TB Laboratory Training Chuuk, FedSM Vasiti Uluiviti Regional Lab Strengthening Coordinator PIHOA November 29 th 218 1 Learning objectives Provide an overview of TB lab activities in the USAPI Demonstration on the proper use of the sputa collection device Explain steps for quality sputum collection for effective TB lab diagnosis Describe TB lab documents Demonstrate proper completion of the AFB Smear Microscopy and Genexpert Request Form Describe the TB Lab Quarterly Workload Statistics and Performance Indicator Form Describe external quality assessment for TB lab activities in the USAPI Discuss general TB lab issues/challenges for improvement 2 Overview of TB lab activities in the USAPI Oct 217 June 218 3 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 1
Overview of TB lab testing in the USAPI LEVEL 3 Mycobacteriology Lab CDC, Atlanta/Other labs Genotyping/ Fingerprinting AFB smear (sedimentation) LEVEL 2 Diagnostic Lab Services Honolulu, HI Specimen packing & shipping NAAT MTB Culture DST AFB smear (direct) LEVEL 1 USAPI Labs Genexpert 4 TB Testing at the Local Lab (Level 1) 5 AFB Smear Microscopy (detects the infectious stage of TB) Duration of process (receipt to reporting) = 3 mins/specimen 1. Sputum smear preparation 2. Sputum smear staining (Ziel Neelsen (ZN) staining) 11/2/218 6 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 2
3. Drying of smears 4. AFB microscopy (1x objectives with oil immersion) Acid Fast Bacilli in ZN stained Sputum Smear AFBs (red pink rods) AFB Result Turn around Time (TAT) = 24hrs 11/2/218 7 AFB smear results shall be reported according to the WHO guideline as indicated below AFB Counts No AFB in at least 1 fields Recording/Reporting No AFB Seen/Negative 1 9 AFB in 1 fields Indicate Actual AFB Count 1 99 AFB in 1 fields 1+ 1 1 AFB per field in at least 5 fields >1 AFB per field in at least 2 fields 2+ 3+ 8 Genexpert TB Testing + test reagents 1mL Genexpert Genexpert Result Turnaround-Time (TAT) = 2 hrs 9 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 3
3 USAPI TB Lab Workload Total number of patients submitting TB specimens for testing between October 217 June 218 Number of patients 25 2 15 1 5 253 243 216 141 14 18 11 93 83 67764 68 54 5 42 12 43 47 46 44 37 38 24 21 8 7 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP 217 Q4 218 Q1 218 Q2 1 Total number of specimens processed between October 217 June 218 Number of specimens 6 5 4 3 2 1 55 54 467 368 32 33 247 212 178 198 171 168 168 123 128 14 127 112 81 91 97 4 26 65 43 23 24 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP 217 Q4 218 Q1 218 Q2 11 Training TB lab refresher training in Palau and Kosrae Additional lab staff trained In-house blind slide rechecking of AFB smears Revision of TB lab manual CE sessions completed Enhancing quality TB specimen collection American Samoa, Ebeye, Majuro, Kosrae, Palau (PIHOA) Guam (GPHL TB lab staff) Local TB lab updates to clinicians per quarter recommended Training of Trainers of Shippers IATA re-certification training As of Aug 7 th 218 15 IATA shipping trainers; 65 shippers in the USAPI 1 2 trainers per lab 1 4 shippers per lab 12 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 4
TB specimen shipping to DLS, Honolulu On going TB shipping negligible shipping incidents As of Aug 7 th 218 15 IATA shipping trainers; 65 shippers in the USAPI TB lab external quality assessment (EQA) Genexpert testing AFB smear microscopy Blind slide rechecking (BSR) 13 Contents of CE sessions completed to enhance quality TB specimen collection (important feedback to TB Program/TB clinicians/dot workers) EXAMPLE TB specimen quality status at Majuro Hospital Jan Sept 217 14 Submission of 3 specimens from TB suspects 217 1 st Quarter 2 nd Quarter 3 rd Quarter Total # TB 71 68 82 suspects # Patients with 3 specimens # Patients with 2 specimens 6 (84%) 8 (12%) 51 (75%) 8 (12%) 56 (68%) 14 (17%) # Patients with 1 specimens 3 (4%) 9 (13%) 12 (15%) Target = 1% of TB suspects submitting 3 specimens % of TB suspects submitting 2 or 1 specimen 15 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 5
