Center periodically for maintainance of the instruments at an affordable cost. They pay maintainance charges and pay for replacements of parts such as instrument tubings etc.when need arises. The maintainance cost so far (within a 17 months period), they say was about US$ 300.00 only.
Compiled by:
Godwin E. Imade and John A. Idoko,
University Teaching Hospital, Jos, Nigeria."
›› The Swiss AIDS Care International’s positive statement’s excerpts on the CyFlow are as follows:
"To whom it may concern: Since February 2004, the Foundation SWISS AIDS CARE INTERNATIONAL provides free anmd comprehensive care, including antiretrovirals, for AIDS patients in an out-patients clinic in Harare, Zimbabwe. At present, the team of Connaught Clinic looks after 1300 patients, of whom 300 are children, and we are currently in the process of expanding our services which will enable us to double the number of patients in the very near future…. After an extensive evaluation of different competitors, we decided to purchase a Partec CyFlow because it was capable to perform a sufficient number of tests per day with the same or better quality than did all other competitors that we tested. However the most obvious advantage was a significantly lower price for the CyFlow equipment and a fixed low price for the reagents which was 3 to 5 times lower than the competitors’. Since the firt week of operation, we have been very satisfied with CyFlow performance. Its installation and instructions took 1½ days only. …. Day to day operation is simple and calibration time is minimal. Power cuts, which have become a common feature in Harare, have no untoward effects because of the UPS which comes with the Partec CyFlow instrument.
Since we are treating so many children, Partec has offered our clinic an upgrade of our system to a CyFlow SL_3 which is capable of determining both absolute CD4 and CD4% counts. In brief, both evaluation studies done in 2006 showed that the performance of the CyFlow is at least as good asif not better than the FACSCalibur/Sysmex system. After 2 years of extensive use and experience, I can recommend highly the use of the Partec CyFlow technology.
Ruedi Luthy, MD, DHC,
Professor Emeritus,
International Medicine and Infectious Diseases
Director Connaught Clinic.
Harare. March 15, 2006."
›› The German aid organization, the Deutsches Medikamenten-Hilfswerk action medeor’ e.V.’s positive statement’s excerpts on the CyFlow are as follows:
"To whom it may concern:
15.03.2006/DA
We are using Partec flow cytometers since August 2003. Since then we use Partec flow cytometers in Africa, Central America, and Oceania. Partec flow cytometers are in use in the following countries:
Zimbabwe, Nigeria, Ethiopia, Kenya, Cameroun, Tanzania, Angola,
Democratic Republic of Congo, Belize, and Papua New Guinea.
We are very satisfied with Partec CyFlow technology because it is reliable, easy to use, and most dedicated for CD4 and CD4% counting. We will continue using Partec CyFlow technology successfully in developing countries for the treatment of HIV/AIDS infected patients.
Yuors sincerely,
Bernard Pastors Dirk Angemeer
Managing Director Head of Sales and Marketing"
N.B. The above positive statement’s use of the sentence: "we will continue using Partec CyFlow technology successfully in developing countries for the treatment of HIV/AIDS infected patients" may be misconstrued as derogatory and offensive. This Report wishes to maintain that such a statement is far from offensive. Instead, it is pragmatic, unlike Prof. Lyamuya’s letter’s idealistic contention that:
"If the CyFlow system is that ideal as described it would be acceptable all over the world. … I would strongly hasitate to accept a test categorized as ideal for developing settings and unsuitable for the first world!"
This is unrealistic. First, the developing countries are the ones which are poorest, hardest hit by the HIV/AIDS scourge, and have more patients who need more affordable, versatile, easy to use CD4 and CD4% counters. Secondly, it is not true to say that affordable CD4 and CD4% counters like the CyFlow are not used or are unsuitable for first world countries.
This Report has given before now, and will give hereunder, long lists of developed countries which possess and use CyFlow instruments satisfactorily. In these developed countries, they are not testing only African blood samples flown in from Africa! Centers in first world countries would not waste so much time and their resources, and risk their reputations in doing multi-center studies with centers in the African countries to develop and perfect CD4 counting technologies "suitable for developing world and unsuitable for the first world"! Thirdly, many reports of comparative studies have been given in the earlier parts of this Report and more are coming in each day, all of which applaud the CyFlow technology:
›› More details of the positive statements of APIN, Jos University Teaching Hospital, Nigeria; as well as others, particularly of University of Ibadan, Nigeria; of the famous Institute of Human Virology, Nigeria; Nigerian Institute of Medical Research; and the Swiss AIDS Care Foundation, Harare, Zimbabwe, are available in the following websites:
http://www.partec.com.distributors/statements/Nigeria-APIN.pdf
http://www.partec.com.distributors/statements/Nigeria-Ibadan.jpg
http://www.partec.com.distributors/statements/Nigeria-IHVN.jpg
http://www.partec.com.distributors/statements/Nigeria-NIMR.pdf
http://www.partec.com.distributors/statements/Zimbabwe-SwissAidsCare.pdf
›› And from: http:www.partec.com/distributors/performance.htlm
more detais of positive Performance Statements by Partec FCM users (see ANNEX 2.58) from USA, Latin America, Europe, Asia, and Africa are given:
Africa:
Africa - German Medical Aid Organization "action medeor e.V.".
Benin - Ministry of Health.
Benin - Ministry of Health – Article in SIDA Report.
Benin - Ministry of Health – Article in SIDA Report.
Benin - ACTION Pour l’Humanite.
Benin - Medicins Du Monde.
Benin - Ministry of Health.
Botswana - Bamalete Lutheran Hospital.
Burkina Faso - Ministry of Health.
Burkina Faso - Exalab.
Cameroun - Ministry of Scientific Researchand Innovation.
Cameroun - Ministry of Health.
Cameroun - Hospital General de Douala.
Cameroun - Hospital Protestant de Bonaberi.
Cameroun - PRESICA – Hopital Militaire de Yaounde.
Cameroun - Litto Libo.
Nigeria - Nigerian Institute of Medical Research (NIMR).
Nigeria - AIDS Prevention Initiative Nigeria (APIN-Havard Boston).
Nigeria - National Institute for Pharmaceutical Research & Development
(NIPRD) – Federal Ministry of Health.
Nigeria - University of Ibadan – Department of Virology.
Nigeria - Institute of Human Virology Nigeria (IHVN).
Nigeria - Gede Foundation.
Nigeria - Nnamdi Azikiwe University Teaching Hospital.
Senegal - Richard Toll Hospital.
Sudan - Sudan National AIDS Control Programme (SNAP).
Tanzania - Bulongwa Lutheran Hospital.
Togo - Ministry of Health – Programme National de Lutte Conre Le Sida
et les IST (PNLS).
Togo - Ministry of Health.
Uganda - Butabika Hospital.
Uganda - St. Raphael of St.Francis Hospital Nsambya.
Zambia - University Teaching Hospital.
Zimbabwe - City Health Department Harare – Beatrice Road Infectious
Diseases Hospital.
Zimbabwe - Ministry of Health.
Zimbabwe - Zimbabwe Swiss AIDS Care Foundation.
Zimbabwe - Hippo Valley Estates.
Asia:
India - Nana Palkar Smruti Samiti.
Papua New Gunea – German Medical Aid Organization "action medeor e.V.".
Vietnam - Dong Da Hospital, Hanoi.
Europe:
France - INSERM.
France - Florimond Deprez.
France - Chemunex.
France - Mertial.
Germany - German Medical Aid Organization.
Germany - German action pro humanity.
Germany - Immuno Tools.
Germany - European Laboratory Association.
Germany - Technical University Dresden.
Germany - University Heidelberg.
Germany - Euro Bio Sciences.
Italy - Azienda Ospidaliera Vorology.
Italy - University of Modena.
Italy - University of Pavia.
Latin America:
Belize - German Medical Aid Organization "action medeor e.V.".
USA
USA - Center of Disease Control and Prevention (CDC) – PASIII/PPCS.
USA - AERAS – Global TB Vaccine Foundation.
Surely all these UN/International Organizations, and research institutions/centres in all these countries of Europe, Asia, Latin America, and Africa could not possibly be praising so much the same CyFlow systems which are getting wrong even the simplest enumeration of CD4 T-cells for low CD4 count samples of <200 cells/μl. Yet everytime I search in the internet specifically for "FACSCount", for instance, I see more information on CyFlow systems (than on FACS systems alone) which have been compared with FACSCount system, where it is invariably found that the CyFlow systems are as good as, and often better than the FACSCount system. Why, the CD4 count results for the CyFlow correlate very well with FACSCount and FACSCalibur systems particularly for low CD4 counts of 0-250 CD4 cells/μl, as will be shown hereunder!
This means that, as demonstrated by perfect results with the Bland-Altman statistics, scientific data substantiate that the separation between the monocytes and the CD4+ T-cells exhibited by the CyFlow systems must be at least as good as for the FACSCount system as will be shown hereunder.
Yet the CyFlow test is by factor of 20 times more affordable than the FACSCount tests. Furthermore, the CyFlow can perform up to 250 tests per day against only about 50 for the FACSCount. And many publications lament the fact that the FACSCount cannot determine the CD4% test for children whereas CyFlow SL do CD4%, and the few types of CyFlow instruments which cannot can be upated easily to CyFlow SL_3 model which can do CD4%. All this, plus the fact that UNICEF, UNAIDS, MSF, and even WHO keep on procuring larger and larger quantities of CyFlow units directly from Partec, making the allegation (of WHO’s Dr. G.Vercuteren and MoHSW’s Dr.F.Ndugulile) regarding WHO’s negative/low opinion of CyFlow technology ludicrously untrue, to say the least.
Furthermore, because the FACSCount did not have any competion until 2002 when the CyFlow was introduced, practically no single international multicenter study exists for the BD FACSCount machine which would match the accurate performance and precission of the large flow cytometers like BD FACSCalibur or Coulter EPICS, or Partec PAS, etc. In contrast to this, several international multicenter studies of CyFlow have been done, and most of them have compared CyFlow with BD FACScan, BD FACSCalibur, Coulter EPICS, BD FACSCount, etc. Thus, unlike the FACSCount, the CyFlow has been tested against all flow cytometry techniques so far established in the scientific field, and CyFlow was always been found to correlate well with all of them.
The amazing thing is that after MUCHS was sent most of these documents appended herewith, instead of trying to wonder if MUCHS may be wrong in its claims that the CyFlow system is inferior or faulty, as vindicated by all these UN and other international organizations, Universities, and research institutions, MUCHS stuck to its claims. The implications of these claims to MUCHS, to MoHSW, to the higher education institutions and public/civil servants, and most important to the young and old patients in Tanzania, is far too devastating to even imagine.
Truly, the total sum of irregularities, inconsistencies, untruths, delays, and the contradictory opinions and orders of various officials of MoHSW, PHLB, MUCHS, NACP, and MSD, do cast shadows of doubt in the impartiality, and give benefit of doubt of graft-related scenarios which does not augur well with the expected reputation/integrity of such an august academic institution like MUCHS.
Tanzania desperately and urgently requires versatile, accurate, precise, easy to operate, yet affordable CD4 machines – more than one type of machines are better for competition – to serve its nearly 2 million HIV/AIDS population in countrywide laboratories with resource limited settings. There exists yet no tangible proof nor justification of limiting procurement of CD4 counters to FACS instruments and make them reference methods while they are themselves as yet unevaluated. And there is no validated evaluation of the CyFlow the world over which supports MUCHS’ disqualification of that Partec’s CyFlow SLR. The question to ask ourselves all of us is , who stands to gain what out of this entire CyFlow Evaluation controversy? Is it realy the HIV/AIDS 2 million patients in Tanzania to whom all our efforts should be concentrated? Or is it a self defeating exercise, and grossly destructive one at that?
(n) In his letter of rebuttal to the MoHSW, Ref.No.MIM/022/01/06 dated 30/01/2006 (ANNEX 2.9), page 3 No. 3(b), Prof. Lyamuya continues explaining the flaws of the CyFlow system in the following way:
"We wish to bring to the attention of the MoH that there are different versions of
CyFlow instruments including CyFlow Counter 1 P, CyFlow SL Green 2 P,
and CyFlow SL Blue 5 P (Ref: Suzanne Crowe, on behalf of the Members
of the CD4 Woorking Group Forum for Collaborative HIV Research)., As such, the various evaluations done in different settings may not have been performed on the same version, rather on different versions of the system. The evaluation done in Nigeria and quoted by Partec, compared the performance of the CyFlow and the Dynabeads (which is not a reference method). With all these facts in mind, it would not be surprising to see differences between studies. Of note also is the fact that in some of the previous evaluations of the CyFlow technology, it has been recommended to carry out multicenter field evaluations to establish performance characteristics in various settings; and also the need to address the issue of internal and external QA (quality assurance) of the system."
» There are several revealing answers to this portion of Prof.Lyamuya’s letter. As in the rest of his letter, there are many indications of lack of reading and/or understanding the profuse literature on the CyFlow systems. Partec has given this Probe Committee and MUCHS and MoHSW oficials many documents and websites thereof, which MUCHS appear not to have read and/or understood:

› If by "differences of results between studies" Prof.Lyamuya’s letter meant to
imply that the CyFlow version which MUCHS evaluated was very different
and that is why it gave imperfect results which are different from any other CyFlow’s results shown in other studies, this inference is wrong. This emanates,
I think, from MUCHS evaluators not reading the operation manuals nor the labels infront and at the back of the CyFlow instrument, to know exactly which version they had evaluated, nor to know that this version has been used in many studies. Apart from a few documents Partecs sent MUCHS and MoHSW, professional immunologists at MUCHS should have been searching the internet regularly in order to know all about CyFlow systems. To show how little MUCHS knew which CyFlow version they were evaluating (and thus they would not know what literature they should read about it), Prof.Lyamuya’s letter’s first paragraph (Background) starts by calling this instrument:
"CyFlow CD4 Easy Count machine (CyTecs GmbH Ser.No. 0480814517)".
This is an obvious misnomer. The product name, "CD4 Easy Count" quoted by Prof.Lyamuya’s letter, is not the name of the CyFlow machine, but it is the name of the IVD and CE approved Kit of reagents which are used in the CyFlow machine to count CD4 cells (see ANNEX 2.41 appended herewith).
In the Partec Invoice No.04093571 dated 22/09/2004, (appended herewith as ANNEX 2.1), the Item Description of the instrument (machine) which MUCHS evaluated, is written clearly as: "CyFlowR SL, Blue, 5 Parameters". This being too long a name, this instrument is popularly known as the CyFlowR or CyFlow Blue, because it is equipped with a blue solid state laser, and it has five optical parameters, namely: forward scatter, side scatter, fluorescence channel 1, fluorescence channel 2, and fluorescence channel 3.
› The back of the CyFlow instrument is written the date of manufacture as 2004, Serial Number as 040814517, and also it has been inscribed: CyTecs GmbH, which is the name of the CyFlow manufacturing company (GmbH). Also written at the back is the physical address where CyFlows are manufactured: "Am Flugplatz 13, D-02828 Görlitz". Görlitz is a city in East Germany. Partec GmbH is the research and administrative section of the whole company known as, "Partec Essential Healthcare" which is physically located in Munster, West Germany. CyFlow is the registered trade mark of CyTecs. It is indispensable to know exactly what machine one is dealing with, in order to succeed in searching for its literature and understanding it thoroughly.
› Each flow cytometer features a specific number of optical parameters. The
number of optical parameters represent the number of different cell
properties that a flow cytometer can measure at the same time. The optical parameters are devided into scatter parameters and fluorescence parameters/channels.

This Partec CyFlowR and its sister the CyFlow R SL_3, to which it can easily be updated, has been used in many multicenter studies for accurate and affordable HIV monitoring in many countries in Africa, Asia, Europe, USA, Latin America, etc., and and has proved just as good and sometimes better that other CD4 counters like FACSCount and FACSCalibur (see ANNEX 2.44, and ANNEX 2.23). The Partec CyFlow R SL_3 complies with the European "IVD" Directive 98/79/EC – a licence allowing the use of reagents and diagnostic techniques for In Vitro Diagnostic use. Only IVD approved products can be used in human health care applications. And because it is "IVD" approved, this CyFlow is also marked with a "CE" sign, which, in Europe, is mandatory for all medical products. The BD FACSCount for instance does not have these important safety standards which CyFlow has – one of the many positive qualities which the Partec CyFlow systems have over the BD FACS systems whose domination of the Tanzanian market is being maintained for many years by ensuring that no CyFlow or any other CD4 counting system is approved to compete with them. There must be clandestine reasons for this state of affairs to be perpetuated this long.
› Prof. Lyamuya’s letter of 30/01/2006 (ANNEX 2.9), page 3 No. 3(b), continued to explain the flaws of the CyFlow system by quoting the "Review of CD4 Technologies" pdf, which Suzanne Crowe published on behalf of "Members of the CD4 Working Group, Forum for Collaborative HIV Research". The link to this very informative pdf file is not as Prof. Lyamuya quoted it, but it is:
http://www.who.int/hiv/amds/Suzzane_Crowe.pdf. Prof. Lyamuya appear not to have known how very positive this pdf file is vis-à-vis the CyFlowR, and that Dr.Suzzane Crowe’s pdf file could not have skipped mentioning the shortcomings with which MUCHS had associated the CyFlow systems. In contrast, Dr. Suzzane’s compilation (see ANNEX 2.59), like the compilation of the Joint UNICEF-UNAIDS-WHO-MSF Project titled: "Summary of CD4+ T-Cell Enumeration Technologies, of June 2005 (and corrected in August 2005)" (see ANNEX 2.23), demonstrate clearly that CyFlow technology compares and correlates well with other CD4 technologies, and sometimes surpasses even the FDA approved FACS instruments like FACSCount, e.g. in being able to do CD4%, and separating the monocytes from the CD4 T-cells, as Dr.Suzzane has illustrated exquisitely by the following histograms/graphs, which corroborate the results of many renowned studies’ results:
› The Cameroon: CD4 Counting – CyFlow vs. FACSCount plot (shown in the appended ANNEX 2.59.1) demonstrates the regression analysis (r) between the two technologies (CyFlow versus FACSCount) with the theoretical and the real coefficient of correlation, r = 0.9899. And, as a matter of fact which is shown by this graph, the correlation is best in the lower CD4 count level (<>500 CD4 cells/µl).

