In 2016, laboratory testing capacity for detection of priority diseases and pandemic preparedness in Belize was identified as one of the main Ministry of Health and Wellbeing (MoHW) gaps to comply with International Health Regulations. With Pan American Health Organization (PAHO)/WHO support, a Joint External Evaluation recommended the need to enhance national laboratory capacity to support surveillance and improve accurate and rapid diagnosis at central, regional and district levels; to increase lab medical equipment and training of human resources, as well as to improve MoHW capacity to initiate effective response action to prevent epidemics. Between 2017 and 2019, PAHO/WHO conducted follow-up missions to develop standard operating procedures to strengthen the National Lab capacity, to evaluate the country public laboratories capacity to respond to emerging and re-emerging infectious diseases and to define public laboratories’ roles and responsibilities as part of the national laboratory network preparedness for an epidemic outbreak.

Although preparedness actions contributed to organize the country´s response to the COVID-19 outbreak, Belize had no laboratory capacity to test for COVID-19 in either the public or private sectors. Therefore, aligning with the nine pillars of WHO COVID-19 Country Preparedness and Response Plan[1], PAHO/WHO supported building the diagnostic capacity and securing supplies and equipment needed to first initiate, then expand testing in-country and to prevent the pandemic spread, as follows:

• Training & capacity building: Two officers of the Central Medical Laboratory (CML) received training by PAHO/WHO virologists to utilize Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) at the Institute of Epidemiological Diagnosis and Reference in Mexico. Training was subsequently replicated in Belize among CML and the Belize Agricultural Health Authority (BAHA) technicians while initiating active surveillance for the detection of SARS-CoV-2.  Since public laboratories had already developed capacity to test for Influenza it was easily adjusted to accommodate for SARS-CoV-2.
• Procurement: In partnership with the European Union, PAHO/WHO supported the procurement of probes and primers for the molecular testing as well as COVID-19 Rapid Antigen test kits and devices to support the decentralization of COVID-19 testing. PAHO/WHO procurement and distribution channels became the primary means through which test kits and consumables were replenished in the country due to the global interruptions in supply chain that greatly affected small economy states such as Belize. By January 2021, over 50,000 PCR and rapid antigen test kits and 250,000 lab supplies have been procured by PAHO/WHO contributing to the conduct of 62,960 tests.  Additional 94,975 rapid antigen tests and several readers have been recently donated as well to further support the decentralized testing strategy to further support the decentralized testing strategy.
• Expanded and decentralized testing: As the number of suspected cases began to increase exceeding the testing capacity of the only equipped laboratory in the country, the MoHW requested that PAHO/WHO review the laboratory network and propose guidelines for the release from isolation and quarantine and for decentralized testing. As a result, the implementation of rapid antigen testing was integrated into primary care and became an option to facilitate testing access, reduce the significant lag in processing the samples and alleviate the burden of testing on the CML. 

In the short term, in a country with an estimated population of 400,000 people, PAHO/WHO interventions have contributed enormously to increase in the number of persons tested and significantly reduced the waiting time for laboratory results. Consequently, the population and health care personnel could take prompt action in regard to quarantine and/or isolation which strengthened the prevention and control measures for COVID-19 at the community level.  The expanded rapid testing strategy raised public awareness of the importance of testing and of taking personal preventive measures to avoid being infected; and built-up the population´s confidence in the health system as actions were perceived as timely and responsive. In addition, health personnel were increasingly made aware of the importance of safety measures inside and outside the labs. At central level, PAHO/WHO support helped raise awareness among MoHW officials to prioritize long-term procurement forecasting and planning to be able to improve supply chain management practices in the country.  Lastly, PAHO/WHO interventions helped to strengthen the partnership with the MoHW, positioning the PAHO/WHO Country Office as the key stakeholder providing technical guidance and cooperation, particularly during epidemic outbreaks. Since February 2020, PAHO/WHO has led the coordinated country response to the COVID-19 pandemic and participates in the multi-sectoral National COVID-19 Task Force, and in the Medical and Communications Sub-Committees. The other key stakeholders are the MoHW, the Ministries of Foreign Affairs and of Human Development, and UN System partners.

In the near future, PAHO/WHO interventions are expected to contribute to private sector engagement to provide rapid testing at the main private facilities in Belize City. The private sector involvement will decrease the burdensome workload of the public laboratory in Belize City, thus improving the efficiency of the CML.

In the long-term, PAHO/WHO interventions are expected to strengthen the national medical laboratory platform for infectious diseases testing, which should enhance the resilience of the health system and lead to a better response to emerging and re-emerging pandemics.