Submission of salivary sputum specimens from TB suspects 217 1 st Quarter 2 nd Quarter 3 rd Quarter Total # scored as saliva Suspects/Dx 14 (83%) Followup/Treatment 17 24 14 3 (17%) 19 (79%) 5 (21%) 1 (71%) 4 (29%) Target = % of salivary specimens 16 Proper use of the sputa collection device 1.Demonstration by a DOT worker/tb nurse 2. Demonstration by facilitator 17 Collection of a quality sputum sample for TB investigation Recommended: Sputum collection device and container 18 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 6
Steps for quality sputum collection for effective TB lab diagnosis 19 1. Enhancing the collection of a quality TB sputum specimen is contributed by: 1. Teamwork Knowing who s who in the team Knowing your responsibilities and performing to the best of your ability 2. Tools Having an adequate supply of the right tools (specimen containers, etc.) to perform the tasks at hand Having an adequate supply of the right tools Having a good support system in place (internet, networking, etc.) 3. Test Testing technician effectively checks quality of specimen received 4. Time Consistent timely communication among team members on status of sputum quality 2 2. Collection of quality TB specimens are the responsibility of: 1. Patient Coached to produce the best quality specimen Provided the correct instructions for collection 2. TB DOTS worker/nurse Coach the patient to collect the best quality sputum specimen Patient s coach Provide the appropriate sputum collection container Ensure specimen container is tightly capped and correctly labeled Ensure completion of the lab request form Timely delivery of the TB specimen & lab request form to the laboratory 3. TB lab technician Receives and ensures specimen matches information on the lab request form 21 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 7
Complexity of a Laboratory System Reporting Patient/Client Prep Sample Collection Personnel Competency Test Evaluations Data & Laboratory Management Safety Customer Service Sample Receipt and Accessioning Record Keeping Quality Control Testing Sample Transport 22 3. How can you help obtain quality sputum specimens? Clinician Use the right specimen container: Sputa collection device is provided by DLS Training: Coach patient in sputum specimen collection Good instructions to patient: DOT/Nurses and patients to train on how to use the sputa collection device Patient to rinse mouth before collecting sputum Collect >5mL of sputum Ensure collection of 3 specimens from TB suspects Good documentation: Take time to adequately complete the lab requisition form Laboratory Good documentation: Take time to adequately correlate the specimen with the lab requisition form Store specimens at 4oC: Refrigerate specimens (for field DOT workers can use small ice boxes with cold ice packs Ship sputum ASAP: Do not hold sputum at clinic/ward; TB lab tech to ship specimen ASAP 23 4. Coaching of patient in the sputum collection very important 24 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 8
YES 5. The best sputum specimen NO Muco-purulent sputum Recommended volume: >5mL Salivary sputum 25 YES Muco purulent sputum vs Salivary sputum NO White cells Epithelial cells Muco purulent sputum Salivary sputum 26 AFBs clustered around or within dead white cells (pus cells) AFBs in or around white cells White cells 27 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 9
Main issues for collection of quality sputum in the USAPI 1. High saliva content 2. Inadequate volume (< 5mL) 3. Over 1 days storage of sputum specimens before shipping to DLS 4. Contaminated sputum from betel nut chewers 5. Incomplete TB lab requisition forms 6. Delivery of leaking sputum specimens to the laboratory 7. Mislabeled specimens 8. Collection of sputum in inappropriate specimen containers 9. Collection of sputum in nonsterile containers 1. Un refrigerated sputum specimen after collection 11. Non submission of 3 specimens from diagnostic/suspect TB patients 28 Impact of these issues on TB testing & results 1. High saliva content 2. Inadequate volume (< 5mL) 3. Over 1 days storage of sputum specimens before shipping to DLS 4. Contaminated sputum