These numerous very positive multicentre studies are the exact opposite of the "imprecision faults" which MUCHS discovered in the CyFlowR determination of low CD4 count samples, and various MoHSW officials echoed in the following reports and/or letters:
~ The final CyFlow Evaluation Report dated 24/10/2005 signed by Dr.Z.Berege, page 2, (see ANNEX 2.14).
~ E-mails from Dr.F.Ndugulile to Dr.G.Vercauteren of EHT, WHO, Geneva, page 1 (see ANNEX 2.42).
~ Minutes of the Special Meeting on 19/06/2006 to discuss the use of the CyFlowR CD4 counter, page 2 (see ANNEX 2.44).
~ Minutes of the Emergency Board, dated 03/07/2006, chaired by Prof. Mhalu, page 2 (see ANNEX 2.46).
~ A Minute dated 12/06/2006 from Dr.G.Upunda, CHO, to the PHLB Registrar, Mr. S.Mrina, page 1 (see ANNEX 2.47).
~ The PHLB’s undated reply to the CHO’s Minute, page 1 (See ANNEX 2.48).
~ A Minute dated 17/07/2006 from the Ag. DHS, Dr. E.Mung’ong’o, to the PS, page 3 (see ANNEX 2.48).
› The Cameroon: CD4 CyFlow vs. FACSCount Bland-Altman plot analysis demonstrates a mean bias of 8 CD4 cells/μl, when comparing the CyFlow and the FACSCount techniques (see ANNEX 2.59.2).
› To clear any lingering doubts about the CyFlow’s capability to differentiate the monocytes from the CD4 T-cells, which MUCHS claimed that it causes imprecision and inaccuracy in determining CD4+ counts in low CD4 count level of < 200 CD4 cells /μl (see ANNEX 2.59.3).
› The ANNEX 2.58.4 demonstrate that the protocol for CD4 counts is simple and
it requires only three pipetting steps of blood, anti-CD4 antibody and
buffer. Incubation time at room temperature in the dark is 10 minutes for CD4 counting. The whole test procedure from pipetting, incubation, and counting to obtain CD4 results, takes about 15 minutes only.
~ When the MUCHS CyFlow Evaluation Report (ANNEX 2.14) talks of faults of the CyFlow as being its imprecision in low CD4 samples of <200 CD4 cells /μl (which has been answered by pdf above (ANNEX 2.59.3), and the need of samples to be stored at 4oC, and daily internal QC being absent, it makes you wonder if the evaluators ever read and followed the instructions of inserts like of CD4 Easy Count Kit – Handling and Storage, as well as Protocol for CD4+ T-cell counting (see ANNEX 2.42, and 2.59.4), operating manuals, and the short and easy instructions of CyFlow’s Word file on the PC desktop named: "CD4 PE PROCEDURE". If and when instructions demand that storage of reagents be between 2-8oC in the dark, and samples should be assayed while fresh (ANNEX 2.41), and MUCHS is leaving the reagents stranded in this tropical Dar heat for about 10 months, no one should expect that MUCHS’ CyFlow Evaluation data to be perfect. And if they are imperfect, the blame should not be laid on the CyFlow, but on this blatant neglect of SOP.
› And ANNEX 2.59.5 & 6 shows positive qualities of the CyFlow technology in resource restrained settings that prevail in developing countries including Tanzania, i.e. simplicity, portability, lowest reagent costs and lower capital instrument costs. In fact, Dr.Suzzane’s paper appears unaware that the CyFlows are capable of doing CD4% and external and internal QA perfectly well.
› Dr. Suzzane’s pdf file corroborates a number of multicenter studies which compared the CyFlow system and the other CD4 and CD4% counting systems. Any academic should know how to search for literature on Partec and CyFlows, e.g. online at PUBMED, http://www.pubmed.org and high-wire hosted journals, http://ajp.amjpathol.org/searchall/, which provides references on more than 300 studies for Partec FCM technology – all satisfactorily successful. For example:
(1) The Zimbabwe-CDC Study published on 31/01/2007 is an Evaluation of Partec
CyFlow SL_3, which is a single platform volumetric FC, against the BD
FACSCalibur/Sysmex XT1800i dual platform assay system in the determination of CD4 absolute counts, and CD4% in the immune monitoring of HIV infected patients in Zimbabwe (See ANNEX 2.39), which concludes that:
"Data showed that the Partec CyFlow SL_3 is comparable to the BD FACSCalibur/Sysmex XT1800i."
(2) The German aid organization, the Deutsches Medikamenten-Hilfswerk action
medeor’ e.V.’s positive statement concludes as follows:
"We are very satisfied with Partec CyFlow technology because it is reliable, easy to use, and most dedicated for CD4 and CD4% counting. We will continue using Partec CyFlow technology successfully in developing countries for the treatment of HIV/AIDS infected patients." Date: 15/03/2006. (see ANNEX 2.57)
(3) The APIN (AIDS Prevention Initiative)/PEPFAR (President’s Emergency Plan
for AIDS Relief) of Jos University Teaching Hospital, Nigeria, in
collaboration with Havard School of Public Health, Boston, USA, which is jointly funded by Bill and Melinda Gates, have published their study in an indexed scientific journal, titled: "Comparison of a new, affordable flow cytometric method (CyFlow) and the Manual Magnetic bead technique for CD4 T-lymphocyte counting in a northern Nigerian setting", by Imade,G.E., et al, Clin Diagn Lab Immunol. 2005 Jan. (see ANNEX 2.55), which concludes:
"The CyFlow instrument is robust and ragged, assaying as many as 70 samples per analyst per day, and it has a capacity to do up to 200 samples per day without instrument fatigue and errors. It is very stable, and CD4 measurements are accurate and precise (for 0-1200 CD4 cells/μl). The CyFlow is user friendly, very easy to operate, and requires short training session, using very simple protocol – the whole tesating procedure taking 15 minutes only."
(4) Another study titled: "Evaluation of a new single platform volumetric flow cytometer for enumeration of absolute CD4 T-Lyphocyte counts in HIV-1 infected Thai patients", by Pattanapanyasat, K., et al, in International Aid Society, 12/07/2004 reports as follows (see ANNEX 2.34):
"HIV-1 infected Thai patients’ blood samples were tested in parallel by 4 techniques: a single platform volumetric CyFlow Green and Guava Personal Cell Analysis (PCA), and two standard SP bead-based methods, TriTest/TruCOUNTTM tube using a FACSCaliburTM FCM, and 2-colour FACSCountTM system. Correlation and agreement were analysed using linear regression and Blamd-Altman analysis.
Results: When compared with the standard TriTEST/TruCOUNTTM and FACSCountTM , the CD4+ T-cell counts obtained from the CyFlow Green showed excellent correlation (R2 = 0.97 and 0.97 respectively). (see ANNEX 2.40).
Conclusion: The volumetric CyFlow Green FCM and Guava PCA system performed well relative to the two standard bead-based systems.
Use of these technologies could make CD4+ T-cell enumeration more affordable in Thailand and other resource-poor settings.
Date: 15/08/2006.
(5) HIV-1 infected and uninfected Senegalese subjects’ blood samples were tested using a research/clinical flow cytometer (FACScan); a dedicated clinical instrument (FACSCount); and a volumetric, mobile, open-system flow cytometer equipped with 3 fluorescence and 2 light scatter detectors (CyFlow SL Blue), and this study was published by Dieye, T.N., et al, as: "Absolute CD4 T-cell counting in resource-poor settings: Direct volumetric measurements versus Bead-based Clinical Flow Cytometry Instruments", in J Acquir Immune Defic Syndr 2005, May 1, 39(1): 32-7 (see ANNEX 2.38).
The results given by the least expensive CD4 counter manufactured by Partec of Munster, Germany, CyFlow SL Blue, had a high correlation (R2 = 0.99) with those produced by the more expensive and technically complicated counters (FACScan and FACSCounter). The CyFlow SL Blue had several additional advantages, such as:
It is easily transportable, and potentially could be transported among clinics in rural settings.
It can use lysed or unlysed whole blood samples, reducing the need for additional supplies.
Unlike other machines, it can provide absolute CD4 counts without having to perform a whole blood cell and total lymphocyte cell count as well, further reducing the costs of each test.
The results reported by Dieye, T.N., et al, are similar to those obtained by Shepherd et al, in their evaluation of 3 low cost instruments, namely:
~ Guava
~ BD Multi Test
~ Partec
These studies are encouraging, and it is hoped that similar progress will be made in developing` low cost testing for viral load

PS 1: The author of the above publication, Dr. Tandakha Ndiaye Dieye, is the
same author who, with Dr.Luc Kestens as one of the co-authors, published
the article titled: "Absolute CD4 T-Cell Counting in Resorce-Poor Settings", in the same journal (!): J Acquir Immune Defic Syndr, Vol. 39, Number 1, May 1 2005, which some MUCHS and MoHSW officials quoted or misquoted when he said, on page 37 (see ANNEX 2.49):
"But accuracy and precission (of the CyFlow SL Blue) MAY be seriously affected as a result of the interference of monocytes, particularly in samples with low CD4 counts (<200 cells/μl) "
As we explained earlier, Dr. Dieye et all used the word MAY to show uncertainty.
And sure enough, when they saw the numerous articles of comparative studies extolling the CyFlow SL Blue technology and that it had enough safeguards to stop the interference of monocytes, on 18/08/2005 Dr. Dieye with Dr. Luc Kestens as one of the co-authors, published the above quoted article in Journal Scan in which he never repeated his previous supposition that "monocytes may interfere", and instead spoke very highly of the CyFlow SL Blue. It often helps to read scientific literature widely all the time.
PS 2: It is even more odd to see that Dr. Dieye, T.N., et al, with Dr. Luc Kestens
again as one of the co-authors, wrote the article titled: "Evaluation of an
affordable instrument for absolute CD4 countingin resource-poor settings against two reference clinical flow cytometers", in International Aids Society, 16/07/2003, in which they concluded that:
"Direct volumetric and bead-based singleplatform measurement on the volumetric CyFlow showed good correlations with gold standard cytometers (for FACSCount, R2 = 0.953; and for TruCount analysis on FACScan R2 = 0.961). The precission of the volumetric measurements on the CyFlow can be improved by including a time versus fluorescence and time versus total cell count plot as an additional internal QC measure."
Once again, no one is imputing that the CyFlow is imprecise for low CD4 count samples (<200 cells/μl) as in these authors’ article of 01/05/2005, just as they are not doing so in their article of 18/08/2005. Instead they both times showing good correlations or agreements with the gold standard instruments!

E. SOME CONCLUSIONS AND NEGATIVE AND POSITIVE STATEMENTS OF THE CYFLOW
THE TERM OF REFERENCE NO.1:
To investigate if there was a deliberate delay in evaluating the Cyflow.
(a) Following the agreement reached at the XV International AIDS Conference in Bangkok from 11-16/07/2004 between the Tanzanian MoHSW delegation and Partec of Germany, one complete CyFlow CD4 counting machine was sent to the MoHSW on 22/09/2004 from Munster, Germany, so that it may be evaluated. The fact that this instrument was not evaluated untilAugust 2005, shows indisputably that there was a delay in evaluating this instrument. Even several MoHSW and MUCHS officials admit that there was a delay, but they give all sorts of justifications for these small delays which totaled up to over one year. All that remains now is to detail the events which demonstrate how the delays occurred, and show whether these delays were deliberate or not.
(b) The Partec Invoice No. 04093571 (see ANNEX 2.1) confirms that the CyFlow instrument complete with all its reagents, left Germany on 22/09/2004, and the Air Waybill No. 724/DUS/42864356 (see ANNEX 2.2) confirms that it reached DIA (Dar es Salaam International Airport) on 27/09/2004. The clearance of the CyFlow from DIA did not start until 11/11/2004, as shown by the Import Declaration Form (see ANNEX 2.3) No. TRA/477391 of MSD (Medical Stores Department); and then it was handed over to NACP (National AIDS Control Programme) on 12/11/2004, by MSD Delivery Note No.14193 (see ANNEX 2.4).
This was the first delay. And although no one has agreed to bear the responsibility of carelessly leaving the CyFlow iits reagents stranded in rather bad conditions at DIA for 1.5 months, inspite of Partec’s several reminders for MUCHS to hurry up, the fault was squarely on this side not on Partec’s side. And since ignorance or forgetfulness is no defence, this first delay may well be termed a deliberate delay.
(c) The two E-mails of the Partec’s Nairobi based Application Specialist Engineer, Mr.Joseph Khisa (see ANNEX 5 & 6) state clearly that this Engineer accompaned by Dr. Benedict Mbawala finally transported the CyFlow complete with its reagents from NACP to MUCHS (Muhimbili University College of Health Sciences), Microbiology /Immunology Department on 15/11/2004, and Mr.Khisa then spent 3 days installing the instrument and training technicians on how to use it (see Mr.Khisa’s E-mails, ANNEX 5 and 6). If any of the reagents were missing (as MUCHS claimed), the installation and the training would not have taken place.