from betel nut chewers 5. Incompletely filled TB lab requisition forms Low chances of detecting the AFBs Volume inadequate to do several other tests at DLS Contaminants overgrowth increases, AFB growth viability decreases Contaminants overgrowth increases, AFB growth viability decreases Specimen will be rejected and not processed 11/2/218 29 Impact of these issues on TB testing & results 6. Delivery of leaking sputum specimens to the laboratory 7. Mislabeled specimens 8. Collection of sputum in inappropriate specimen containers 9. Collection of sputum in nonsterile containers 1. Un refrigerated sputum specimen after collection Specimen will be rejected Specimen will be rejected Transfer of sputum may leave some sputum in the old container, exposure to contaminants increased Other bacterial contaminants may overgrow AFB growth 11. Submission of 1 2 specimen Low chances of recovery of Mtb 11/2/218 3 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 1
Other recommended specimen types & volumes required for AFB testing CSF 3mL Sterile body fluid 5mL Urine 4mL Stool 1g Gastric lavage/washing fluid >5-1mL Collect in the morning soon after patient awakens in order to obtain sputum swallowed during sleep. Collect fasting early morning specimen on three (3) consecutive days. Use sterile water. Adjust to neutral ph with sodium carbonate immediately after collection. Label the contain with the unique patient identifiers. Label the specimen as Gastric lavage/washing. Place into the biohazard bag and seal it. Store at 2 8 o C is transport to the lab is delayed for more than 1 hour. Specimen should be transported or shipped to the lab at 2 8 o C ASAP. Neutralization is a critical step in preserving the integrity of this specimen type. No specimen will be rejected. However, specimens that are not neutralized will be tested on Genexpert MTB/RIF at DLS and reported. 31 What constitutes a quality TB specimen delivered to the lab? Muco-purulent sputum specimen Free of betel nut and food particles 3 specimens (if TB suspect) Volume of >5mL Correctly labeled specimen container Tightly capped specimen container Correctly completed AFB smear microscopy and Genexpert Request Form Timely delivery to the lab 32 TB lab documents & records 33 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 11
TB lab documents and records Various types of TB lab documents and records Each document relates to the type of TB lab activity involved Types of TB lab documents and related activities: 1. TB Standard Operating Procedure (SOP) Manual Documents test methods TB lab manuals are 5 years old or more Need review and update to reflect current practice 2. AFB Smear Microscopy and Genexpert Request Form Specimen receipt Testing & reporting Revised version will be used from Jan 219 3. TB Register Lab registration of specimen Recording of TB lab results Each patient s specimen results need to be completed (e.g. DLS TB culture results) Compilation of TB lab quarterly reports 34 4. TB Lab Quarterly Workload Statistics and Performance Indicator Form Compilation of TB lab quarterly reports Revised version will be used from Jan 219 5. TB specimen manifest & other shipping documents (TB shipping protocol, AWB, etc.) TB specimen shipping 6. Problem log Specimen rejection Existence of problem logs in some labs Review and share with TB program in your scheduled TB program meetings 35 Description revised lab documents AFB Smear Microscopy and Genexpert Request Form (version- Nov218) TB Lab Quarterly Workload Statistics and Performance Indicator Form (version-nov218) Group exercises 36 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 12
Comparison of Performance Indicators across the USAPI labs: October 217 June 218 37 3 25 Positivity rate among specimens between October 217 June 218 23 25 29 Percentage 2 16 16.8 15 13 14 1 1 8 8 8 7 7 6 5 4 7.3 4 5 3 3 3 3 2 1 1 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP 217 Q4 218 Q1 218 Q2 Note: Yap figure not available for 217 Q4 38 Percentage 18 16 14 12 1 8 6 4 2 8 8 7 3 2 1 Positivity rate among TB patients between October 217 and June 218 15 13 13 2 2 11 17.9 12.5 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP 15 1 7 6 217 Q4 218 Q1 218 Q2 9 14 4 5 2 9 8 39 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 13
4 35 3 Proportion of specimens scored as saliva between October 217 October 218 4 37 34 28 Percentage 25 2 15 1 5 19 18.8 18.6 15 9 9 8 8 9 5.5 5 6 3 2 1 1 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP 217 Q4 218 Q1 218 Q2 NOTE: CHK, ASA, MAJ, PAL, YAP No% indicated 4 16 14 Total # of specimens vs average TAT % October 217 June 218 Target = 1% 1374 12 Count/Percentage 1 8 6 4 2 982 783 477 386 418 3 19 1 99 85 95 97 1 87 112 66 99 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP Total # specimens Average % TAT 41 External quality assessment (EQA) for TB lab activities in the USAPI 42 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 14
External Quality Assessment (EQA) EQA is a system for objectively checking the laboratory s performance using an external agency or facility.(who) Organization Personnel Equipment Purchasing & Inventory Process Control Information Management Laboratory Quality Management System (LQMS) Documents & Records Occurrence Management Assessment Process Improvement Customer Service Facilities & Safety Implementing Quality Management does not guarantee an ERROR-FREE Laboratory But it detects errors that may occur and prevents them from recurring Organization Personnel Equipment Purchasing & Inventory Documents & Records Process Control Occurrence Management Information Management Assessment Laboratories not implementing a quality management system guarantees UNDETECTED ERRORS Process Improvement Customer Service Facilities & Safety Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 15
EQA methods Proficiency tests Rechecking/retesting On-site evaluation EQA provider: Sends unknown PT samples to a group of labs Labs analyze samples Results reported to labs Results compared across labs Laboratories: Send patients slides/samples examined/tested to external assessor Comparison of results Results reported to labs External assessor: Conducts onsite lab assessment Provides lab assessment report to lab assessed Acid fast smear proficiency test (PT) panels An AFB sample is tested by multiple USAPI labs 1 AFB-smeared slides per participant Ziel Neelsen (ZN) stain AFB smear microscopy Reported back to DLS on or before the deadline Attain 8% score to pass Results compared across all USAPI labs 47 Blind-slide Rechecking (BSR) Re-checking of patients AFB smeared and stained slides from local labs 1% of total number of AFB smears performed by the local lab (previous year) Slides for BSR are selected at random What s assessed? Quality of the AFB smear (sputum quality) Quality of the stain Quantification of AFB (if positive) Categories of errors for positive AFBs: Major quantification error (QE) e.g. Local lab 1+ DLS 3+ Minor QE e.g. Local lab 1+ DLS 2+ False positive e.g. Local lab AFB positive DLS AFB negative False negative e.g. Local lab AFB negative DLS AFB positive 48 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 16
On-site lab assessment An assessment of the real situation onsite A better view of current lab practices An opportunity to interview lab staff if needed An opportunity to consult with lab management to rectify or correct any inadequate practices or situations if encountered 49 Importance of EQA in TB lab testing Participation in an external quality assessment program provides valuable data and information which: allows comparison of performance and results among different test sites; provides early warning for systematic problems associated with kits or operations; provides objective evidence of testing quality and lab practices; indicates areas that need improvement(reliability of methods, materials, equipment) and develop and implement corrective actions identifies training needs and monitor training impact creates a network for communication a good tool for enhancing a national laboratory network samples received for EQA testing are useful for conducting continuing education activities EQA helps to assure customers, such as physicians, patients, and health authorities, that the laboratory can produce reliable results. EQA participation a requirement for lab accreditation. Overview of TB lab testing in the USAPI LEVEL 3 Mycobacteriology Lab CDC, Atlanta Genotyping/ Fingerprinting AFB smear (sedimentation) LEVEL 2 Diagnostic Lab Services Honolulu, HI NAAT MTB Culture & DST Specimen packing & shipping AFB smear (direct) LEVEL 1 USAPI Labs Genexpert Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 17