(d) Although no one told us when and who requested for the Reference Methods reagents, the evaluation was delayed further until 24/06/2005 when the MoHSW delivered them to MUCHS, and further delayed until 12/07/2005 when the Calibration Beads which MUCHS claimed were missing were donated by Dr.Mbawala and delivered to MUCHS by the PLHB (Private Health Laboratories Board) Registrar, Mr. Mrina (see Prof. Lyamuya’s letter, ANNEX 2.9, page 1). When on 19/07/2005 the CyFlow screen refused to display, the evaluation had to be delayed again until Partec’s Mr.Khisa came from Nairobi on 23/07/2005 and resolved the problem which was caused by fungal growth (due to the instrument lying idle, unattended, and uncleaned for all these months) blocking the instrument tubings. (see Prof. Lyamuya’s letter ANNEX 2.9, page 1-2; and Mr. Khisa’s E-mails ANNEX 2.5 & 6). Prof.Lyamuya’s letter then says, "subsequently" they commenced evaluating the CyFlow (see ANNEX 2.9, page 2) possibly from 24/07/2005.
This constituted the second delay of 8.5 months (from 15/11/2004 when the CyFlow was delivered to MUCHS to 24/07/2005 when MUCHS finally started evaluating the CyFlow). This made the delay to total up to 10 months (1.5 + 8.5). Whether MUCHS was late to request or the MoHSW was late to order, or who was responsible for leaving the CyFlow and its reagents idle and unattended and uncleaned for all those months, the fault here too is on this side and not on Partec’s side, and so this may be termed a deliberate/unwarranted delay.
This is also born by the fact that once they seriously commenced evaluation, they completed the evaluation by late August 2005, barely one month since they started the evaluation on 24/07/2005, showing that if they were better organized, this evaluation could have taken at most 2 months. Instead, it took about 13 months from the date the CyFlow reached DIA, 27/09/2004, to the date MoHSW issued the CyFlow Evaluation Report on 24/10/2005. Although the MoHSW stipulated 6-12 months total duration of the evaluation, all MoHSW and MUCHS officials were busy giving justifications for the indisputable and unwarranted delays in evaluating the CyFlow, showing that they too realized that the delays were rather overdone and unrationalized.
(e) When the delaying tactics did not appear to succeed to frustrate Partec out of the competition for the Tanzania market for CD4 counters, the strategy resorted to was to opt for an ultimate solution of disqualifying the CyFlow as well as discredit the CyFlow so as to ensure that it forever does not get a market in Tanzania as well as the world ovr. Hence several MoHSW and MUCHS officials, aided by some officials of NACP, AMREF, MSD, and even WHO, jumped on the band wagon of repeatedly discrediting CyFlow and justifying its disqualification by calling it "imprecise" when determining the very important low CD4 count samples (<200 cells/µl), in spite of the numerous positive multicentre studies having exactly the opposite (positive) opinion of the CyFlow.
Since this "imprecision" story constituted 4.5 pages out of the 6 pages of Prof.Lyamuya’s letter (ANNEX 2.9, p.1-2), and comprised 12 out of the 18 pages of Dr.Berege’s final CyFlow Evaluation Report (ANNEX 2.14, p.1-2), and since all the adverse assertions against CyFlow were the basis of disqualifying the CyFlow SL Blue as well as all other CyFlows, I deem it fit to dwell on this point for a substantially long time. First we will start with the negative reports. Then we will end up with the numerous positive scientific reports of the CyFlow.
Negative Reports of the CyFlow System
As if it were not enough to release the negative CyFlow Evaluation Report on 24/10/2005, MoHSW officials kept on exchanging several documents and convening several Meetings to "discuss the CyFlow systems" many months later. One cannot help wondering why:
(i)The CyFlow Evaluation Report of 24/10/2005 (ANNEX 2.14, p.2) signed by Dr.Z.Berege, says: "CyFlow has low accuracy and precision in CD4 count < 200."
(ii) E-mails of 23/12/2005 from Dr.F.Ndugulile (former Director of Diagnostics) to Dr.G.Vercauteren, of the Essential Health Technologies of WHO, Geneva, (see ANNEX 2.41, p.1-2), says: "Findings from evaluation has shown the CyFlow to have less precision with low count samples <200 cells/µl." {It is perplexing what motives Dr.F.Ndugulile had in leaking this CyFlow information to WHO in Geneva barely 2 months after the final CyFlow Evaluation Report was released!}
(iii) Minutes of the Special Meeting dated 19/06/2006 (8 months after the final CyFlow Evaluation Report) (ANNEX 2.43, p.2) says: "Performance of CyFlow was compared to reference methods (FACSCount and FACSCalibur) for 3 categories of CD4 T cell ranges, and the results indicated for CD4 T cell levels <200 cells/µl misclassified 48% of the samples."
{N.B. MUCHS appear to have corroborated their claim that the CyFlow is imprecise for low CD4 count samples by articles which have been contradicted by the same or other authors. We will mention these in the Positive Reports of the CyFlow systems}
(iv) Minutes of the Emergency Board Meeting dated 03/07/2006 (8.5 months after the final CyFlow Evaluation Report) (ANNEX 2.45, p.2), chaired by Prof. Mhalu, says: "The machine is not reliable in counting CD4 less than 200."
(v) A Minute from Dr.G.Upunda, CHO, dated 12/06/2006 (8 months after the final CyFlow Evaluation Report) to the PHLB Registrar, Mr.S.Mrina, says (ANNEX 2.46): "in the evaluation done at the Reference Laboratory, this machine (CyFlow) was faulty in measuring CD4 between 0-200."
(vi) The PHLB Registrar, Mr. Mrina’s undated reply (replied say on 15/06/2008) to the CHO’s Minute (8.5 months after the final CyFlow Evaluation Report), (See ANNEX 2.47) said some eye opening revelations of how the PHLB functions or does not function:
(1) The 27th PHLB’s decision stands that "CyFlows should be used in Referral Hospitals since their performance may be better quality controlled in that level"
(2) The quality of all CyFlows in Tanzania should be followed from July 2006.
(3) Ban any further importation of all CyFlow machines.
(4) The PHLB will communicate with the MoHSW as the recommended actions which will be taking place.
{None of these decisions by the Board were ever implemented. Instead several Meetings were convened to cancel these decisions!}
(vi) A Minute of the Ag.DHS, Dr.E.Mung’ong’o to the PS dated 17/07/2006 (8.5 months after the final CyFlow Evaluation Report) (ANNEX 2.48) says:
(1) This is a summary of the advisory Meeting on the banning of use of all CyFlow machines because it is unsatisfactory.
(2) Many CyFlows were imported here before completing the evaluation.
(3) Research by Luc Kestens in J AIDS Vol.39(1) 1 May 2005, pp 32-37 says:
"Single parameter CD4 gating using a single monoclonal antibody is indisputably more affordable than any multiparameter CD4 measurement, but accuracy and precision MAY be seriously affected as a result of the interference of monocytes, particularly in samples with low CD4 countd (<200 cells/µl). Results of this research resemble the results of the evaluation which was carried out here."
{This article is authored by Dr.T.N.Doieye, and Dr. Luc Kestens is only one of the co-authors (see ANNEX 2.49, p.36-37)}
(4) Also, WHO has not evaluated/validated it. From the WHO Consultation on Technical Operational Recommendation for Scale up of Laboratory Services and Monitoring HIV Anti-Retroviral Therapy (ART) in Resource Limited Settings, Geneva 13-15 December 2004: Partec has the CyFlow Counter, which is a self-contained flow cytometer with one parameter, and the CyFlow Green which has 2 parameters. Both can run on a car battery. More powerful cytometers can be ordered from Partec and are built on order. Field experience has shown that the CyFlow systems MAY NOT YET have overcome technical challenges related to robustness of the equipment or reproducibility of results. The 1 parameter CyFlow counter instrument may also be inappropriate for TB co-infected patients.
(5) The evaluation which was done here shows that: Countinting CD4 cells below 200 shows weak results by 48%. And because results of less than 200 CD4 counts is used to enter patients into AIDS treatment of lengthening life, many people may be barred from getting the treatment. Therefore this machine is unsuitable.
(6) The CyFlow which was imported here has no capability of measuring %CD4 for children.
(7) Therefore the decision as to whether on not this machine should be allowed to be used in Tanzania, should be based on the evaluation which was done here as was explained.
(8) I suggest that the manufacturer should improve the machine and then bring it here to evaluate if it is suitable, according to the existing regulations.
Dr.E.Mung’ong’o
Ag. DHS.
(vii) The article dated 01/05/2005 (6 months before the final CyFlow Evaluation Report was released) written by Dr.Tandakha Ndiaye Dieye, et al (see ANNEX 2.49, p.36-37) has been construed by some MoHSW and MUCHS officials to bear negative reports of the CyFlow performance is infact mostly praising the CyFlow more than the other CD4 counting instruments. As we shall show in the following section on the Positive Reports of the CyFlow Dr. Ndieye has authored other articles (with Dr. Luc Kestens as a co-athor), on studies which compare the CyFlow with other CD4 counters, and the correlations between them is astoundingly close.
(viii) Similarly, some officials of MoHSW and MUCHS have misconstrued the following WHO document dated 13-15/12/2004 (10 months before the final CyFlow Evaluation Report) to be criticizing the CyFlow systems. Infact, the "WHO Consultation on Technical and Operational Recommendations for Scale-Up of Laboratory Services and Monitoring HIV Anti-Retroviral Therapy (ART)in Resource-Limited Settings – Geneva – 13-15 2004" (ANNEX 2.50) is no more than a draft write up of ideas brain-stormed by a few scientists, and its recommendation are neither final nor binding. That is why the names of the scientists consulted are not given; and that is why also this WHO report carries a lot of noncommittal and rather vague terms like "may" or "may not" to show that the Reccommendations are not definitive nor final. Indeed, the final crystallization and revamping of these draft recommendations of that first WHO consultation Committee ciulminated into: "Summary of CD4+ T-Cell Enumeration Technologies" which were compiled and published in June 2005 and revised in August 2005, by a Joint UNICEF-UNAIDS-WHO-MSF Project (see ANNEX 2.23), which includes positive appraisal of the CyFlow technology.
(ix) A Minute dated 22/07/2006 (8.5 months after the final CyFlow Evaluation Report) from Ag. PS, Dr.G.Upunda, the CMO, to the Hon. Minister for Health (see ANNEX 2.51), advising him to agree with MUCHS’ verdict of disqualifying the Partec CyFlow and perhaps consider re-evaluating the CyFlow after its manufacturer rectifies its short comings. Dr. Upunda limited his criticism of the CyFlow to only 3 points written on half a page as follows:
"Please refer to your Minute Ref.No.WAUJ/JUN/06/106 to the DHS,concerning the CyFlow machine. Together with this Minute, I am enclosing the report which made us consider this machine unsuitable for our country setting. {Ofcourse we never saw these enclosures, nor the Hon. Minister’s Minute to the DHS.}
(a) The CyFlow gives unreliable results for CD4 below 200, which is our limit for deciding whether or not to start therapy on our patients. {From quite a lot of evidence we have given above, it has been made crystal clear that:
(1) Since the evaluators of the CyFlow appear not to have read and/or follow the instructions of the Package Inserts, Intrument Operation Manual, nor preparation, protocol and other procedures, it is futile to expect to get correct results.
For instance, handling and storage conditions demand that are stored at 2-8oC in the dark, but theCyFlow machine and its reagents were left lying in the tropical heat at DIA for 1.5 months and on MUCHS bench for a further 6.5 months, well after their 6 months Shelf Life expiry, and ultimately used to evaluate the CyFlow using two BD reference instruments whose reagents were freshly procured! This is contrary to all SOP (Standard Operating Procedures). (see Reagent Insert ANNEX 2.42; see the FACSCount CD4 Machine Logistics Fact Sheets (see ANNEX 2.21.1); and see Partec CD4 Easy Count Kit label ANNEX 2.21.2).}
(b) These machines do not measure well in environments where there is TB infection. This finding has come from WHO. {Clearly Dr.Upunga is referring to the statement on page 9 of the WHO paper on ""WHO Consultation on Technical and Operational Recommendations for Scale-Up of Laboratory Services and Monitoring HIV Anti-Retroviral Therapy (ART)in Resource-Limited Settings – Geneva – 13-15 2004" (ANNEX 2.50)", which states simply that:
"The one parameter CyFlow counter instrument MAY also be INAPPROPRIATE FOR TB CO-INFECTED patients". (ANNEX 2.50, p 9)
And ofcourse, if this were CERTAIN it would be catastrophic, since most patients who are HIV positive in Tanzania also suffer from TB. But:
(1) This WHO paper’s statement is far from certain, i.e. it means that the CyFlow machine MAY OR MAY NOT be inappropriate.
(2) This WHO paper was describing the "CyFlow Counter 1 Parameter". Neither Dr.Upunda nor Prof. Lyamuya looked at the back of the instrument, and at its literature to know that the version of CyFlow machine MUCHS evaluated was the "CyFlow SL Blue, 5 Parameter", it was not a one parameter CyFlow machine.
(3) As we said in No. (viii) above, The recommendations which the WHO Consultative Committee made in Geneva on 13-15/12/2004 were preliminary brain-stormings and its recommendation are neither final nor binding, but they were refurbished and crystallized until they ended up as a more certain and more accurate compilation of the Joint UNICEF-UNAIDS-WHO-MSF Project which is captioned : "Summary of CD4+ T-Cell Enumeration Technologies" of June 2005 and revised in August 2005 (see ANNEX 2.50), which includes positive appraisal of the CyFlow technology. This final WHO/UNICEF/UNAIDS/MSF compilation ofcourse there is no mention of any shortcomings of the CyFlow technology, proving again that Dr. Upunda and his collegues did not understand that WHO consultative Committee statement and/or quoted it out of context. All this will be corroborated in the Positive CyFlow Reports we will give hereunder.
(c) The other Study which the CyFlow manufacturers quoted at length {Dr.Upunda has not mentioned which study!} is one in which he (the manufacturer) or his agents participated. {This full Report of the Probe Committee, above and below here, will end up mentioning nearly hundreds of Multi Center Studies, most of which compare the CyFlow technology with other flow cytometric and manual technologies.
And in all those studies, the CyFlow systems have proved to be as good as if at times not better than all the other CD4 counting systems.
Besides, what precisely is wrong with an expert to contribute his/her expertise in a joint study? It is ludicrous to even think that one scientist can possibly deceive/pressurize (bribe) all other scientists with whom he/she participates in joint studies all the time. And what about those hundreds of other studies in which Partec people did not participate – is it not absurd for anyone to insinuate that all those people who give positive reports of the CyFlows performances in all those joint studies must have been bribed by Partec?}
I suggest that we should accept the suggestion we were given by our researchers (MUCHS) that these machines are unsuitable for our settings right now. If the manufacturer can improve its performance, them we shall re-evaluate it and make decisions at that time.
Dr. Gabriel L.Upunda
Ag. Permanent Secretary.
Now let us try to find out the rationale or motives of convening this many meetings and communications about the already condemned CyFlow machine:
(x) Raison d'être Behind Discussing the CyFlow Long After Disqualifying It
After a judge convicts and condemns a person to the gallows it is utterly futile to start discussing that persons case 8 months or even one hour after the guilty verdict, unless there is proof beyond reasonable doubt that there was a mistrial. Similarly, after the final CyFlow Evaluation Report dated 24/10/2005 there was no point in discussing the CyFlow nor ask the Hon. Minister to accept the highly orchestrated guilty verdict 8 months after MUCHS’s verdict, because obviously MUCHS would not easily withdraw its verdict, even if there were too many popular outcries of unfair play. The following table attempts to fathom out the rationale behind these hurried Meetings on the already convicted CyFlow:
Chronological Order and Reasons for the flurry of Meetings to Discuss the
CyFlow several months after releasing the final CyFlow Evaluation Report
No.
Date and Title
Criticisms/Faults of the
CyFlows reported by
Articles/Minutes,&Answers
The rebuttals of criticisms of the CyFlow
by MUCHS and interpretations of belated
Meetings and Minutes concerning CyFlow
1
24/10/2004
CyFlow
Evaluation
Report by
Dr.Berege
(a) Partec CyFlow has low
accuracy & precision with
low CD4 count.
(b) Needs samples to be stored at 4oC overnight.
(c) Daily Internal QC not
incorporated.
(d) Local technical support
is not available.
The following are answers to the above criticisms.
à{(a) Precission and accuracy has not been CyFlow’s fault, since many multicentre studies which compared CyFlow systems and the FACS as well as other CD4 counters show very good correlation between them (see Partec insert of CD4 Easy Count Kit, ANNEX 2.42,p 2-3); also Zimbabwe-CDC Study (see ANNEX 2.39); Nigeria-Havard, Boston Study (ANNEX 2.36); Zimbabwe-Stanford Study, (ANNEX 2.29). The cause of this fault may be due to MUCHS not observing SOP e.g. by keeping its reagents for 8 months (well beyond their prescribed 6 months Shelf Life), while the reagents were exposed to tropical heat of >30oC instead of 2- 8oC}
à Continue to next column
{(b) Like the FACSCount’s CD4 Logistics Sheets (ANNEX 2.21.1), both the CyFlow Sheets for Partec CD4 Easy Count Kit do have "Handling and Storage" conditions instructing to storereagents at 2-8oC and in dark (see ANNEX 2.42); and the storage temperature is repeated in the Reagent Bottle Label (see ANNEX 2.21.2). It is strange to expect perfect analysis results when this simplest operating procedure of storing reagents at 2-8oC is turned into exposing reagents to 30oC heat for 8 months (well beyond their Shelf Life of 6 months)?
(c) A glance at Operation Manual and other literature of CyFlow clearly shows that CyFlows do incorporate QC, and any trained Technician uses this every time they wish to count CD4 T-cells.
(d) "Local technical support not available" is a strange requirement for a Ministry which signed a Contract of Technical Support with a local BD FACSCount supplier, yet over 50% of the 50 or so FACSCounts are constantly out of order! Besides, the Nairobi based Partec Engineer jetted to MUCHS to run a 3 day training session for Technicians, and the second time he came to MUCHS’s rescue when the CyFlow’s dirt and fungi in its tubing stopped its screen displaying. And in spite of many offers for him to assist MUCHS, he and all Partec people were banned from visiting MUCHS ever again! Wasn’t it wiser to expect Partec to establish a local technical support at least after and not before the CyFlow was evaluated?}
2
13-15/12/2004
WHO article titled:
"Consultations
on Monitoring
HIV ART in
poor settings",
which MoH &
MUCHS quote as evidence of
CyFliws’ faults.
This article’s statements which they quote are:
"CyFlow MAY NOT be
appropriate for TB co-
infected patients. Field
experience shows that
CyFlow MAY NOT YET
have overcome technical
challenges of robustness or reproducibility of results."
The answer is as follows: à Continue reading to the next column.
{The expression MAY is not a definitive
or precise word, and can mean "May" or "May not" be inappropriate for TB, and may or may not have overcome robustness and reproducibility. The truth is, these WHO consultants’ recommendations were
not finalized in December 13-15/12/2004 until June 2005 (and they were revised in August 2005), when a Joint WHO-UNICEF-UNAIDS/MSF Project compiled
the approved/recognized CD4 enumeration technologies which included the CyFlow technology (see ANNEX 2.23); and this definitive concise compilation did not mention any such CyFlow faults at all.}
3
01/05/2005
Article by Dr.
Dieye,TN et al
co-authored by
Luc Kestens
and is quoted a lot byMoHSW /MUCHS as their evidence of the CyFlow systems faults, is published in J Acquir Defic Syndr, Vol. 39 No. 1, 01/05/2005.
Various officials of MoH &
MUCHS have quoted
statements of Luc Kestens’ article (which is the same as Dieye,T.N. et al’s as evidence of the CyFlow systems being faulty. Infact it gives mainly positive attribuites of the CyFlow. The statements they often quote are on page 37 of ANNEX 2.49 saying that: "Single-parameter gating using single monoclonal antibody is indisputably more affordable than any multiparameter CD4 counte but accuracy & precision of the CyFlow MAY be affected by the monocytes especially in low CD4 counts of <200 cells/μl, because the Monocytes do express CD4 molecules."
There are many answers:
{(a)‘May’ is a tentative and word which can mean ‘may’ or ‘may not’. Thus it is not worth quoting it.
(b) DrDieye and DrKestens have also written other very positive articles about CyFlow with no mention of this criticism of CyFlows:
(i) Journal Scan dated 18/08/2005, together with its more positive comments by Dr. Art Ammann (see ANNEX 2.38).
(ii) International AIDS Society, dated 16/07/2003 in which they conclude that: "Direct volumetic and bead-based single platform CyFlow correlated very well with gold standard cytometers (FACSCalibur & FACSCount)."
àcontinue to next column
(c) Dr.Suzanne Crowe’s pdf files illustrate how easily CyFlows separate the monocyte from the CD4 T-cells and from backgroung fluorescence (ANNEX 2.59.3)
(d) See in the ANNEX 2.54, the screen shot of the correct (setting) QC run (Fig.5), done using the CyFlow returned from MUCHS, in which the T-cell (taller) peak is well separated from the monocytes peak (shorter, of weaker fluorescence). Cf. Fig.6 and 7 when the same returned CyFlow is using incorrect setting, and so fails to separate the monocytes.
(e) The application note of Partec "CD4 Easy Count Kit" (see ANNEX 2.42, pp2-3) shows the same type of picture of a direct counting result by using CD4 Easy Count Kit, successfully separating the monocytes from CD4 T-cells. This application note has a: "NOTE: Please always refer to package insert of the CD4 Easy Count, to check the preparation procedure of the whole blood (fresh) samples and the dilution factor – about which the evaluators of the CyFlow did very little of.
(f) ANNEX 2.16 shows printouts of samples from a CyFlow SL Green, belonging to Dr. Mbawala, showing all 3 categories of CD4 cell counts, low, medium and high, all showing perfect separation of monocytes from CD4 T-cells, using FACSCount as a control.
(g) Partec Application Note (ANNEX 2.15), on page marked 2/4 shows a similar picture of analysis of a sample from a health donor using a 3 parameter CyFlow SL_3, with the monocytes well separated from the CD4 T-cell cluster.
(h) The imprecision observed by MUCHS may have been caused by non observance of SOP e.g. use of 8 months old reagents whose 6 months shelf life had expired, and the same reagents were left unattended, and exposed to the tropical heat of >30oC (instead of being kept at 2-8oC, as the Operating Procedures in the inserts and Instrument Manual stipulates) for many (about 8) months.}
4
06/10/2005
Prof. Lyamuya of MUCHS
submitted
his final
CyFlow
Evaluation
Report to the MoHSW.
Presumably, this Report (we did not have access to MoH files) cited the "imprecision" of the
CyFlow system when determining Low CD4 count samples <200 cells/μl.
à continue on the next
column
{Having known about these two above
Articles: "WHO Consultation on Technical … Recommendations … in Geneva, dated 13-15/12/2004 (ANNEX2.50)" and "Dieye et al’s ‘Absolute CD4 T-cell Counting …’ dated 01/05/2005 (ANNEX 2.49)", and enterpreted them as being anti-CyFlow, what followed was obviously to quote that CyFlow was faulty and quote these two articles, as well as Suzzane Crowe’s pdf file (ANNEX 2.59) as evidence that MUCHS’ results were corroborated by those two articles. But in actual fact, these 3 articles were very pro-CyFlows, and their statements preceded by "MAY" were misunderstood to be anti-CyFlow.}
5
23/12/2005
Dr. Ndugulile
Of MoHSW E-mailed Dr.
Vercauteren of WHO telling him about Tanzanian findings on CyFlow show
that the
CyFlow machine is
flawed.
Dr.F.Ndugulile, former
Director of Diagnostics of
Tanzanian MoH leaked to
Dr.G.Vercauteren of WHO EssentialHealth Technolgy, Geneva, by E-mail, this same story of CyFlow’s imprecision at low CD4 count. It is unclear if he was quoting the MoH’s final CyFlow Evaluation Report and/or Luc Kestens’ article that other MoH officials kept on quoting as evidence of CyFlow’s imprecision.
{(a) Dr.Ndugulile "leaked" to our Probe Team these E-mails (ANNEX 2.41) in confidence, and asked us not to quote them nor him! Whatever his motives were in leaking CyFlow’s Report to a third party as far away as Geneva, one thing is clear that from that time onwards, WHO tended to be against CyFlow systems.Dr.R.Gohde of Partec had to complain to Dr.Vercauteren several times, and later to the two WHO Assistant Director Generals before things cooled down a bit (see ANNEX 2.52.1-4).
(b) This claim of CyFlow’s imprecision at low CD4 count (<200 cells/μl) which has been voiced too often by many officials of MoH and MUCHS has been rebutted more than enough in all the points 1-4 above. Since many multicenter Studies to compare CyFlow systems and many other CD4 counting systems show close correlation between them (see ANNEX 2.59.1-3; 22.56; 2.35; 2.39; 2.29), either all these CD4 counters including the CyFlows are faulty, or none of them are faulty at all.
(c) Dr. Ndugulile is the one who also tried hard to prevent Dr.Mbawala from importing his CyFlow SL Green machine but when comfronted by the then PS he gave in. He then resorted to using some
WHO officials to poison International organizations’ opinions against CyFlow
with little success.}
6
12/06/2006
Dr.Upunda,
CMO, minuted
Mr.Mrina,PHL
BoardRegistrar
to advise MoH
Dr.Upunda’s letter started by saying the Reference Laboratory found CyFlow to be faulty when testing CD4 between 0-200. Dr.Upunda therefore asked
PHLB to advise MoH what to do about the 5-6 CyFlow
Machines which are already
imported into Tanzania.
{Although MUCHS had evaluated only
one CyFlow, and although it was known
that there are various versions of them,
this Minute appears to want the PHLB to condemn all the CyFlow machines! Observe what follows, particularly when Mr.Mrina’s reply seemed to soften this Minute’s very rigid stand.}
7
ca 15/06/2006
Mr.Mrina, the
PHLB Registrar
Returns a reply to the CMO’s
Minute.
Mr.Mrina replied that:
(a) The advise of the 27th PHLB Meeting that the CyFlows should be allowed to be used in Tanzania, but only in Referral Hospitals. (b) All the CyFlows already here, should be evaluated, and the results of their evaluations should be discussed by the PHLB on 30/09/2006.
(c) All further importations of CyFlow machines be banned until the requested evaluations are completed.
(d) The PHLB will liase with the MoHSW as the evaluation results of those CyFlows are released.
This is what followed:
{(i) Mr.Mrina’s reply was too bitter to swallow, as it would disturb the status quo and bring competition, albeit a lop sided one, of the CyFlows versus the FACSCount. This would jeopardize the over 10 years of FACSCount’s monopoly
(ii) If PHLB’s advice were applied, the CyFlows would supply one unit to each region, ie. 20 CyFlows only in all; against FACSCounts which will supply well over 100 units – one unit to each District!
(iii) But even this lop sided distribution of these affordable CyFlows versus the very expensive and difficult to use FACSCounts having several disadvantages over the CyFlows, did not satisfy some people whose objective was to rid Tanzania of all CyFlows somehow.
(iv) From this time on, the PHLB Chairman and Registrar missed quite a few Meetings convened to "discuss" the CyFlow machines.
(v)The decisions of the 27th BoardMeeting
(a) To use CyFlow machines in Referral Hospital was reversed.
(b) To evaluate the other CyFlow machines was overturned.
(c) Instead, all those 6 or so CyFlows should be banned, and replaced by FACSCounts!! (To implement this new decision, so far Bulongwa has received its FACSCount, and it is doubtful if they would stop using their two CyFlows which were more satisfactory for their setting than the FACSCount which was often breaking down).
(d) Can suppliers of FACSCount forget to return/reward such acts of favouring BD FACSCount?}
8
19/06/2006
A Special
Meeting was
called to
discuss the
use of CyFlow
machines in Tanzania
This Special Meeting was not attended by the PHLB Registrar nor by the PHLB
Chairman. It was attended by only 5 members including Dr.F.Ndugulile of MoH, Prof.E.Lyamuya of MUCHS and Dr.R.Swai of NACP. and one invitee, Partec’s Dr. Mbawala.
à Dr.Ndugulile gave the history saying that:
(i)The delay in evaluating CyFlow was due to failure of suppliers to supply reagents in time
{This is untrue, since the
CyFlow came with a full Starter Kit, i.e. a complete set of supplies (see packing list ANNEX 2.11}.
à He said that when evaluated, the CyFlow was found misclassifying 48% of low CD4 count samples below 200 cells/μl.
{This was not caused by CyFlow’s fault, as stated in all the above points 1-5 above. Besides, many studies (see the Positive CyFlow Reports below, also see multicentre studies, which compare CyFlow systems with FACSCount and other CD4 counters, and didn’t come across this fault (ANNEX 2.44)}.
Continue to next column à
~ The Meeting grilled Dr.Mbawala to
the point of asking him to elaborate the
criteria he used to make his assessment
on the accuracy of the CyFlow system!
{If these Minutes are correct, I wonder
why Dr.Mbawala didn’t tell them he
owns a CyFlow whose results are
comparable to those of a FACSCount
which assayed same samples. But what
criteria were used to test the accuracy
of FACSCount?}.
~ Prof.Lyamuya concluded by asking
Dr.Mbawala to: (a) submit evidence of
WHO Multicenter evaluation, and
(b) submit list of other countries using
CyFlows other than Africa!
{(a) WHO has no Laboratories to
evaluate CyFlow or any other
counters. WHO recognizes studies
made by one or more centers which
then invite WHO to recognize or
validate them. Proofs of WHO
recognition of CyFlow systems is:
(i) WHO continues to procured many
CyFlow units (see ANNEX 2.25;
2.26; 2.27; 2.28).
(ii) WHO, UNICEF, UNAIDS, MSF
jointly published lists of CD4
counting Technologies and their
good attributes which they recognize,
including CyFlow systems
(see ANNEX 2.23).
(b) Countries, other than Africa,
which are using CyFlows are
numerous. ANNEX 2.58 gives the
result of a rapid search of the
Internet: http://www.partec.com/distributors
Performance.htlm only which has 35 centres in Africa; 3 centres in Asia; 14 centres in Europe; 1 centre in Latin America; and 3 centres in USA, which use various Partec systems including the CyFlow SL Blue which MUCHS evaluated.
~ And there are quite a few more. But so what do we conclude by all this evidence? That therefore MUCHS’ claims against CyFlow are null and void?}
9
03/07/2006
Emergency Meeting to
discuss what
THISDAY and
KULIKONI
alleged about
HIV Rapid
Test Kits
This Meeting was chaired by Prof F.Mhalu in the absence of Dr.Z.Berege.
Not surprisingly, they also discussed CyFlow (Partec),
and made fundamental
changes to their previous
decisions concerning the
CyFlow shown on the
next column à.

{(a) They said that: this CyFlow is incorrect below 200. {The answers to this are well covered in points 1-7 above.}
(b) The Budget Meeting of 26/06/2006 also discussed the CyFlow {I didn’t have access to its Minutes}.
(c) Centres which possess CyFlows in Tanzania have proven faulty, and some didn’t participate at all in the evaluations. {I wonder why these were not named, nor wer there 18 pages CyFlow Evaluation Reports for each of them}.
(d) The Board withdrew its decision of 26/06/2006 which allowed CyFlows to be used in Referral Hospitals.
(e) CyFlow machines are unsuitable, and before removing them, NACP should replace them with FACSCounts {So far
Bulongwa has already been given one FACSCount machine}

10
17/07/2006
A 4 page
Minute from
Dr. E.P.
Mung’ong’o
Ag. DHS to
The PS on
CyFlow
Machine
Dr. Mung’ong’o refers to
The PHLB Emergency
Meeting of 03/07/2006.
(a)He refuted Partec’s claim that the reagents for CyFlow Evaluation were not expired.
{(i) He did not mention the 6 months Shelf Life which certainly had elapsed.
(ii) But even if there were only "Expiry date" to consider, you don’t buy a medicine and wait until 1 or 2 months before the expiry date to use the medicine. And in this case, the 8 months old reagents (whose 6 months’ Shelf Life had expired) which was exposed to tropical temperatures of > 30oC instead of keeping them at 2-8oC, were compared to FACS machines reagents which were new and fresh! How can one expect reasonable results from this abrogation of SOP? }.
(iii) He said although it was cheap, the CyFlow gives incorrect measurements at low CD4 counts, and quoted JAIDS Vol 39(1) of
1/5/2005, pp 32-37
{This journal article is exactly the same as Dieye, et al’s, as explained above.
As is the issue of separation of monocytes from T-cells in order to avoid imprecision at low CD4 counts.}. Continue next column à
(iv) He said WHO has never validated/evaluated the CyFlow.
{The answer is simply ‘neither has FACSCount nor any other counter been validated by WHO, because WHO, having got no laboratories, merely validates /recognizes studies which have been done by centres recognized by it. And certainly WHO recognizes/approves the CyFlow system and included it in a list of Systems selected by a Joint WHO-UNICEF-MSF-
UNAIDS Project in June 2005 (and revised in August 2005 (see ANNEX 2.23)}.
(v) He said that CyFlow MAY NOT be
appropriate for TB co-infected patients, quoting as evidence the WHO Consultative
Committee’s Recommendations (see ANNEX 2.50) which were draft ones and not final until June 2005 when WHO-UNICEF-UNAIDS-MSF jointly published
the lists of recognized CD4 counting technologies which included the CyFlow technology (see ANNEX 2.23).
(vi) He repeated the claim that counting CD4 cells below 200 gives poor results, thus this machine is unsuitable.
{This has been well argued in all yhe above numbers 1-9.}
(vii) he said that this CyFlow cannot do CD4% for children.
{This too is caused by a lack of reading the Operation Manual, reragent inserts, and other CyFlow literature.Unlike FACSCount
the CyFlow systems do have capability to do CD4%.}.
11
22/07/2006
A one page
Minute from
Dr.G.Upunda
the then Ag.
PS and CMO, to the Hon.
Minister for
Health and
SocialWelfare.
Dr.Upunda is referring to a
Minute Ref.No. WAUJ
/JUN/06/106 {We did not see this Minute, nor the attachments he gave him}.
(a) He said that CyFlow is
unreliable at CD4 - 200 {This claim has been answered well in No. 1-8}.
(b) He said that CyFlows are unreliable for TB co-infected patients, quoting as his evidence WHO Consultative Committee’s draft Recommendations. {This claim too has been answered in No. 2 above}.
Continue next column à
(c) He said another Study which Partec referred to is unreliable because the Partec person himself was a co-participant in the study. {This claim too was answered earlier. Very few of these 300+ Studies involved Partec people, and even those few comprised many researchers and centers of repute to be able to be influenced (bribed) by bending the joint Reports.}.
(d) Consequently Dr. G.Upunda advised the Hon Minister to accept MUCHS’s verdict of the faults of the CyFlow such as imprecision and failure to separate monocytes from CD4 cells.

Positive Reports of the CyFlow System
1. While detailing the faults of the CyFlow, Prof. Lyamuya’s letter of 30/01/2006 (ANNEX 2.6, page 3) quoted Dr. Suzzane Crowe’s pdf file as his evidence. On the contrary, Dr. Suzzane’s is one of the many documents which praises the CyFlow System very highly, as the following graphs/plots demonstrate:
› The Cameroon plot captioned: CD4 Counting: CyFlow vs. FACSCount plot (see ANNEX 2.59.1) shows excellent correlation (r=0.9899) when comparing the CyFlow and the FACSCount techniques. As it is clear from the plot, in fact the correlation between these two is better at low levels of 0-200 cells/μl than at higher levels of 500-1500 cells/μl. So, if anyone claims that CyFlow is imprecise at low CD4 counts (<200 cells/μl), then FACSCount is also imprecise, which no one has ever admitted.
› Statistical analyses of these two instruments for precission, correlation and agreement/comparability were performed, and as shown by the Cameroon: CyFlow vs FACSCount Bland-Altman Plot, mean bias obtained was 8 CD4/μl (see ANNEX 2.59.2).
› To clear any lingering doubts about the CyFlow’s capability to differentiate the monocytes from the CD4 T-cells, which would lead to imprecision and inaccuracy in determining CD4+ counts in low CD4 count levels < 200 cells/μl, Dr. Suzzane Crowe has given an excellent plot of the separation of the monocytes from the CD4 T-cells and from the Background fluorescence (see ANNEX 2.59.3).
› These authentic plots clear the main two or three allegations of the CyFlow’s imprecision, inaccuracy, and the separation of the CD4 monocytes from the CD4 T-cells, on which MUCHS and MoH based their ban on all (!?) CyFlows.
› The ANNEX 2.58.4 demonstrates that the protocol for CD4 counts is simple and
it requires only three pipetting steps of blood, anti-CD4 antibody and
buffer. Incubation time at room temperature in the dark is 10 minutes for CD4 counting. The whole test procedure from pipetting, incubation, and counting to obtain CD4 results, takes about 15 minutes only (cf. 70 minutes for FACSCount).
~ When the MUCHS CyFlow Evaluation Report (ANNEX 2.14) talks of faults of the CyFlow as being its imprecision in low CD4 samples of <200 CD4 cells /μl, caused by the failure to separate the CD4 monocytes and CD4 T-cells, Dr. Suzzane’s print out (ANNEX 2.59.3) answers that claim. And when the final CyFlow Evaluation Report complains of the need of samples to be stored at 4oC, and daily internal QC being absent, it makes one wonder if the evaluators ever read and followed the instructions of inserts like of CD4 Easy Count Kit – Handling and Storage, as well as Protocol for CD4+ T-cell counting (see ANNEX 2.42, and 2.59.4), operating manuals, and the short and easy instructions of CyFlow’s Word file on the PC desktop named: "CD4 PE PROCEDURE". If and when instructions demand that storage of reagents be between 2-8oC in the dark, and samples should be assayed while fresh (ANNEX 2.41), and MUCHS is leaving the reagents stranded in this tropical Dar heat for about 8 months, no one should expect MUCHS’ CyFlow Evaluation data to be perfect. And if they are imperfect, the blame should not be laid on the CyFlow’s imprecision or other faults, but should be placed on this blatant neglect of SOP.
› And ANNEX 2.58.5 & 6 shows positive qualities of the CyFlow technology in resource restrained settings that prevail in developing countries including Tanzania, i.e. versatility, simplicity, portability, ease of operation, lowest reagent costs and lower capital instrument costs.
› Dr. Suzzane’s pdf file corroborates a number of multicenter studies which compared the CyFlow systems with the other CD4 and CD4% counting systems. Any academic should know how to search for literature on Partec and CyFlows, e.g. online at PUBMED, http://www.pubmed.org and high-wire hosted journals, http://ajp.amjpathol.org/searchall/, which provides references on more than 300 studies for Partec FCM technology. All these studies are satisfactorily successful, with correlation between CyFlow systems and FACS and other CD4 counting systems being very good. I am not sure if officials of MUCHS and MoHSW have seen Reports of these 300+ Studies. For example:
(1) The Zimbabwe-CDC Study published on 31/01/2007 reports the Evaluation of
Partec CyFlow SL_3, which is a single platform volumetric FC, against the
BD FACSCalibur/Sysmex XT1800i dual platform assay system in the determination of CD4 absolute counts, and CD4% in the immune monitoring of HIV infected patients in Zimbabwe (See ANNEX 2.39), which concludes that:
"Data showed that the Partec CyFlow SL_3 is comparable to the BD FACSCalibur/Sysmex XT1800i." This answers claims that CyFlows cannot perform a CD4% count.
(2) The German aid organization, the Deutsches Medikamenten-Hilfswerk action
medeor’ e.V.’s positive statement concludes as follows:
"We are very satisfied with Partec CyFlow technology because it is reliable, easy to use, and most dedicated for CD4 and CD4% counting. We will continue using Partec CyFlow technology successfully in developing countries for the treatment of HIV/AIDS infected patients." Date: 15/03/2006. (see ANNEX 2.57).
(3) The APIN (AIDS Prevention Initiative)/PEPFAR (President’s Emergency Plan
for AIDS Relief) of Jos University Teaching Hospital, Nigeria, in
collaboration with Havard School of Public Health, Boston, USA, which is jointly funded by Bill and Melinda Gates, have published their study in an indexed scientific journal, titled: "Comparison of a new, affordable flow cytometric method (CyFlow) and the Manual Magnetic bead technique for CD4 T-lymphocyte counting in a northern Nigerian setting", by Imade,G.E., et al, Clin Diagn Lab Immunol. 2005 Jan. (see ANNEX 2.55), which concludes:
"The CyFlow instrument is robust and ragged, assaying as many as 70 samples per analyst per day, and it has a capacity to do up to 200 samples per day without instrument fatigue and errors. It is very stable, and CD4 measurements are accurate and precise (for 0-1200 CD4 cells/μl). The CyFlow is user friendly, very easy to operate, and requires short training session, using very simple protocol – the whole tesating procedure taking 15 minutes only."
(4) Another study titled: "Evaluation of a new single platform volumetric flow
cytometer for enumeration of absolute CD4 T-Lyphocyte counts in HIV-1
infected Thai patients", by Pattanapanyasat, K., et al, in International Aid
Society, 12/07/2004 reports as follows (see ANNEX 2.34):
"HIV-1 infected Thai patients’ blood samples were tested in parallel by 4 techniques: a single platform volumetric CyFlow Green and Guava Personal Cell Analysis (PCA), and two standard SP bead-based methods, TriTest/TruCOUNTTM tube using a FACSCaliburTM FCM, and 2-colour FACSCountTM system. Correlation and agreement were analysed using linear regression and Blamd-Altman analysis.
Results: When compared with the standard TriTEST/TruCOUNTTM and FACSCountTM , the CD4+ T-cell counts obtained from the CyFlow Green showed excellent correlation (R2 = 0.97 and 0.97 respectively). (see ANNEX 2.40).
Conclusion: The volumetric CyFlow Green FCM and Guava PCA system performed well relative to the two standard bead-based systems.
Use of these technologies could make CD4+ T-cell enumeration more affordable in Thailand and other resource-poor settings.
Date: 15/08/2006.
(5) HIV-1 infected and uninfected Senegalese subjects’ blood samples were tested using a research/clinical flow cytometer (FACScan); a dedicated clinical instrument (FACSCount); and a volumetric, mobile, open-system flow cytometer equipped with 3 fluorescence and 2 light scatter detectors (CyFlow SL Blue), and this study was published by Dieye, T.N., et al, as: "Absolute CD4 T-cell counting in resource-poor settings: Direct volumetric measurements versus Bead-based Clinical Flow Cytometry Instruments", in J Acquir Immune Defic Syndr 2005, May 1, 39(1): 32-7 (see ANNEX 2.49).
The results given by the least expensive CD4 counter manufactured by Partec of Munster, Germany, CyFlow SL Blue, had a high correlation (R2 = 0.99) with those produced by the more expensive and technically complicated counters (FACScan and FACSCounter). The CyFlow SL Blue had several additional advantages, such as:
It is easily transportable, and potentially could be transported among clinics in rural settings.
It can use lysed or unlysed whole blood samples, reducing the need for additional supplies.
Unlike other machines, it can provide absolute CD4 counts without having to perform a whole blood cell and total lymphocyte cell count as well, further reducing the costs of each test.
The results reported by Dieye, T.N., et al, are similar to those obtained by Shepherd et al, in their evaluation of 3 low cost instruments, namely:
~ Guava
~ BD Multi Test
~ Partec
These studies are encouraging, and it is hoped that similar progress will be made in developing` low cost testing for viral load.

8. HAS THERE BEEN AN UNNECESSARY DELAY IN ONGOING EVALUATIONS OF HIV TEST KITS INCLUDING SD BIOLINE SO AS TO ENTER SUCCESSFUL ONES INTO THE NATIONAL ALGORITHM?
1. Background
In this SD Bioline investigation, we encountered two opposing forces. On one side is "SD (Africa) Ltd.", a local company representing "Standard Diagnostics Inc." of Kyonggi-do, South Korea, the manufacturer/supplier of diagnostics including the SD Bioline HIV Rapid Test Kit which SD (Africa) sent to the MoHSW (Ministry of Health and Social Welfare) for evaluation. The President of the mother company, Standard Diagnostics is Dr. Young-Shik, Cho, while the Managing Director of SD (Africa) is Mr. James Chae, P.S., and the local representative of Mr. Poong Suk Chae is Lt. H.G.Chifupa (Retired), General Manager of another company called "Tega International Communication and Supplies Ltd." who was the one following up the progress of the SD Bioline evaluation most of the time. SD (Africa) used to complain that, since their SD Bioline HIV 1/2 3.0 Rapid Antibody Test Kit underwent Phase I evaluation successfully, and obtained a positive Report Ref.No. ACD.T/083/02/03 dated 14/03/2003 from AMREF, and another positive Report from MUCHS Ref. No. MIM/022/A.5 dated 03/04/2003, they deserve getting their product registered and entered into the new National Algorithm, before marketing it.
SD (Africa) and its officials repeatedly used to argue that, the motive for the MoHSW delaying the announcement of the new Algorithm is ostensibly so as to continue giving Tenders to the firm which has been supplying the unevaluated and uncertified Capillus and Determine HIV Test Kits since 2001, i.e. the Biocare Health Products Ltd. which is owned by a local wealthy businessman Mr. Bharat Rajani of the CyFlow saga fame (see various newspaper reports in Annex 2.6.3, 2.60.4 2.60.5, 2.60.7, 8, 2.60.9, 2.60.10, 2.60.11, 2.60.12 and 2.60.13).
On the opposite side, there are the MoHSW, MUCHS (Muhimbili College of Health Sciences), NACP (National AIDS Control Programme), MSD (Medical Stores Department), AMREF (African Medical and Research Foundation), and their various officials who performed the evaluations and exchanged hot corresponded with SD (Africa) about this delayed evaluation. Their various officials always answered back simply that they were still carrying out the evaluations all this time (2002-2006) in order to enable them to compile the new and better National Algorithm, without hinting (even to our Probe Team) what exactly remained to be evaluated nor how long that would take.
For this SD Bioline saga too, officials of the MoHSW, MUCHS, NACP as well as AMREF who dealt with the CyFlow evaluation, are more or less the same officials who dealt with this SD Bioline. Naturally, none of these officials could or did come forward to confirm that there was a deliberate delay, nor tell us who exactly is responsible for the delay, if any, and why.
And it was not easy to find fault with MoHSW’s regular answer of: "The evaluations which will produce the new National Algorithm is not yet complete".
We therefore had to resort to literature in addition to letters and documents from various sources including several often multiple interviews of willing persons.
2. Some of the Many Available HIV Rapid Test Kits and Their Specifications
The infection of this awful pandemic HIV which gets worse and worse each day, in resource poor settings of developing countries like Tanzania, need rapid testing strategies in spite of the existing lack of reliable electric power and skilled manpower, and efficient transport and cold storage facilities. There is therefore an acute need of appropriate regularly evaluated HIV rapid testing algorithms and protocols, to support the many national HIV programmes in both urban and rural areas. The selected HIV Tests in appropriate algorithms must be thoroughly and regularly evaluated and registered.
This will invariably increase the confidence in results obtained for blood safety, surveillance, voluntary counseling and testing (VCT), and diverse diagnostic activities, in poor settings like the one obtaining in Tanzania where resources are limited, as is the potential to provide required testing with conventional EIAs.
There exist over 100 HIV Rapid Test Kits on the market today, only a few of which are shown in the Table hereunder.
A WHO BULK PROCUREMENT SCHEME 2003
SPECIFICATION OF HIV TEST KITS
SIMPLE RAPID ASSAY KITS
Rapid Assay Test Kit Name
(Manufacturer)
Tests
/Kit
HIV
Type
Assay Type
Antigen
Sample Type
Cost/Test
US $
SD Bioline HIV 1/2 3.0
{Standard Diagnostic Inc.
(SEAR & WPR only)}
30
HIV-1
HIV-2
Lateral flow
Recombinant proteins
Whole blood
Serum/Plasma
0.92
Determine HIV 1/2
{Abbott}
100
HIV-1
HIV-2
Lateral flow
Recombinant proteins
Synthetic peptide
Whole blood
Serum/Plasma
0.80-1.00
Capillus HIV 1/2
{Trinity Biotech plc}
20
100
HIV-1
HIV-2
Agglutination
Recombinant proteins
Whole blood
Serum/Plasma
1.10
UNI-GOLD HIV 1/2
{Trinity Biotech plc}
20
HIV-1
HIV-2
Lateral flow
Recombinant proteins
Whole blood
Serum/Plasma
1.25
SERODIA HIV 1/2
{Fujirebio}
100
220
HIV-1
HIV-2
Agglutination
Recombinant proteins
Serum/Plasma
1.11
1.11
ADVANCED QUALITY
Rapid HIV Test {InTec
Products Inc} SEAR WPR only
40
HIV-1
HIV-2
Lateral flow
Recombinant proteins
Whole blood
Serum/Plasma
0.50
FIRST RESPONSE HIV
WB Card Test {Premier Medical Corporation (SEAR & WPR)}
30
HIV-1
HIV-2
Lateral flow
Recombinant
Proteins
Whole blood
Serum/Plasma
0.70
INSTANTCHECK HIV 1/2
Rapid Test {EY Laboratories
SEAR & WPR Only}
40
100
HIV-1
HIV-2
Lateral flow
Whole blood
Serum/Plasma
1.07
1.00
HIV 1/2 DOUBLECHECK
{Orgenics Ltd.}
40
HIV-1
HIV-2
Lateral flow
Recombinant
proteins
Serum/Plasma
1.00
IMMUNOCOMB II BISPOT
HIV 1/2 {Orgenics Ltd.}
36
HIV-1
HIV-2
Dipstick
Sythetic
peptides
Serum/Plasma
1.00