TB Laboratory EQA Activities in the USAPI WHO TB Reference Lab (Brisbane, Australia) EQA AFB PT Panels LEVEL 2 Diagnostic Lab Services Honolulu, HI EQA Genexpert PT Panels LEVEL 3 Mycobacteriology Lab CDC, Atlanta AFB PT Panels BSR Genexpert PT Panels PIHOA Regional Lab Coordinator EQA Annual onsite visits LEVEL 1 USAPI Labs Comparison of TB Lab EQA Performance among the USAPI labs: 216-217 Acid-fast bacilli staining & microscopy PT Blind-slide rechecking (BSR) Genexpert PT Total number of specimens processed between October 217 June 218 Number of specimens 6 5 4 3 2 1 55 54 467 368 32 33 247 198 212 178 171 168 168 123 128 14 127 97 112 81 91 65 4 26 43 23 24 ASA CHK CNMI EBE GUA MAJ PAL PNI YAP 217 Q4 218 Q1 218 Q2 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 18
Performance trend of acid fast smear proficiency testing (PT) among the USAPI labs: 216 217 Average Percentage 12 1 8 6 4 2 89 89 9 9 9 93 85 92 98 8 7 95 83 8 83 9 65 42 88 1% ASA CHK CNMI EBE GUA KOS MAJ PAL PNI YAP 216: CHK did not participate MAJ 1% (1 participant) 216 217 TARGET: 1% score PASS: 8% 217: GPHL & EBE 1% (2 participants) Number of errors 1 9 8 7 6 5 4 3 2 1 Blind slide Rechecking (BSR) Overview of Results 216 217 Target: Zero errors 9 5 4 4 3 3 3 3 3 2 2 1 1 1 1 1 1 Major QE Minor QE False pos False neg Percentage score 12 1 8 6 4 Genexpert PT performance: 216 217 Target = 1% 85 9 65 1% 2 ASA CHK CNMI EBE GUA KOS MAJ PAL PNI YAP 216 A 216 C 217 A Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 19
References http://www.who.int/ihr/training/laboratory_quality/1_b_eqa_contents http://www.who.int/ihr/training/laboratory_quality/11_cd_rom_tb_eqa_wpro.p df General TB lab issues/challenges for improvement 59 Medical Lab Workforce TB Lab Section Current status: 1 2 TB lab staff in each lab (with supportive back-up) PCSI Lab Coordinators (Palau & RMI-Majuro) Training Upcoming plans: Professional development of TB lab techs Annual professional development (online) for USAPI TB lab techs Adoption of TB lab technician core competency requirements (x48) by all other USAPI labs TB lab training in Pohnpei and any other lab (determined by the 218 EQA results) 6 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 2
Reporting of 4+ AFB smears by DLS Only reported sedimented TB sputum specimens (not for AFB PT panels) Gastric lavage specimens NEED TO BE NEUTRALIZED FOR BEST RESULTS!!! 1. Are all gastric lavage specimens received in the lab correctly labelled as such? 2. Are gastric lavage specimen being neutralized at the collection site? 3. Do you have sodium carbonate for neutralizing gastric lavage specimens? Q# Chuuk Ebeye CHC, Saipan 1 Not always Pohnpei Kosrae Palau Majuro Yap GPHL A/Samoa Yes Yes Yes None received so far Yes No None received so far NR NR 2 No No Yes No N/A No No N/A NR NR 3 No No Yes No No Yes No No NR NR 61 Upcoming plans: How do you prefer to handle neutralization of gastric lavage specimens? for discussion Options: 1. Neutralize at collection site Prepare sodium carbonate package and deliver to collection site 2. Neutralize in the lab Collect and deliver GL to lab ASAP Prepare sodium carbonate package and neutralize in lab as soon as GL is received 62 TB Specimen Shipping DO NOT SEND PRE-SHIPPING NOTIFICATIONS TO DLS COMMUNICATE! COMMUNICATE! COMMUNICATE! Reminders: Include logistics-dispatch@dlslab.com in your post-shipping email notification For all DLS shipments: Indicate on AWB under Handling Information : PLEASE CONTACT DLS DISPATCH UPON ARRIVAL. TELEPHONE: 88 589-513 63 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 21
Thank you!!! vasitiu@pihoa.org 64 Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 22