Rapid Assay Test Kit Name
(Manufacturer)
Tests
/Kit
HIV
Type
Assay Type
Antigen
Sample Type
Cost/Test
US $
ELISA ASSAY KITS
VIRONOSTIKA HIV
UNIFORM II PLUS O
{Biomerieux BV}
192
576
HIV-1
HIV-2
HIV-0
Recombinant proteins.
Synthetic
peptides
450 nm
0.69
0.49
UBI HIV 1/2 EIA
{United Biomedical}
192
HIV-1
HIV-2
Snthetic
peptides
492 nm
0.40
HIV EIA
{Anilabsystem Ltd. OY}
96
480
960
HIV-1
HIV-2
Synthetic
peptides
450 nm
0.43
0.39
0.37
HIV-1 / HIV-2 g0 EIA
{Abbott}
100
1000
HIV-1
HIV-2
HIV-0
Recombinant
proteins
492 nm
0.85
0.60
ENZYGNOST ANTIHIV 1/2
plus {Dade Behring AG}
Enzygnost/TMB Reagent Kit
2x96
10x96
HIV-1
HIV-2
HIV-0
Recombinant
proteins
450 nm
0.99
0.75
Aid Agencies like WHO have a list of some HIV Rapid Test Kits, but they always caution each country to conduct its own thorough evaluations of many Kits so as to come up with best possible algorithms most suitable for its own national conditions, which will need reviewing regularly so that only the best algorithm remains in use.
3. Objectives of the Evaluations
The overall goal is to evaluate groups of five commercially available simple HIV Rapid Test Kits, which are as affordable, fast, easy to operate, and user-friendly as possible, using the following three-phase approach, for each:
1. Validate their Sensitivity and Specificity of the Rapid Test Kits within a Reference Laboratory setting. This is called Phase I of the evaluation.
2. Determine the Sensitivity and Specificity of the Rapid Test Kits when used at points of service, and develop algorithms of established testing characteristics. This is called Phase II of the evaluation.
3. Implement quality-assured testing Algorithms in multiple points of service testing sites (Phase III).
The advantage of having more than one Algorithms, which keep on being re-evaluated regularly, cannot be overemphasized. It ensures that always one has a reliable Algorithm to fall back to, within minimum phasing out/in period, in case one or more of the combination members of the incumbent Algorithm is found to be wanting or if another Algorithm proves to be better than the incumbent one.
4. What Does the Evaluation Actually Entail?
(a) So as to help estimate how long it takes to come up with a new National Algorithm, we better have a look at the work load involved.
(b) Specifications like storage and assaying temperatures, cost per test, shelf life/expiry dates, equipment requirements, assay type antigen, sample type, speed of the test, etc. could easily be obtained from manuals or specifications or instructions given by the manufacturers of the Rapid Test Kits.
The bulk of the evaluation work lies in determining the Test Kits’ sensitivity and specificity (Phase I, II and III), where characteristics such as storage/working temperatures and shelf lives could also be verified, if need be.
Phase II of the evaluation is conducted in two steps: In Phase IIa, residual specimens stripped of identifiers is used for testing five HIV Rapid Test Kits at the collection sites, and assay results are compared to the EIA method. In Phase IIb, assay results from algorithm derived from Phase IIa above are compared to the results of the reference EIA method. Phase IIa is conducted at three sites for Dar es Salaam: (i) AMREF ANGAZA. (ii) PASADA. (iii) Muhimbili HIV Information Center (MHIC).
Phase III will be the implementing and monitoring for each Point of Service (POS), to determine how the selected tests perform on a limited number of specimens from people who are attending POS as a quality assurance for the selected algorithm used based on Phase I and Phase II results.
Samples collected, 1,500 – 2,000, would be anonymized and given randomized numbers, tested and the evaluation results compared to the previous results by going back to the site with the site numbers. A proficiency panel of specimens comprising 10 samples (five HIV positive, and 5 HIV negative) was performed before conducting tests on the 600+ samples was carried out to see how the technicians and the tests will fair. The persons performing the HIV testing do not know the original HIV Test results on any of the specimens being tested. To minimize bias as to the HIV Test results obtained with the other Rapid Tests evaluated, the laboratory technicians switch the specimens they are working on. These and any other checks and counter-checks are meant to reduce bias or inter-reader variabilities.
5.How Many HIV Rapid Test Kits Were Involved in the Evaluation? Which?
Peoples’ and news media chorus of disapproval of unfair play compelled the MoHSW to issue a Press Release dated 10/11/2006 to announce the long awaited "Change of National HIV Rapid Testing Algorithm". The Press Release
talked of: "Some 18 different tests that are currently on the market were considered for evaluation", without mentioning their names or whether they were all evaluated. And from the Final Report of Phase I Evaluations dated 23/10/02, the following 8 HIV Rapid Test Kits were evaluated at the Laboratories of MUCHS and AMREF. NB. By 24/2/2003 Kenya had 36 Test Kits in use.
Test Kit
Its Manufacturer
Report Reference and/or Date
Capillus
Trinity Biotech, Ireland
23/10/2002
Determine
Abbott, USA
23/10/2002
Hemastrip
Saliva Diagnostic Systems,USA
23/10/2002
Oraquick
Orasure Technologies, USA
23/10/2002
Unigold
Trinity Biotech, Ireland
23/10/2002
SD Bioline
Standard Diagnostics, Inc,Korea
MIM/022/A.5 dated 3/4/2003
ENZYGNOST
ANTIHIV1/2 plus
Dade Behring AG
Enzygnost/TMB Reagent Kit

ELISA
Biometrieux BV

SUMMARY OF PHASE I EVALUATION RESULTS 2002/2003
Test
Capillus
Determine
Hemastrip
Oraquick
Unigold
SD Bioline
Number
positive
269
267
258
265
270
302
Number
true +ve
268
267
258
265
269
301
Number
false +ve
1
0
0
0
1
1
Number
negative
1153
1155
1164
1157
1152
198
Number
true -ve
1150
1151
1151
1151
1150
198
Number
false –ve
3
4
13
6
2
0
Sensitivity
98.89%
98.52%
95.20%
97.79%
99.26
100.00%
Specificity
99.91%
100.00%
100.00%
100.00%
99.91%
99.50%
Considering that detailed Phase I Evaluations for at least six HIV Rapid Test Kits available in the market in Tanzania were already conducted officially by MUCHS and AMREF by the years 2002/2003 (see the Tables above).
If Phase II and III Evaluations were well coordinated and seriously conducted, they should have taken weeks or a few months, instead of nearly four years for the new National Algorithm to be concluded and announced by the Press Release on 10/11/2006.
6. Who Are Responsible for Evaluating, Registering, and so Entering or Not Entering an HIV Test Kit Such as SD Bioline in the New National Algorithm?
This is a very pertinent question for our Probe Team, though it can be easily misconstrued to mean that we are already accusing certain particular persons or offices of certain misdeeds. As the Probe Team had no access to MoHSW files, the only way to clear this possible doubt is to bring in at this juncture, a few letters dealing with application and complaints letters to MoHSW and their agents, from SD Africa and their agents, wishing to put their SD Bioline in the National Algorithm List, and the sort of replies they were getting, so as to detect any possible signs of delay there.
Some of the Letters and Other Documents of Complain Concerning the Alleged Delay in the Inclusion of SD Bioline in the New National Algorithm
(a) A positive letter Ref.No. HC/49/421/01/432 dated 15/10/02, from the PHLB Registrar, to SD Africa, saying that he was glad to allow SD Africa to import SD Bioline and other lab supplies for trials/evaluations at MUCHS and AMREF.
(b) Another encouraging letter from Dr.R.Swai, NACP Director dated 20/04/03 to Mr. Poung Suk Chae, Managing Director of SD Africa, praising the SD Bioline.
(c) Another very positive letter Ref.No.GA.134/209/07/ dated 1/7/2003, which was signed by Dr.G.Upunga, the CMO, on behalf of the PS, to SD Africa Ltd., (see Annex 2.65 appended herewith) putting on record what these two discussed:
(i) That SD Africa showed the CMO a formal Registration of their SD Bioline.
(ii) That this Registration followed tests performed by the Tanzanian researchers who were satisfied with the performance of those (SD Bioline) Test Strips which SD Africa had supplied to be assessed.
(iii) The CMO liked to put on record the fact that the registration of SD Bioline by the PHLB, means that this product is now allowed to circulate and be used by the Health Facilities in Tanzania, both public and private.
(iv) In conclusion, the CMO strongly advised SD Africa to market its product (SD Bioline); and as for its use in public Institutions, the CMO advised SD Africa to wait until the Medical Tender Board called for Tenders for such items and SD Africa could bid like any other company.
{It makes one wonder why, after all this high praises from a top MoHSW official, SD Africa was faced by constant delaying tacticts and obstacles to the point of failing to market SD Bioline nor bidding in Tenders for such items because all the Tender Invitations, without any compunction, persistently used these items’ trade names of Capillus and Determine, although these two had never been registered to be eligible for bidding at any Tender.
And this gave the suppliers of Capillus and Detrmine virtual monopoly of supplying billions worth of these unevaluated HIV Test Kits from 2001 to date!}
(d) On 10/11/2003, SD Africa wrote a short letter to PHLB, submitting copies of its registration which it received from PHLB since 03/10/2002, so that PHLB would give SD Africa a final Evaluation Report of SD Bioline from MUCHS, as PHLB promised by its letter Ref. No. HC/49/421/01/432 dated 15/10/2002.
(e) On 14/02/2003, a "Report on the Evaluation of SD Bioline HIV 1/2 3.0 Rapid Antibody Test", Ref.No. ACD.T/083/02/03, from AMREF to NACP (see ANNEX 2.61) was issued which made the following 8 concluding strong points, 1 weak points, and recommendations – all highly praising SD Bioline:
Strong Points:
1. The Test Kit was user friendly – no reagent preparations, 2 step procedure for whole blood.
2. The Test Kit was ideal for small batch testing (VCT sites, Small transfusion sites).
3. The Test Device may be stored for future reference.
4. Minimum training is required.
5. Disposal of Test end products is easy – only plastic device (no glass products i.e. bottles, vials,
pipettes, carcinogenic or corrosive chemicals).
6. Refrigerator is not essential, though may be required.
7. Storage conditions 2-30oC.
8. Based on this limited evaluation, it is assumed that the SD Bioline HIV 1/2 3.0 Rapid Antibody
Test may conform to the nationally acceptable standards (Sensitivity 100%, and Specificity 100%).
Weak Points:
Materials supplied were not adequate for 30 clients i.e. lancet, capillary dropper and pipette dropper – only one of each was supplied.
Recommendations:
The sample size was too small for a comprehensive evaluation. It is recommended that proper evaluation should be conducted to determine the sensitivity and specificity based on local situation in Tanzania.
{Clearly, this MUCHS Phase I Evaluation Report is full of praises for SD Africa’s SD Bioline , with hardly any criticism of SD Bioline , bearing in mind that MUCHS is the only recognized Reference Laboratory in Tanzania.}
(e) On 03/04/2003, a "Report of Phase I Evaluation of SD Bioline HIV 1/2 3.0 Test Kit", Ref.No. MIM/022/A.5, from MUCHS to SD Africa (see ANNEX 2.62), giving the following 9 Merits, 3 Shortfalls, and a Conclusion of SD Bioline:
Merits of the Test Kit:
1. The Test Kit is user friendly.
2. Small and light Kit, well packed for easy storage.
3. Does not require intensive training to be able to operate the Test Kit correctly.
4. Minimum steps, hence it is easy, fast and minimal biohazard risks.
5. Does not require cold storage, and no step is dependent on electric power supply, hence can be
used reliably in hard to reach settings.
6. One can use whole blood, plasma or serum. Whole blood can be kept at 2-8oC for up to 3
days before testing.
7. the sample volume for testing is very small.
8. The point of service Test Kit format is designed in a way that is very convenient for
use in a Voluntary Counseling and Testing (VCT) setting.
9. Disposal of end products is easy because these are plastic materials.
Shortfalls:
1. In some of the sachets for point of service Kits, the diluent was present in very small amounts,
such that there wouldn’t be more to draw in case there was an accidental spill. However this small amount was sufficient for the test.
2. We could not determine reproducibility of the test in this evaluation because we needed more
Kits for this purpose.
3. Due to lack of seroconversion panels, we could not determine the relative seroconversion
sensitivity index for this test. Such well characterizes panels are only available in big
reference HIV testing Centres.
Conclusion:
This Report presents results of the Phase I Evaluation of a Simple/Rapid HIV Test, i.e. Evaluation done in a Reference Laboratory. The findings indicate that the Test has excellent performance characteristics and has several advantages that make it a good Test for use in HIV Testing Sites in hard to reach settings.
{Clearly, this AMREF’s Phase I Evaluation Report too is full of praises without any criticism for SD Africa’s SD Bioline; and AMREF’s Laboratories are second only to MUCHS’s, if not equal, in reliability.}
(f) Things began to take a "U" turn with the 3 page letter from PHLB to SD Africa, Ref.No.HC.49/421/Vol.11/170 dated 6/2/2004, captioned: "Board Response on the Evaluation of SD Bioline HIV 1/2 3.0 Rapid Test Kit, performed by MUCHS and AMREF", which gave the following conclusions :
HIV 1/2 assay Kits had no positive and negative controls.
There is no evidence of registration of the product in South Korea where they were manufactured.
Apart from a WHO Draft Report which was submitted with the Kits, there was no indication of any other laboratory outside Tanzania where evaluation was carried out, neither were there any publications on the products.
It was not indicated what the Kit assays were meant for, whether for blood donors screening or diagnostic testing and if so whether they were meant to be used alone or in combination with other assays.
Ideally HIV tests should be evaluated on several sources of samples such as: (i) HIV/AIDS suspect patients, (ii) Blood donors, (iii) Pregnant women, (iv) other difficult (indeterminate) samples, (v) early seroconverters…
Conclusion: In view of the information basing on the short comings reflected in the evaluation report for the two Test Kits, that is SD (Bioline) HIV 1/2, and Syphilis Test Kits, the Board does not approve the two Test Kits in their present form. Further evaluation will be needed as recommended by the Technical Team".
{The main thrust or focus of this letter’s criticisms are not really substantive. PHLB should have asked SD Africa to fulfiled all those requirements before starting the evaluation of the SD Bioline, e.g. positive and negative controls, Korean registration, evaluation results from outside Tanzania, etc. It is doubtful if other Kits like Capillus or Determine were given the same treatment.
The truth is, from this time onwards, MoHSW officials started criticizing SD Bioline on fake criticisms which would delay even more the completion of its evaluation and so its inclusion into the National Algorithm.}
(g) A letter Ref.No. HC.49/421/01/230 dated 20/05/2004, signed by Dr.Z.Berege on behalf of the MoHSW PS, captioned "Evaluation of SD Bioline SD HIV 1//2 Kits and Others", addressed to Lt. H.Chifupa, Managing Director of TEGA International Ltd., representative of SD Africa, informing him that: SD Africa was to submit additional 18 Kits (540 tests), their request regarding the use of AMREF evaluation results was not appropriate, and the issue of a temporary registration permit was not advised.
{It is strange! Not only are all these stringent orders have never been given
to any other HIV Test Kit like Capillus and Determine which are the only Kits allowed to bid in all Tenders, but Dr. Berege’s attitude and remarks towards AMREF leave much to be desired. Not only has PHLB always directed suppliers to submit samples for evaluation to both MUCHS and AMREF who liase very closely, but AMREF’s results are invariably copied to MUCHS and vice versa. Why has the situation changed abruptly?}
(h) Another letter Ref.No. HC.49/421/Vol.II/232 dated 21/05/2004, addressed to SD Africa is now exhibiting open conflict against SD Africa. It is criticizing SD Africa for not replacing the Professional Mr. Hatibu Mritta (after his resignation) who had a lengthy meeting with the PHLB!) and for not involving him in all technical issues of SD Africa, and only a Technical Officer should handle SD Africa’s tehnical matters and correspond with the PHLB(!), etc. The PHLB held a lengthy discussion with Mr. Mrita, one wonders what about!
(i) A letter Ref.No. ACD.T/407/06/04 dated 11/06/2004 captioned "Report on a field evaluation of Bioline SD HIV 1/2 Rapid Antibody Test", from Dr. Awene Gavyole, Ag. AMREF Country Director, addressed to Programme Manager, NACP. This Final Phase II Evaluation Report gave another excellent performance of SD Bioline, as it was for its Phase I Evaluation, unsurpassed by any other HIV Rapid Test Kits on the Tanzanian market, as following summary shows:
Results for Phase I Evaluations
No.
Name of Rapid Test Kit
Sensitivity
Specificity
01
Capillus
98.89
99.9 1
02
Determine
98.52
100.00
03
Hemastrip
95.20
100.00
04
OraQuick
97.79
100.00
05
Unigold
99.26
99.91
06
SD-Bioline
100.00
99.50
Results for Phase I Evaluations
No.
Test
Test Results
1.
HIV Antibody Positive (Sensitivity)
44
2.
HIV Antibody Negative (Specificity)
551
3.
Bioline SD Positive, other 5 Rapid Assays were Negative
3
4.
Bioline SD Negative, other 5 Rapid Assays were Positive
2

Number of Samples Tested
600
Note: The 5 samples which were discordant against the other 5 Rapid Test Kits, have not been verified by any other assay, because all the residual samples were sent to MUCHS Reference Laboratory for EIA and further confirmatory tests.
Conclusion: In the Phase I of the Laboratory based Evaluation, characterized samples with known serostatus were used, and the Assay Performance was very good.
In the Phase II of this Evaluation, samples from the general population attending VCT services were used; and with the assumption that the HIV prevalence in general is low (about 11.8%, as per NACP Report No. 17, of March 2003). In this particular population, the prevalence was about 8% . Therefore, with the Sensitivity of 95.7% and Specificity of 99.5%, we can conclude that the Performance of BIOLINE SD HIV 1/2 3.0 Rapid Antibody Test was of acceptable level and standard if used with other assays.
N.B.: The following results appear not to have been submitted with this Report until later when it was requested by SD Africa’s Representative:
Spec
No.
Oral
Quick
Deter
mine
Uni
gold
Hema
strip
Capi
llus
Vironostica Uniform II
Ag/Ab
OD CO OD/CO
Vironostica Uniform II
Plus O
OD CO OD/OC
3067
N
N
N
N
N
0.056
0.176
0.320
0.037
0.167
0.220
3172
N
N
N
N
N
0.044
0.174
0.250
0.043
0.177
0.250
3187
P
P
P
P
P
3.466
0.174
19.92
2.778
0.165
16.84
3080
P
P
P
P
P
3.268
0.159
20.55
2.489
0.167
14.90
3114
P
P
P
P
P
3.236
0.159
20.35
3.748
0.177
21.18
3124
P
P
P
P
P
2.741
0.159
17.24
03.56
0.177
20.11
3344
N
N
N
N
N
0.066
0.171
00.39
00.04
0.144
00.28
Recommendations: Based on the results and the performance in the field, it is recommended that the rapid SD Bioline HIV 1/2 3.0 Tapid Antibody Test be considered for inclusion into the List of potential Rapid HIV Test Kits to be used in the country.
Strong Points: The following observations were made:
1. The Test Kit was user friendly – no reagent preparations, 2 step procedure for whole blood.
2. The Test Kit was ideal for small batch testing (VCT sites, Small transfusion sites).
3. The Test Device may be stored for future reference.
4. Minimum training is required.
5. Disposal of Test end products is easy – only plastic device (no glass products i.e. bottles, vials, pipettes, carcinogenic or corrosive chemicals).
6. Refrigerator is not essential, though may be required.
7. Storage conditions 2-30oC.
8. Based on this limited evaluation, it is assumed that the SD Bioline HIV 1/2 3.0 Rapid Antibody Test may conform to the nationally acceptable standards (Sensitivity 100%, & Specificity 100%).
8. Local Representation is available.
N.B.: There were no Weak Points reported this time around.
N.B.: This Report was copied to MUCHS as well as to NACP."
(j) Apart from SD (Standard Diagnostics) making Letters of Intent with Aid Agencies like WHO or UNESCO to supply them with SD Bioline HIV 1/2 Rapid Tests Kits, some of the aid agencies after performing the evaluation, they found SD Bioline to have very good evaluation results, as shown in the Table hereunder, and as AMREF’s Phase II Evaluation Report stated – "the SD Bioline HIV 1/2 3.0 Rapid Antibody Test may conform to the nationally acceptable standards (Sensitivity 100%, & Specificity 100%).":
WHO Evaluation (Phase I) of SD Bioline HIV 1/2 Rapid Test
1. Result Table

2. Results of Sensitivity

Reference

A. Sensitivity 100%

+
-

1) HIV - 1 : 100%
+
157
2
159

2) HIV – 2 : 100%
-
0
294
294

B. Specificity 99.3%

157
296

C. Seroconversion panel:
Similar result with
Behring HIV ELISA

3. Benefit: Qualified HIV Test in the World
~ Participation in WHO HIV Test Kit Bulk Procurement Scheme
~ Participation in Global Tender
~ Excellent Promotional Data
(k) Even the Ministry of Health Zanzibar Aids Control Programme wrote an Internal Memo Ref.No.ACP/2 dated 24/02/2004 extolling SD Bioline:
INTERNAL MEMO
To: Dr. Omar M. Shauri, Principal Secretary, Ministry of Health
From: ZACP Manger – Dr. Mohammed Dahoma
Subject: Evaluation of the Standard Diagnostic Kit, SD Bioline HIV 1/2 3.0
Details: Following the Agency Tanzania Co. Ltd. request (letter Ref. No. ATCO/TZ2001/54/03 dated 31/10/03), we had to provide the Central Mnazi Mmoja Laboratory with 60m Kits for quality assurance.
Comparative evaluation on SD Kits against the currentlyused gold standards in Zanzibar has revealed that the Kits are sensitive and specific as was initially determined by AMREF and WHO and MUCHS.
With this background I suggest that the Kits be registered to the Pharmacy Board before being allowed in circulation.
(l) It came as a surprise when AMREF decided to revise its positive Phase II Evaluation results (see ANNEX 2.71) all of a sudden from a Sensitivity of 95.7% to 97.8% and issued another report captioned: "Report on field evaluation of Bioline SD HIV 1/2 3.0 Rapid Antibody Test: An Amendment of Results." Ref.No. ACD.T/454/07/04 dated 13/7/2004, one month after issuing the same Report dated 11/06/2004, and gave the reason for so doing as:
"This Report compliments the earlier Report dated 11/06/2004. There is an upward adjustment in the sensitivity and specificity when compared with results received from MUCHS."
Our efforts to have access to the "MUCHS’s Phase II Evaluation of SD Bioline HIV 1/2 3.0 Rapid Antibody Test Kit", and/or to get AMREF to explain why this Report had to be revised, were in vain. The amended Report was like this:
No.
Parameters
Test Results
1.
HIV Antibody Positive (Sensitivity 97.8%)
45
2.
HIV Antibody Negative (Specificity 99.8%)
553
3.
Bioline SD False Positive
1
4.
Bioline SD False Negative
1
5.
Positive Predictive Value (PPV 97.8%)

6.
Negative Predictive Value (NPV 99.8%)

7.
Test Efficiency (99.7%)

Number of Samples Tested
600
(m) In response to frequent complaints from the suppliers of SD Bioline and its agent Tega International, Dr. Z.A.Berege signed for MoH PS a letter Ref.No.HC.49/421/01/230 dated 20/05/2004 (see ANNEX 2.69), addressed to TEGA International stating, among other things, the following:
"In a joint meeting of the officials of SD Africa, PHLB, and MoH, it was agreed:
~ SD Africa to submit additional 18 HIV Test Kits (540 tests) instead of the 700 tests it submitted to AMREF earlier, because MoH likes to stick to expert advice.
~ SD Africa’s request to use AMREF test evaluation results was denied.
~ The issuing of a Temporary Registration Permit to SD Africa was denied too."

{~The fact that AMREF deemed it fit to amend their original Report only after comparing its Report with that of MUCHS, and MoHSW chose to find that amendment unacceptable, raises doubts as to the inter-departmental/inter-reader influence and bias, which are supposed to be absent in proper scientific investigations.
~ AMREF’s original and amended results differed slightly as follows:
AMREF’s Results
Of Phase II SD
Bioline Evaluation
Sensitivity
Specificity
Original,Ref.No. ACD/407/06/04
dated 11/6/2004
95.7%
99.5%
Amended,Ref.No. ACD.T/454/07/04
Dated 13/7/2004
97.8%
99.8%
Change Effected by the Amendment
+ 2.1%
+ 0.3%
Now, any increase in Sensitivity and Specificity of SD Bioline, means an increase in the good performance of SD Bioline, which would be more unpalatable for anyone who wished to downgrade SD Bioline for any good or bad reason. Some MoH officials appear to have been so angry at AMREF’s action of ‘upgrading’ SD Bioline by amending the original sensitivity from 95.7% to 97.8% that someone in the MoHSW hierarchy reprimanded AMREF for this ‘blunder’, although no one at AMREF is ready to avail us a copy of that letter of reprimand. But the attitude of disliking AMREF for this blunder is evident in many MoH letters including this very one under discussion, i.e. Ref.No. HC.49/421/01/230 dated 20/05/2004.
~ Clearly, the onslaught against the SD Bioline HIV 1/2 3.0 Rapid Test (Kit) had started in earnest, and it continued in spite of frequent complaints from SD Africa whose SD Bioline had passed successfully all evaluations.
And since only parameters were adjusted by the amendment, one can assume that the positive recommendations given by the original AMREF Field Evaluation Report remained valid, and PHLB had no objection to them. And we have so far failed to see the MUCHS’s Report of "Field Evaluation (Phase II) of SD (Bioline) HIV 1/2 Rapid Test (Kit)" which made AMREF amend its original Report, and directly or indirectly made PHLB strike back by stating that:
"~And in the revised report the sensitivity of Bioline SD HIV 1/2 Rapid Test was updated from 95.7% to 97.8%, which PHLB still considers to be unacceptable. Gold standard must be 100%! Therefore:
~ PHLB’s Conclusion: The Committee decided to hold on the earlier decision that from the results provided, Bioline SD HIV 1/2 Rapid Test does not qualify for use in Tanzania in its present form."
Comppare this NEW PHLB opinion with old opinions of PHLB, CMO, NACP, AMREF and MUCHS:
Date
Authority Which Approved/Disapproved SD Bioline
Annex
3/10/02
PHLB approves/praises SD Africa’s SD Bioline

15/10/02
PHLB approves/praises SD Africa’s SD Bioline

14/2/03
AMREF’s PhaseI Evaluation approves SD Bioline
2.61
03/4/03
MUCHS’s PhaseI Evaluation approves SD Bioline
2.62
20/4/03
NACP’s letter approves/praises SD Bioline
2.65
01/7/03
CMO of MoHSW approves/praises SD Bioline
2.66
6/02/04
PHLB disapproves SD Bioline contradicting all the
above letters including MUCHS’s and AMREF’s
2.68
11/6/04
AMREF’s Phase II Report still approves/praises SD
Bioline despite PHLB’s above disapproval of SD Bioline written only 4 months back.
2.71
13/7/04
AMREF’s Ammended Phase II Report still approves /praises SD Bioline despite being reproved.
2.72

This is strange and revealing in many ways:
(a)Since MUCHS’s Phase I Results dated 23/10/2002 appeared good, as shown in the following Table, for reasons best known to SD Africa’s adversaries, AMREF appear to have been expected NOT to give any results that are better than those of the other 5 Kits:
HIV Kit
Capillus
Determine
Hemastrip
Oraquick
Unigold
SD Bioline
Sensitivity %
98.89
98.52
95.20
97.79
99.26
97.80
Specificity %
99.91
100.00
100.00
100.00
99.91
99.50
Even then, the Sensitivity of 97.8% for SD Bioline was still lower than those
of Capillus, Determine and Unigold, which could make a handsome Algorithm
(provided they also pass Phase II Evaluation, WHICH THEY DID NOT!), and at the same time this conspiracy would eliminate SD Bioline which has been the main goal right from the beginning.
But since the Press Release of MoHSW dated 10/11/2006 finally declared SD
Bioline as the best of all these six Test Kits, it must have undergone further
evaluations whose results, unlike these above here, surpassed (beat) the results of the other five Test Kits, which the adversaries of SD Bioline badly wanted to win.
And that is why these SD Bioline’s adversaries persist in retaining Capillus and Determine in the National Algorithm and keeping SD Bioline out, although Capillus and Determine until now, although they failed to get registered until now, according to MoHSW’s own Press Release’s admission (see ANNEX 2.64).
Unfotunately, we were not privileged to see the results of these further evaluations (and that may be one of the reasons why we were given no access to MoHSW files). Nonetheless we do know that finally, a letter Ref.No.HC.49/421/Vol.IV/190 dated 30/01/2005,captioned "Report of Phase II Evaluation of SD Bioline HIV 1/2 3.0 Rapid Test", from the PHLB Registrar to SD Africa, announced that PHLB had at last passed the SD Bioline:
"The MoHSW has seen the importance of having such a Test Kit and therefore has decided to include it in the planned National HIV Diagnostic Test Algorithm Evaluation."
But this did not end all the woes of the SD Africa and its SD Bioline as one might have expected. Believing that they have not yet lost the battle, the adversaries fought on using another front to fulfil the original goal of keeping SD Bioline (and any other possible competitor) out of the competion once for all:
(n) Invitation for Tender No. 08-MoHSW of 2006/2007, and Invitation for Bids No. MSD/T.02/2006/2007, for the Supply of HIV Rapid Test Kits
As usual, the Ministerial Tender Board put out a public announcement that it wished to use part of the Global Fund monies for payments under the contract for the supply of HIV Rapid Test Kits which we have been talking about up to this minute. This Tender announcement given in October 2006 had some faithfully precise statements as well as some confusing and contradictory statements:
The "Invitation for Tender No. 08-MoHSW of 2006/2007 for the Supply of HIV Rapid Test Kits" stated succinctly that the Ministry of Health "Ministerial Tender Board" invites sealed Tender from interested eligible tenderers, and that tendering will be conducted through the International Competitive Tendering Procedures specified in the Procurement (Goods, Works, Non-Consultancy, and Disposal of Public Asset) Regulation, 2005, Government Notices No. 97 of 15th April 2005, and is open to all tenderers from eligible source countries as defined in the Regulations. Interested eligible tenderers may inspect the tendering documents at the MoHSW Headquarters from Monday to Friday, from 09.00-15.30 hpurs local time excluding public holiday. Tenders must be delivered to the MoHSW Headquarters at or before 09.00 hours on 17th November 2006, and Tenders will be opened in the presence of the tenderers’ representatives who choose to attend at 09.00 hours on Friday 17th November 2006, at the MoHSW Headquarters, 36/37 Samora Avenue, Dar es Salaam.
Of the many requirements and specifications, I will quote a few only, especially the highlighted, underlined, and the upper-cased ones on which I would wish to comment:

SECTION VI: SCHEDULE OF REQUIREMENTS AND SPECIFICATIONS
Name of
Item
Unit
Number of
Packages
Arrive Dec 2006
Arrive March 2007
Arrive June
2007
Capillus
Test Kit
Kit/ 100 Tests
3285
3285
3284
Determine
Test Kit
Kit/ 100 Tests
530
530
530
SECTION III: TENDER DATA SHEET
Whenever there is a conflict, the provisions in the TDS (Tender Data Sheet) shall prevail over those in the ITT (Instruction to Tenders).
ITT 6.4(b) ALL PRODUCTS TENDERED MUST BE REGISTERED BY THE PHLB (Private Health Laboratories Board) to allow them circulate in the market. BIDDERS MUST THEREFORE SUBMIT COPIES OF REGISTRATION CERTIFICATES OF PRODUCT TENDERED ISSUED BY PHLB AND/OR Documentary evidence to prove the manufacturer comforms to the United Nations Pre-Qualification System (WHO) approved standard for HIV Rapid Test Kits…
PREPARATION OF TENDERS
Copies of Registration Certificates of registered products for products tendering issued by the PHLB (Private Health Laboratories Board) OR otherwise the products should appear under the National Health Laboratory Supplies List
Contradiction of ITT
(a) If the process of evaluating SD Bioline has taken over 4 years, it is ludicrous to announce the Tender in October 2006 and expect the product tendered to be registered by the PHLB by 17th November 2006 (within about one month only) [after fulfilling all the the 5 conditions stipulated by the Private Health Laboratories (Conditions Pre-Requisite to Registration and Management of Private Health Laboratories)], whose GN No. 226 sub-section No. 2.5.2 (The Health Laboratory Products or Supplies to undergo Phase I and Phase II evaluation), as per 5 conditions it stipulates, (i) – (v). (See page 42 of "The Private Health Laboratories Regulations, ACT, 1997 (No. 10 of 1997) appended as ANNEX 2.75 at the end of this Main Report which all the Tender Boards always quote but they never observe it this at all. They advertise the Tenders in such a way that they list the names of the tendered product by their trade-names of Capillus and Determine (see the Table under: SECTION VI: SCHEDULE OF REQUIREMENTS AND SPECIFICATIONS) instead uf using their generic names or descriptions, which means that only these two unregistered HIV Test Kits can tender. This is a great taboo and illegal, according to the PPRA (Publuc Procurement Regulatory Aouthority) Act, Regulations 22 of the PPRA Regulation of 2005 as the Dr. R.S. Mlinga, the Chief Executive Officer of PPRA whwn trying to stop those Shoddy Temders (see newspapers reports (ANNEX 2.60.3-13).
(b) Section III of this Tender Data Sheet states specifically that "ITT 6.4(b) – All the Products tendered MUST BE REGISTERED BY PHLB". But the real super powers of MoHSW have all this time been tendering Capillus and Determine although the MoHSW admitted at its Press Release of 10/11/2006 that these two HIV Kits were never registered. This too is grossly illegal, and although PPRA has often times tried to halt this Tender, MoHSW has ended up finding an excuse to defy the PPRA and the PHLB Acts quite openly, and so far have gotten away with all this!
There was a time when rumours circulated that that MoHSW officials bamboozled PPRA to permit them (MoHSW) to float that Tender and they did!
(c) The same Section III announced by MoHSW did state that: BIDDERS MUST THEREFORE SUBMIT COPIES OF REGISTRATION CERTIFICATES OF PRODUCT TENDERED ISSUED BY PHLB , but tried to water this down by squeezing in the phrase "AND/OR" following it with the statement that: "AND/OR Documentary evidence to prove the manufacturer comforms to the United Nations Pre-Qualification System (WHO) approved standard for HIV Rapid Test Kits…" But Aid Agencies like WHO have always emphasized that each country has the onus to decide which Laws and Regulations their nation can use after they (and not the Aid Agency) evaluate a bunch of them and select the best one/s most suitable for their resource strained settings. Once a nation promulgates a Law or regulation and a product does not conform to it, no one can say: "the tenderer can use the national one OR can use an outside one." Either this AND/OR is a misprint, or someone is taking the law into their own hands and creating a new law and regulation.
(d) Again another OR occurs inappropriately in the following section – and all these can give pretexes for some adversaries to flout the laws and regulations in order to favour rotten products at the expense of better performance products:
"PREPARATION OF TENDERS
Copies of Registration Certificates of registered products for products tendering issued by the PHLB (Private Health Laboratories Board) OR otherwise the products should appear under the National Health Laboratory Supplies List."
For Health Laboratory supplies, our mother promulgation to constantly consult is the PHLB Act and Regulations. For the above mentioned Preparation of Tenders, let us peruse through sub-section 2.5.2 (iii) on the same page 42 which states that:
"The PHLB after receiving the evaluation or trchnology trial Report which may consider necessary, and if it is satisfied that the Health Laboratory Product or Suppliy is suitable for the purpose which was intended, and if it complies with the quality requirements, shall approve the registration of the Health Laboratory Product or Supply, subject to such conditions as it may impose, and enter it in the "National Health Laboratory Service Supplies List", whose latest List dated 2005 has amazingly included Capillus and Determine (see ANNEX 2.76 appended herewith), although these two HIV Test Kits have never passed the Evaluation or Technology Trial, as the MoHSW admits in her Press Release dated 10/11/2006 (see ANNEX 2.64 appended herewith). For reasons best known to the MoHSW, this "National Health Laboratory Service Supplies List 2005" was kept confidential even to some officials of the MoHSW e.g. MSD, who were sometimes given misleading and confusing information, by PHLB and MoHSW.

(o) Some of the PHLB and MoHSW officials gave misleading information, and PHLB/MoH prepares Orion Trading Company to Supplant SD Africa
MSD (Medical Stores Department) is certainly one of the MoHSW Departments which must be kept fully uptodate with the National List of Health Laboratory Supplies and Procuts, so that they may procure laboratory supplies and products for the whole of Tanzania according to the latest laws and regulations. It was with this aim Ms. Nderimo, the Quality Assurance Manager of MSD wrote a short and commendable letter Ref.No. MSD/003/73/2006/2007 dated 24/08/2006 asking the PHLB Registrar to be availed the full "National Health Laboratory Service Supplies List 2005".
Two weeks later she got a reply full of half truths, Ref.No. HC/49/421/Vol.V/60 dated 11/08/2006, which did not give her the "National Health Laboratory Service Supplies List 2005" she had asked for, which the MoHSW had already released the previous year (in 2005), about which the PHLB must have known. Instead Mr.Mrina replied that:
"The completed National Health Laboratory Services Supplies List SHALL BE PROVIDED LATER BY THE MINISTRY",
which is not true, because this National List had been released by the MoHSW in the previous year, 2005. And so as to ensure no one should dare to even think of supplanting from the monopolistic position which Capillus and Determine has been enjoying all these past 10 or so years, the PHLB Registrar Mr. Mrina’s letter added that:
"The National HIV Algorithm is still Capillus and Determine",
although this is not what Ms. Nderimo asked for!
Since Mr.Mrina’s letter did not dare to state if and how Capillus and Determine were entitled to be in the "National HIV Algorithm" without first passing both Phase I and II of the mandatory Evaluations and obtaining the mandatory PHLB Registration Certificate, and if and how these two pet HIV Test Kits deserve to be included in the "National Health Laboratory Service Supplies List 2005", naturally Ms. Nderimo and her colleagues continued gallantly asking for correct information in order to discharge their duties correctly and legally.
On 07/09/2006, Orion Trading Co. Ltd. wrtote a ‘Complaint’ letter to the current MoHSW PS, Mrs. Hilda Gondwe asking for:
"In conclusion, through you Madam, I request the Registrar to provide ORION with the following:
(1) Ammended Permit which will include SD HIV and other Rapid Diagnostic Kits, EXACTLY like the one he issued to SD Sfrica Ltd."
(2) The HIV Evaluation Report for Phase I and Phase II (although Orion had never submitted any laboratory product/supply for evaluation at all!)."
This complaint letter is one of the many letters I do not possess because we had no access to MoHSW files.
In order to prepare Orion for a ‘coup de tat’ against SD Africa:
(i) Dr. F.Ndugulile, the then MoHSW Head of Diagnostic, gave Orion the Permit to import SD Bioline HIV 1/2 3.0 Test Kit even before the PHLB authorized this.
(ii) On 18/09/2006, the PHLB Registrar Mr.Mrina wrote a letter REF.No. PHL/D/34/13 to MSD certifying Orion Trading Company Ltd. as a registered importer of Rapid Diagnostic Kits and Laboratory Consumables.
(iii) Mr. Mrina also gave Orion Phase II Evaluation Report of SD Africa for which Orion paid $ 4,500.
When SD Africa complained, the then MoHSW PS Mrs. Mwafisi intervened by convening a PHLB Emergency Meeting on 09/01/2006, and Orion was paid back its $4,500 after returning the SD Bioline Phase II Evaluation Report. God only knows how and why a firm which did not submit Test Kits for evaluation could be given their Evaluation Report! Were any steps taken to reprimand the culprit and ensure such open corruption doesn’t recur?
(iv) On 11/09/2006 Dr.Z.Berege signed a letter on behalf of the PS, Ref.No. HE.270/426/Vol.1/76 addressed to Orion Trading Co. Ltd. which included the following remarks: "Regarding HIV Evaluation Reports for Phase I and II, the Ministry is reluctant to provide you with that information since it is restricted to SD Africa Ltd. who provided the Kits for evaluation. The beneficiary of the Evaluation include the Orion Trading Co. Ltd., as well as all Tanzania in general. On the other hand, if you are not satisfied , the Ministry is ready to discuss the issues with you at your most convenient time." This another one of the letters I do not possess because we were not given access to MoHSW files!
(v) All this was done despite the fact that SD Africa did possess a "Certificate of Registration" (PHL Cert.6) dated 21/06/2006, and SD Africa also possessed an SD Africa-SD Korea Contract, as authenticated later by an Authorization letter dated 02/11/2006, from the President of SD Korea (authorizing SD Africa) to MSD.
Orion never possessed any of these certifications, other that the letter Ref.No PHL/D/34/13 dated 18/09/2006 which Mr. Mrina gave Orion in confusing circumstances.
On 12/10/2006 the chivalrous MSD officials Ms.L.Nderimo and Mr. Hezron Shayo wrote a letter Ref.No. MSD/003/1372006/2007, addressed to the PHLB Registrar captioned: "Certificate of Registration for Health Laboratory Products/Supplies" in response to the PHLB Registrar’s letter REF.No. PHL/D/34/13 certifying Orion Trading Company Ltd. as a registered importer of Rapid Diagnostic Kits and Laboratory Consumables. These two conscientious MSD officials reminded the PHLB Registrar, Mr. Sabas Mrina that, instead of submitting their Test Kits with the PHLB issued PHL.Cert.6 (Certificate of Registration), some of the applicants submit only Permits. This is contrary to the Section 2.5.2, (i) - (v) of the "Private Health Laboratories (Conditions Pre-Requisite to Registration, 2005, Govt. Notice No. 226 published on 05/08/2005)".

For the health laboratory products/supplies to be eligible to enter the "National Health Laboratory Supplies/Services List", they must conform to the above stated PHLB Regulations conditions, AND be issued a Certificate of Registration, pursuant to the sub-section 2.5.2 (iv) of the above stated Regulations. We kindly request you to urgently avail us of the "National Health Laboratory Supplies/Services List". You may recall that they had already asked for this same thing, but the Registrar offered them other things they did not even ask for.
After failing to get the "National Health Laboratory Supplies/Services List" from the PHLB, they resorted to the MoHSW Assistant Director of Diagnostics.
On 19/10/2006 MSD’s Ms. L.Nderimo and Mt. H.Shayo wrote a letter Ref.No.MSD/003/151/2008/2007, captioned "National Algorithm for HIV Rapid Test Kits", and asked ADD to urgently give them a (list of) registered products of HIV Rapid Test Kits as per National Algorithmas, so that they may know which Test Kit has been evaluated completely and satisfactorily and also given the PHLB Certificate of Registration. This letter was short because they had sent many letters such as this without mentioning any names of health laboratory products/supplies.
But the ADD (Assistant Director of Diagnostics) knew which side of bread needs to be buttered, ans so went straight ahead to mention names of Capillus and Determine only, and so he replied Ms.Nderimo and Mr.Shayo’s letter as follows.
The MoH Assistant Director of Diagnostics Defends the use of Trade Names
On 19/10/2006 the ADD, Dr.C.G.Massambu, wrote a letter Ref.No. HE.270/381/01/ captioned: "National Algorithm for HIV Rapid Test Kits", in response to the above letter of Ms.Nderimo and Mr. H.Shayo of 19/10/2006. This letter was so blunt in its support for maintaining the monopoly of Capillus and Determine that it is worth quoting him in verbatim so as to understand this saga:
"Ministry of Health and Social Welfare is in the process of looking for a new National Algorithm for HIV rapid tests. At the moment until when decided the old National Algorithm of Capillus and Determine continue to be used with the ‘serial’ method of HIV testing. Because of maintaining laboratory quality standards and accuracy throughout the country, BRANDED NAMED ARE used, since these rapid tests were selected out of several HIV rapid tests AND WE DO NOT HAVE GENERIC NAMES SO FAR SO THESE TWO TESTS."
Although some of the words are incomprehensible, the gist is clear that the good Doctor’s main intent is to defend the monopoly of the unregistered Capillus and Determine by hook or by crook.
If this good doctor did not know generic names/description to use instead of brand names, and he did not know that it is a cardinal PPA (Public Procurement Act) taboo to use brand names in competitive Tenders, here below is how we and even MSD had adroitly gone around this good doctor’s artificial dilemma in inviting Tenders without using brand (trade or proprietary) names.
We used an all inclusive "generic description" like: "Particle agglutination type HIV 1 & 2 Rapid Antibody Test Kit", which will allow to bid not only Capillus but any other HIV Rapid Test Kit which uses the principle of particle agglutination in its operation. And this is the true and just spirit of any Competitive Tender System. Similarly we use the "generic description" of "Lateral flow chromatographic type HIV 1 & 2 Rapid Antibody Test Kit", which will allow not only Determine but any other HIV Rapid Test Kit which uses the principle of lateral flow chromatographic its operation, such as SD Bioline. This is the spirit of even field competitive bidding which any decent inviter of Tender ought to adhere to. The following is one example of Invitation for Bids (ofcourse without the advisory column on the right hand side) we had proposed.

N
o.
Item Names
Or Item
Description
Details of Specifications
Trade Names
should never be
used in Invitations
1.
HIV 1&2
Rapid Antibody
Test Kit, Particle
Agglutination
Type
In vitro, visually read, simple, rapid qualitative
Immunoassays for the detection of antibodies to
Human Immunodeficiency Virus (HIV) Type One
and Two in human serum, plasma, and whole
blood, using Particle Agglutination Technology.
Samples should be submitted along with the
Following PHLB documents: (a) Phase I and II
Evaluation Reports of the Kit. (b) Approval of its
Registration.. (c) Its inclusion in the National
Health Laboratory Service Supplies List of 2005.
and (d) PHLB Certificate of Registration.
Only Bidders may give
the name of principle or
technology which is
used by this Kit and may
mention its Trade Name
in parenthesis, e.g.
Particle Agglutination
(Capillus)
2.
HIV 1&2 Rapid
Antibody Test
Kit, Lateral Flow
Chromatographic
Type
In vitro, visually read, simple, rapid qualitative
Immunoassays for the detection of antibodies to
Human Immunodeficiency Virus (HIV) Type One
and Two in human serum, plasma, and whole
blood, using Lateral Flow Immuno-
chcromatographic Technology. Samples should
be submitted along with the Following PHLB
documents: (a) Phase I and II Evaluation
Reports of the Kit. (b) Approval of its
Registration.. (c) Its inclusion in the National
Health Laboratory Service Supplies List of 2005.
and (d) PHLB Certificate of Registration.
Only Bidders may give
the principle or
technology which is
used by this Kit and may
mention its Trade Name
in parenthesis, e.g.
Immunochromatographic
(Determine or
SD Bioline)

The use of brand names is a major PPA (Public Procurement Act) taboo because it allows no other, perhaps better, Test Kits to enter the competition and let the best one win the Tender.
The Medical Stores Invitation for Bids, IFB No. MSD/T.02/2006/2007 whose wording was exactly like the one illustrated above was perfect except for a few minor inconsequential errors such as the use of "Or" instead of "and" highlighted above. But with all due respect, the Ministerial Tender No.08-MoHSW of 2006/2007 was wrong in using brand names of Capillus and Determine.
And we deemed it fit to mince no words in requesting the MoHSW to readvertise it in a proper legal manner, using generic descriptions as shown above.
The ADD’s letter was grossly mistaken in defending the use of brand names in competitive Tenders for the supply of HIV Rapid Test Kits. He was also mistaken in his reason why some officials engaged in the exercise of inviting these tenders have been using these brand names of Capillus and Determine. The reason is not "because of maintaining laboratory quality standards and accuracy throughout the country" as the good doctor claims. Their reason or motivation is purely to illegally protect and support the suppliers of Capillus and Determine (BD of USA through Mr.B.Rajani of Dar) to perpetuate the monopoly ("cooperation") of supplying Capillus and Determine throughout Tanzania, thereby reaping billions some of which, hopefully, would trickle down to them one way or the other. To them, the longer the competition is kept out and the announcement of a new Algorithm is delayed, the longer this monopoly is maintained, and the more part of those billions will trickle down to them. Exactly as it was with Partec’s CyFlow CD4 counting machines, this habit of using only one type or one set of equipment or Kits comprising two or three only diagnostic Kits is too hazardous. The healthier policy is to use more than these, say 4 or more sets so that they may function competitively, and they can be cross checked against each other. And when one set goes wrong, we can always resort to another set from another supplier. We gathered that by 24/02/2003, Kenya was using 36 different HIV Test Kits, while Tanzania, for undoubtedly iladvised or outright illegal reasons, elected to have a National Algorithm of only Capillus and Determine, supplied by Bharat Rajani’s Biocare Health Products Ltd. and Mr. Mehebob Poptan’s Kas Medics respectively. Had we had competitors to these two suppliers, each supplier would be kept on his/her toes for fear of being replaced immediately if his/her Test Kits starts functioning unsatisfactorily.
(q) Public Procurement Regulatory Authority (PPRA) Tries to Stop the MoHSW Tender No. 08 for the Supply of HIV Rapid Test Kits
(i) On 27/10/2006, a letter Ref.No. PPRA/PPC/45/Vol.III/87was written by Dr. Ramadhani S.Mlinga, the PPRA Chief Executive Officer, to the Permanent Secretary of the MoHSW, captioned: "Tender No. 08 of 2006/2007 for the Supply of HIV Rapid Test Kits". It mentioned that it was acting on complaints from Pharmavet Tanzania Ltd., M/S TEGA International Communication and Supplies Ltd., and from an anonymous citizen regarding the specifications of the HIV Rapid Test Kits. The letters complained that, the specifications provided were directed to a specific trade mark or producer which, if it is true, is contrary to Regulation 22 of the Public Procurement (Goods, Works, Non-Consultancy Services and Disposal of Public Assets by Tender) Regulations of 2005.
It directed the MoHSW PS to extend the deadline for submission and opening of Tenders for the tender in reference so as to amend the said specifications and furnish the PPRA with the clarification on the above referred complaints.
(ii) A few days prior to this PPRA letter, I sent an E-mail to the PPRA suggesting they ask MoHSW to change their Tender Invitation and Specifications and use "generic description" like "particle agglutination" instead of trade name like Capillus, and use "lateral flow" instead of "Determine", but I got no response.
(iii) I later heard the PPRA advised the MoHSW Tender Board to halt floating that Tender as it stood, but they ignored the advise, or perhaps PPRA exempted them.
(iv) Even the newspapers were confused – many times believing that MoHSW’s Tender had been halted, and each time mentioning a different halting authority. Out of the 13 newspapers I collected in 13 different days, front page headlines of 11 of them scream foul play by the MoHSW. But inspite of these news media reports, as well as many repeated stern efforts to suspend these lop-sided Tenders favouring Mr. Bharat Rajani, nothing seems to be happening – and the unregistered HIV Test Kits Capillus and Determine (which MoHSW’s own Press release admitted are unsuitable) continue to be supplied by Mr. B.Rajani, instead of the SD Africa’s registered and better HIV Kit SD Bioline, as outlined below.
What Newspapers Said
14/09/2006, THISDAY – "Supplier of HIV Kits Shuts Up on Media". The supplier
being the famous Mr.Bharat Rajani who also supplied over 40 FACSCount
CD4 cell counting machines of the CyFlow saga.
26/10/2006, THISDAY , headline: "Health Ministry At It Again", saying the HIV
Tests Capillus and Determine never passed Phase II evaluation and was
thus not registered; and so was not eligible to bid, as the Tender Invitation and Regulations stipulate. This article blamed MoHSW for using the old Algorithm and Tender Invitation which favours Capillus and Determine.
16/11/2006, Rai, headline: "Ministry of Health is playing Dangerous Games with
Tanzanians" by advertising Tenders for Capillus and Determine which have been declared unsuitable by the same MoHSW’s Press Release.
23/11/2006, Rai, headline: "Remove Professor Mwakyusa" before his corrupt
officials tarnish his reputation, according to some senior MoH officials in a
letter they sent to H.E. the President. Their aim is to enrich their benefactor
Mr.B.Rajani by giving him more Tenders to supply unsuitable HIV Kits.
30/11/2006, Rai, "German Scientists Divulge Secrets of MoHSW in the Country".
MUCHS evaluated CyFlow, a machine used to monitor the treatment of AIDS which they disqualified because they said it was unsuitable. When the Germans took back this machine to Germany and reprinted the MUCHS results from the machine’s "black box (Harddisk)" they discovered that MUCHS had manipulated the machine to read false results. The MUCHS disqualification of this CyFlows the field wide open for the supplier of the rival CD4 counting machine, the FACSCount (Mr.B.Rajani) to continue with his 10 year monopoly, in the same way they let Mr.B.Rajani have the monopoly of supplying the faulty unregistered HIV Test Kits Capillus and Determine instead of a better and registered HIV Test Kit SD Bioline supplied by SD Africa.
07/12/2006, Rai, "The Chaos of the Tender for AIDS Test Kits–MoHSW STOPS
THE TENDER", and some of their officials suspected of corruption are in
the hands of PCB. The MoHSW said the stopped this Tender after PPRA advised them against floating this Tender, because they used trade names instead of using generic descriptions.
12/12/2006, THISDAY, "HIV Rapid Test Kits – FRESH PROBING IN THE
OFFING". It said a stop order coming straight from the State House has bungled a spanner into plans of MoHSW to purchase 10,000 more HIV Test Kits of Capillus and Determine valued at 2.08 billion shillings. The Treasury was directed to suspend this procurement forthwith, and form a Probe Team.
14/12/2006, THISDAY, "Report says: HIV Rapid Test Kits are used illegally –
Medical Authorities Probe Team shows". HIV Test Kits Capillus and Determine should not be purchased directly nor through Tenders, because they had never passed Phase II evaluation nor possess a PHLB Registration Certificate, whereas the HIBV Test Kit SD Bioline passed all Phase and is registered by PHLB, but is not allowed to bid simply because Tender specification mentions the trade names of Capillus and Determine only as being eligible to tender, when the reverse is true. This was said by the Probe Team members Dr.P.J.Madati, Prof.P.Hiza, and Prof. R. Lema.
25/01/2007, THISDAY, "Authority blocks Shoddy Tenders at Health Ministry ." It
says the PPRA (Public Procurement Regulatory Authority) has sto[pped the Tender which was to be opened on 26/01/2007. Donors such as the Global Fund , and President Bush’s Emergency Fund had since threatened to withdraw the funds. Some suppliers have complained that Tender specification are favouring only Mr.Bharat Rajani the supplier of the unregistered unsuitable Kits of Capillus and Determine. Mr.B.Rajani appers to be favoured to supply many other HIV machine like the FACSCounts valued at 20 billion shillings, and other health laboratory suppliesThe PPRA has since formed a Probe Team.
23/02/2007, THISDAY, "HIV Rapid Test Kits: New Scandal in the Air". It says a
bid by the PPRA and various donors to put a stop to the continuing importation of Capillus and Determine appear to have floundered indefinitely as a result of intervention by higher Government Officials. Despite open disapproval by donor institutes, some politicians (names withheld by the paper) and MoHSW went ahead and and offered a Tender to the famous Mr. Bharat Rajani to supply 10,000 Test Kits of Capillus and Determine valued at 2.08 billion shillings. The MoHSW Probe Team of Dr.P.J.Madati, Prof.P.Hiza, and Prof.R.Lema had already said these particular Test Kits are being used illegally since they have not been registered as required by PHLB Regulations.
17/03/2007, THISDAY, "Anti-AIDS Fund not used to buy Capillus ". It said that
officials of the Global Fund to fight AIDS, Malaria, and Tuberculosis regularly make follow ups on the procurements of drugs and medical equipment by MoHSW, and that there is no evidence that its hgrants are used to buy substandard ARVs and medical equipment including Capillus.
The news that all the many efforts of the PPRA, and of higher Government offices as well as the donor agencies to stop MoHSW from floating those Tenders using trade names purely to help Mr. B.Rajani keep on supplying unsuitable HIV Test Kits dangerous to out AIDS patients keep on floundering or falling on deaf ears, is simply mind boggling, to say the least! I cannot comprehend how it can be allowed in a bribe free and good governance country like Tanzania.
(r) The MoH Press Release – Change of National HIV Rapid Testing Algorithm Dated 10th November, 2006 and How it Contradicts MoH’s Actions
Before we review the honoured Press Release, let us remind ourselves what the PHLB’s Private Health Laboratories Regulations Act 1997 says about the "National Health Laboratory Service Supplies List", since I have not located the place in this Regulations Act where it mentions "National Algorithm":
"The Board after receiving the Evaluation or Technology Trials Report" … shall approve the Registration of the Health Laboratory Product or Supplies … and enter it in the "National Health Laboratory Service Supplies List".
Then the Board shall issue a Certificate of Registration to the applicant.
Where the Board refuses to approve Registration… it shall inform the applicant in writing of such a decision and reasons thereof.
(see these pertinent Regulations in Section 2.5.2 (iii), (iv) & (v), Annex 2.75)"
The fact is that all this did not happen to Capillus and Determine at all because they did not have any full (Phase I & II) Evaluation, therefore no Report, and therefore were not approved nor issued a Registration Certificate, and therefore should not have been entered into the "National Health Laboratory Service Supplies List 2005" (see the List in Annex 2.76 where Capillus and Determine have been mysteriously inserted!), and so should never have been in the "National HIV Rapid Testing Algorithm", old or new! It is flabbergasting to see Capillus and Determine break all those Regulation (i)-(v), and yet the MoHSW hasn’t even issued Mr. Bharat Rajani a written notification of the PHLB’s refusal to register him and why!! And he and the officials who have disobeyed all these Regulations remain absolutelu unscathed!!
Where is the proof that Capillus and Determine are unsuitable and unregistered?
The answer is, either ask Mr.B.Rajani to show proof that his Capillus and Determine were registered. But for now let us get the proof straight from the horse’s mouth:
The Press Release on "Change of National HIV Rapid Testing Algorithm" given by the MoHSW on 10/11/2006 said only this:
"The MoHSW in collaboration with the MUCHS conducted an evaluation of the new Tests with the view of identifying those that are most suitable for the Tanzanian environment. Some 18 different Tests that are currently on the market were considered in the evaluation. The evaluation took into consideration not only storage issues but also costs, shelf life apart from specificity and sensitivity issues and came up with a new testing Algorithm as shown below (paragraph 4 of the Press Release):
1. The first Kit will be ‘SD Bioline’. If the results are HIV negative, the results
will be communicated to the client that he/she is HIV negative. "
2. If ‘SD Bioline’ gives a positive HIV result, another test will be conducted
using ‘Determine’, and if the results are the same (positive), the client will
be given his/her results as positive.
3. If both tests, ‘SD Bioline’ and ‘Determine’ show HIV positive results, the
client will be told with confidence that he/she is HIV positive.
4. Likewise, if results of ‘SD Bioline’ and ‘Determine’ will not tally, another
test using ‘Unigold’ will be conducted.
5. If there is a problem of results’ compliance between ‘SD Bioline’ and
‘SD Bioline’, results resulting from ‘Unigod’ test will be taken as final
and communicated to the client."
In spite of the same MoHSW Press Release earlier on (in paragraph 3) stating that:
"The system of ‘Capillus’ test has, of late, proved a problem for use in some parts of the country as they require cold storage…."
The same MoHSW Press Release’s conclusion reads as follows:
"The ongoing system of ‘Capillus’ followed by ‘Determine’ will continue for some time pending preparations by the MoHSW to introduce ‘SD Bioline’ and ‘Unigold’. Preparations include procurement of the new tests and training of technical staff on the new algorithm. MoHSW will announce a date the use of the old algorithm will cease."
Such are the contradictions and audacity all Tanzanians are having to swallow without even asking: If Capillus has OF LATE proved a problem (i.e. unsuitable) because they require cold storage (and temperatures in tropical Tanzania are between 20-35oC), then why use it at all – so as to fatten Mr.B.Rajani’s pockets while his Capillus lies about the HIV status of every patient tested with it? Lord have mercy. Does even a clear issue like this require a public debate or a referendum or a vote for an urgent remedial action to be taken to save infected Tanzanians?

2007-10-31T11:05:00.000-07:00

CONFIDENTIAL
C O N T E N T S
Prove Team Members 02
Introduction 03
Methodology 05
Term of Reference No. 1: Any Deliberate Delay in the Evaluation
of the CyFlow Machine? 08
A. Chronology of Movements of the CyFlow Machine and the
Handling of Evaluation of CyFlow and Other Machines 06
B. Different Treatment of Various CD4 Cell Counting Machines 14
C. Evaluation of CyFlow was Completed by 30/8/2005, But the Report
Sent to Partec on 24/10/2004 Raised Many Question 16
D. The CyFlow Machine is Returned to Germany, and its Retrieved
Data is Claimed to Show MUCHS’ Manipulations of Data 19
Term of Reference No. 2: Were the Reagents Used Expired? 23
"Expiry Dates" versus "Shelf Life" 23
Term of Reference No. 3: What Types of CyFlow Exist in Tanzania,
Where, and How Did They Enter Tanzania? 25
Characteristics of CyFlows and Comparability with FACSCount s 27
Term of Reference No. 4: Which Type of CyFlow was Evaluated? 29
Term of Reference No. 5: Did MUCHS Follow Correct Procedures
While Evaluating the CyFlow Machine? 31
Term of Reference No. 6: Was Any Bribery Used to Influence
the Results of Evaluation Obtained? 32
Term of Reference No. 7: Has WHO Ever Done Any Multi-Center
Study of the CyFlow, and What Results Did They Get? 36
WHO Does Not Have Laboratories to Do Studies, But Recognizes
Studies Done by Good Laboratories, Procures Supplies for
Them, and Disseminate Information Useful for Human Life 36
Probable Conspiracy of Some Organizations Officials to Discredit
Some Manufacturers or Researchers, Helped by Individuals 39
Miscallaneous Questions Including the Latest Evidence Submitted 45
Term of Reference No. 8: Was There Any Unnecessary Delay in Evaluation So As to Enter SD Bioline in the National Algorithm

PROBE TEAM ON EVALUATION OF CYFLOW CD4 COUNTING MACHINE AND THE SD BIOLINE HIV RAPID TEST KITS
( Dar es Salaam, September 2006 – January 2007)

Members:

1. Prof. Philip R.Hiza, Retired Consultant Surgeon/Chief Medical Officer,
Ministry of Health and Social Welfare, Dar es Salaam.Tanzania.
2. Prof. Raphael A.Lema, Retired Consultant Pathologist, now Vice
Chancellor of IMTU, Dar es Salaam. Tanzania.
3. Dr. Jumah P. Madati, Retired Chief Government Chemist,
Ministry of Health and Social Welfare, Dar es Salaam. Tanzania.

Rapporteur: Dr. Jumah P. Madati

Secretariat: Dr. Jumah P. Madati

REPORT OF THE PROBE TEAM CONCERNING THE CYFLOW CD4 COUNTING MACHINE AND
SD BIOLINE HIV RAPID ANTIBODY TEST KIT

INTRODUCTION
MINISTERIAL APPOINTMENT OF THE PROBE TEAM
The Hon. Minister for Health and Social Welfare of the United Republic of Tanzania, Professor David Mwakyusa, M.P., by a letter Ref.No. WAUJ/V/C/09/2 dated 1st September 2006, which is appended herewith as ANNEX 0.1, appointed a three-men team to look into the allegations of corruption leveled against some officials of the Ministry of Health and Social Welfare (MoHSW), as well as some researchers and technicians of the Microbiology/Immunology of the Muhimbili University College of Health Sciences (MUCHS).
There are two separate promoters/suppliers of Health Laboratory Supplies and Products who are accusing MoHSW and MUCHS officials of dishonesty in performing the evaluation of their equipment and reagents according to the "Private Health Laboratory (Conditions Pre-Requisite to Registration and Management of Private Health Laboratories), of the Private Health Laboratory Regulations Act 1997".
The first supplier is Partec Essential Healthcare company of Munster, Germany, which markets the CyFlow SL Blue CD4 T-Cells counting machine, which Partec offered to MoHSW to evaluate and register, ostensibly with the ultimate hope and aim of entering their CyFlow machine in the Tanzanian market. They were disappointed when ultimately their machine was disqualified, and so they started alleging that some MUCHS and some MoHSW officials had been bribed by the suppliers of the rival CD4 cell counting machines, viz BD FACSCount and BD FACSCalibur, which are marketed by Biocare Health Products Ltd. of Dar es Salaam, and manufactured by Becton Dickinson company of USA. As if this were not enough, the Tanzania news media orchestrated strong and persistent support of the Partec CyFlow machine promoters’ allegations.
The second supplier is SD (AFRICA) Ltd. Of Dar es Salaam, a South Korean based company which markets the SD Bioline HIV 1/2 3.0 Rapid Antibody Test Kit, which SD (AFRICA) Ltd. submitted to the PHLB (Private Health Laboratories Board) of the MoHSW to evaluate and register, presumably with the ultimate aim and hope of entering their Kit in the Tanzanian market.
They were frustrated when, in spite of passing successfully both Phase I and Phase II of the mandatory evaluations stipulated by PHLB, and in spite of being registered by PHLB, and satisfying all the five conditions according to the Sub-Section 2.5.2, GN No. 226 of the "Private Health Laboratory (Conditions Pre-Requisite to Registration and Management of Private Health Laboratories), of the Private Health Laboratory Regulations Act 1997", the MoHSW kept on delaying entering their Kit into the National Algorithm, which is a pre-requisite for being invited to tender for the supply of HIV Test Kits. When finally the MoHSW insisted on inviting discriminatory Tenders using trade names of the unregistered HIV Test Kits of Capillus and Determine and excluding SD Bioline, although the MoHSW itself announced in a Press Release that thenceforth SD Bioline would be the front-line HIV Test Kit, the SD Bioline promoters and news media including some unnamed senior MoHSW officials cried foul. Ultimately the PPRA (Public Procurement Regulatory Authority) and the State House had to intervene and stop MoHSW Tender Board allowing Capillus and Determine win the Tender without being registered. Naturally, SD (AFRICA) Ltd. kept on purporting that some MUCHS and some MoHSW officials must have been influenced by suppliers of the HIV Test Kits Capillus and Determine. The local marketing company of Capillus and Determine happen to be the same Biocare Health Products Ltd. of Dar es Salaam, which has been for many years the suppliers of the BD FACSCount and BD FACSCalibur CD4 cell counting machines (see the above paragraph which introduces the "CyFlow saga", twin sister of the "SD Bioline saga").
In this (SD Bioline) saga too, the news media sided squarely with the SD Bioline suppliers in their allegations of corruption, and condemned the MoHSW and its affiliates for openly opting to "kill" prematurely HIV infected persons by insisting on testing them with the Capillus Test Kits which even MoHSW itself admitted in a Press Release of 10/11/2006 that it is not registered, and it is prone to giving wrong HIV test results. The SD Bioline promoters and news media also alleged that the Hon. Minister for Health and Social Welfare was being constantly misinformed or not informed at all about all this.
This prompted the Hon. Minister for Health and Social Welfare to appoint a team of independent, experienced professionals to investigate these and related allegations and find out how, if at all, any corruption or bribery has played a role in these two sagas. The Hon. Minister for Health and Social Welfare guided the Probe Team by giving them the Terms of Reference which are appended herewith as ANNEX 0.2.

The Probe Team comprised the following persons:
Prof. Philip R. Hiza, retired Consultant Surgeon, and once the CMO.
Prof. Raphael A. Lema, retired Consultant Pathologist and currently the Vice Chancellor of IMTU.
Dr. Jumah P. Madati, B.Sc. (Chem.), M.Sc. (Anal. Chem.), Ph.D. (Phyto.
Chem.), Fellow of the Royal Society of Chemistry (F.R.S.C); Chartered
Chemist (Ch.Chem.); who was Chief Govt. Chemist (1979-1987), retired
from civil service since 1992, and currently a free lance consultant.

METHODOLOGY
The Probe Team started work on 14th September 2006 by deliberating on the Strategies of the Enquiry, and decided that it would attempt to gather all sorts of documents such as: Air Waybills, Bills of Lading, Invoices, Import Declaration Forms; Requisition, Issue, and Dispatch Vouchers/Notes, in order to establish the exact movements and transit stops made by the CyFlow machine, the SD Bioline Test Kit, and their reagents. The Probe Team endeavoured, by this way, to establish any delays that occurred, when, why, and whether the dalays were deliberate, identifying each stop over and persons who handled them, and when and how their evaluations commenced, were performed, and the Evaluation Report issued. All these documentary evidences were assigned end-note numbers and appended herewith as ANNEX 2... The Probe Team also scrutinized the letters and Reports exchanged between different stakeholders, and Minutes of the various Board and Committee Meetings and those, including all those letters and newsprints of complaints from the suppliers/promoters and their agents and responses to them by the various officials of MoHSW, MUCHS, AMREF and their affiliates. All the documentary evidence is assigned end-note numbers and appended as ANNEX 2. …. At the end of this Repot.
The Probe Team interviewed a number of persons who carried these items from one spot to the other, who ran samples of patients’ blood in the CyFlow machine and SD Bioline HIV Rapid Test Kit, in the course of evaluating the machine and the Kit, before submitting the evaluation results to the PHLB and subsequently sending the Final Evaluation Report to the MoHSW and thence to the suppliers/promoters. The Probe Team read through several documents given by the interviewees and some which were downloaded from the internet. The names of the persons who were interviewed are given hereunder, and their Interview Reports are appended herewith as ANNEX 0.3. …
These Reports are not in chronological order, since many of the interviewees were too busy with their routine chores to talk to the Probe Team exactly when the Probe Team wanted to interview them. The following is the list of intrviewees.
1. The Hon. Minister for Health and Social Welfare, Professor David Mwakyusa.
2. The previous Hon. Minister for Health and Social Welfare, Mrs. Anna Abdallah
3. The Permanent Secretary Mrs. Hilda Gondwe (it wasn’t possible to consult her).
4. The previous Permanent Secretary of the MoHSW, Mrs. Mariam Mwafisi.
5 The Chief Medical Officer of MoHSW, Dr. Gabriel L. Upunda.
6. The Director of Hospital Services, Dr. Zechery A. Berege.
7. The Registrar of the Private Health Laboratories Board, Mr. Sabas Mrina.
8. The Programme Manager of National Aids Control Programme,Dr.Roland Swai
9. Mr. Hasan S. Khalid, Laboratory Technologist of NACP.
10. The former Ag. Head of the Diagnostic Section of MoH, Dr.Faustin Ndugulile.
11. Dr.Carnelia Atsyor, Ag. WHO Resident Representative.
12. Dr.Magani,WHO Representative to Tanzania (it wasn’t possible to consult him
13. Prof. Eligius F.Lyamuya,Assist. Professor and Head of Microbiology,MUCHS
14. Professor Fred Mhalu, Professor of Microbiology, MUCHS.
15. Mr. Sufi, Head Technologist, Microbiology Laboratory, MUCHS.
16. Mr. Severin Mgonja, Technologist, Microbiology Laboratory, MUCHS.
17. Mr. Charles Kagoma, formerly with MUCHS, but currently with WHO.
18. Mr. Mbena, Technologist, MUCHS (it wasn’t possible to interview him)
19. Mr. Joseph Mgaya, Director General, Medical Stores Department (MSD).
20. Ms.Lucy Nderimo, MSD Quality Assurance Manager.
21. Mr. Hezron Shayo, MSD Quality Assurance Officer (Diagnostics).
21. Mr. Msemu, Procurement Officer, MSD (It was not possible to interview him).
22. Dr. R.S. Mlinga, Chief Executive Officer, PPRA (Public Procurement
Regulatory Authority).
23. Mrs. Ndomondo-Sigonda, MD of TFDA (It was not possible to interview her).
24. Dr. Benedict P. Mbawala, Managing Director, Oysterbay Hospital, DSM.
25. Lt. Mr. Hamisi Gabriel Chifupa, Director General, Tega International, DSM.
26. Dr. Urasa, CDC (it wasn’t possible to consult him).
27. Dr. Wictor, CDC (it wasn’t possible to consult him).
28. The AMREF Country Director (it wasn’t possible to consult or his affiliates).
29. Dr. Florence Temu Mbaga, Head of Programmes, AMREF.
30. Dr. Msolla, AMREF
31. Dr. Ocheng, AMREF
32, Mr. Barhat Rajani, Managing Director, Biocare Health Products Ltd.
33. Dr.Rainer Brandl, Bulongwa Hospital (It wasn’t possible to interview him).
34. Several Technicians working in Health Facilities all over Tanzania which possessed CD4 counters and HIV Rapid Test Kits, were interviewed about the status of these Health Laboratory Supplies, and asked to remain anonymous.
Unfortunately, we were unable to visit Health Facilities which possess and use CyFlow CD4+ T-cell counting machines in Tanzania, and in some neighbouring African countries, at least. This was a pity since some of these Health Facilities or Centers apparently are very happy with the performances of their CyFlow machines that are manufactured by Partec of Germany, and which exhibit no shortcomings – certainly not like what MUCHS observed in this one CyFlow which they evaluated in mid 2005. These proud owners of various CyFlow machines have written several Reports praising their performances and even comparability to other CD4+ T-cell counting machines made by companies like Becton-Dickinson of USA, namely FACSCount, FACSCalibur, FACScan, etc.

_________________________________________
ANNEX 0
Letter Ref.No. WAUJ/V/C/09/2 dated 01/09/2006 of appointment of the Probe Team.
2 Terms of Reference (Hadidu za Rejea) of the Probe Team concerning the CyFlow CD4 counting
machine and the SD Bioline HIV Rapid Antibody Test Kit.
3 Interview Reports – 1-34

THE UNITED REPUBLIC OF TANZANIA

EVALUATION OF THE CYFLOW CD4 COUNTING MACHINE AND THE SD BIOLINE HIV TEST KITS

A Report of the Ministerial Probe Team on
Evaluation of the CyFlow CD4+ T-Cells Counting Machine
And the SD Bioline HIV Rapid Antibody Test Kits

Dar es Salaam
Ministry of Health and Social Welfare

February 2007

THE UNITED REPUBLIC OF TANZANIA

EVALUATION OF THE CYFLOW CD4 COUNTING MACHINE AND THE SD BIOLINE HIV TEST KITS

A Report of the Ministerial Probe Team on
Evaluation of the CyFlow CD4+ T-Cells Counting Machine
And the SD Bioline HIV Rapid Antibody Test Kits

Dar es Salaam
Ministry of Health and Social Welfare

February 2007

THE UNITED REPUBLIC OF TANZANIA

Ministry of Health and Social Welfare

EXECUTIVE SUMMARY OF
EVALUATION OF THE CYFLOW CD4 COUNTING MACHINE AND THE SD BIOLINE HIV TEST KITS

February 2007
Dar es Salaam

ANALYSIS OF DISCUSSIONS WITH INTERVIEWEES
By virtue of being the Head of the Microbiology/Immunology Department until very recently, August 2006, Prof Lyamuya is a key interviewee who should know better than almost anyone else about this CyFlow machine saga, as well as the SD Bioline HIV Rapid Antibody Test Kit saga.
Professor Lyamuya said that the CyFlow Easy Count machine (CyTecs Gmbh Ser.No. 040814517) was delivered to MUCHS with NACP Local Stores Requisition and Issue Voucher Nos. ………………. by the Laboratory Technician of the NACP (National Aids Control Programme), Mr. Hasan S. Khalid, on 24/12/2004.
Evaluation of this CyFlow machine could not commence immediately because MUCHS had no reagents for the reference assay method, flow cytometry. Since the supplier of the machine, Partec or Prof. Roland Gohde had not sent the reagents with this machine, the MoH offered to provide them. These reagents were not delivered to MUCHS until 24/06/2005, six months after the arrival of the CyFlow machine itself.
Even then, the evaluation could not commence because it was discovered that calibrating beads were missing. When he was informed about this, the Registrar of the Private Health Laboratories Board (PHLB), Mr. Mrina delivered the calibrating beads on 12/7/2005, one month later, and then MUCHS started operating the machine on 19/7/2005, when this CyFlow screen was observed to give no display at all. When he was informed about this, Mr. Mrina called in the CyFlow engineer from Nairobi, Mr. Khisa Joseph, who arrived on 23/7/2005, and rectified the problem. He also instructed the MUCHS Technician, Mr. Sufi how to operate the machine properly. Then MUCHS proceeded to evaluate the CyFlow machine till late August 2005, analyzed the data, and issued a final Evaluation Report on 6/10/2005, only two months since the start of the evaluation.
This refutes one allegation made by Prof Gohde that "the CyFlow machine lied idle for 14 months before its evaluation started". If the CyFlow reached MUCHS on 24/12/2004 and the evaluation did not start until 19/7/2005, and the Evaluation Report was issued on 5/10/2005, this evaluation took 2 months and not 14 months as claimed by Prof Gohde, unless we can discover other Local Stores Requisition and Issue Vouchers showing that the CyFlow reached MUCHS much earlier than 24/12/2004.
Prof Lyamuya briefed the Probe Team on the assay methodology they used, demonstrating the operation of the CyFlow machine, and showed it the printouts (See Appendix 2) obtained for the sample No. 6137 which were tested on 2/8/2005 using this machine running parallel to BD Facs count and Beads count, as follows:
CD4 Counting Machine Used
CyFlow SL
FacsCount
Bead
CD4 T Lymphocytes Counts
191
64
57
This clears another allegation that MUCHS evaluators never produced any printouts which are usually kept at the evaluating laboratory, and also demonstrates how the CyFlow machine gives a falsely inflated CD4 T-lymphocyte counts of 191 for samples which are as low as 57 and 64. This kind of performance of the CyFlow machine is catastrophic, because blood samples with lower CD4 T-lymphocytes count of less than 200 cells/µl will read on the CyFlow machine well above 200 cells/µl, a fact that will disqualify them to start AntiRetroviral Therapy, which will send them to unduly early deaths.
As regards the allegation of reagents’ Expiry Date having elapsed by the time MUCHS evaluated the CyFlow machine with them, Prof Lyamuya showed the Probe Team the reagents whose bottles show clearly (see photographs of them in Appendix 3) that they were all used long before their expiry dates elapsed taking into consideration that the evaluation assays were performed up to August 2005, as shown below:
NAME OF THE REAGENT
EXPIRY DATE
TIME USED
BEFORE
EXPIRY
CyTecs CD4 Easy Count Dilution Buffer
Code No. CY-R-1004; Lot No. 041020wd
December 2005
Four
Months
CD4 Easy Count CD4 PE
Code No. CY-R-104; Lot No. X27008
February 2006
Six
Months
Calibration Beads
Code No. 9544000
October 2005
Two
Months
Therefore the allegation of using the reagents after their expiry dates had elapsed, is null and void.
Even the excuse which was raised by the suppliers’ agent, Dr. Mbawala, those reagents had two types of "Expiry Dates", the above mentioned Expiry Dates which have been proven adequately not to have elapsed by the time MUCHS carried out the CyFlow machine evaluation. Another "Expiry Date" which they called "Shelf Life of 6 months if well stored under a refrigerator" which they claim was "applicable only to assays performed for purposes of the evaluation of the CyFlow machine", while the real Expiry Dates are applicable only to assays that are performed on patients in the field. This is not a "Standard Operation Procedure" nor is it a "Standard Nomenclature". What is known internationally is that delicate or sensitive items are normally labeled clearly like "To be stored at temperature xoC" so that even Airlines and the Airport Cold Rooms automatically keep the items refrigerated, ofcourse at a nominal charge. And if the suppliers seriously wanted those reagents to be used before their "Shelf Life" elapses, they should have labeled them:
"To be stored at a temperature of xoC, and must be used before 6 months", and in the covering letter which was accompanying them, and even in manuals of instructions, it should have emphasized this type of warning. There were no such warnings at all!
Prof Lyamuya, in his rebuttal of Partec’s, Prof Gohde, and Dr. Mbawala’s allegations, wrote a detailed 9 pages letter Ref. No. MIM/022/01/06 dated 30/1/2006, and another 7 pages letter Ref. No. MIM/022/06/06 dated 23/6/2006, which answered the remaining allegations which show clearly that:
(a)The MUCHS Microbiology/Immunology Department staff, including Prof Lyamuya himself are well learned, experienced; and doubtlessly performed the evaluations not only to international standards but exactly to the letter i.e. exactly according to the instructions given by the suppliers of the CyFlow machine including the instrument manuals and analytical manuals.
Apart from seeing and inspecting the CyFlow machine which MUCHS received from Germany to evaluate, whose full name is "CyFlow Blue, 5 Parameters" which goes by the name label of "CyTech`", the Probe Team did not have the opportunity to see about ten other CyFlow machines scattered all over Tanzania, except the smaller version known as CyFlow Green possessed by Dr. Benedict Mbawala, the proprietor of the Oysterbay Hospital, Dar es Salaam. Dr. Mbawala used this machine to complain that he sent doubles of blood samples to MUCHS which he had assayed in his CyFlow Green and assay results of MUCHS’ CyFlow Blue he says, agreed very well with assay results of the CyFlow Blue of MUCHS. We thought that it was wrong of Dr. Mbawala to compare results of machines and perhaps settings which were not comparable.
From the investigations we have thus far carried out, we have yet to find evidence of deliberate delay or tampering of any sort, or demand or receipt of any bribe on the part of MUCHS evaluators, although claims by Prof. Gohde and Dr. Mbawala that the CyFlow Blue did come with the "Starter Kit" of reagents with which the Nairobi based Partec engineer, Mr. Joseph Khisa trained MUCHS’ Technicians in Dar in November on how to operate the CyFlow Blue machine seems so far convincing. Therefore, up until now, the Probe Team is in no position to state that MUCHS was responsible for all or part of the delay in evaluating the CyFlow Blue or not. The Probe Team could neither confirm what caused the lower +precision of CyFlow Blue machine when determining blood samples with lower CD4 T-lymphocytes count of less than 200 cells/µl, if at all such an imprecision exists. Now that Prof Godhe and Dr. Mbawala have taken away the CyFlow Blue to Germany to retrieve all results from its "Black box" i.e. its Hard Disk, we shall have to wait until they and we scrutinize its print-outs to see if there is any evidence of tampering with or sabotaging the CyFlow Blue, and where, when, and how that might have taken place.