tb laboratory training chuuk, fedsm

Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018

Quality Sputum Collection for TB Testing in the US-affiliated Pacific Islands 1

https://www.currytbcenter.ucsf.edu

TB Laboratory TrainingChuuk, FedSM

Vasiti Uluiviti

Regional Lab Strengthening Coordinator

PIHOA

November 29th 20181

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 USAPIOct 2017 – June 2018

3




LEVEL 2Diagnostic Lab

ServicesHonolulu, HI

LEVEL 3Mycobacteriology LabCDC, Atlanta/Other labs

LEVEL 1USAPI Labs

Genotyping/Fingerprinting

AFB smear(sedimentation)

Genexpert

Specimen packing & shipping

Overview of TB lab testing in the USAPI

4AFB smear (direct)

NAAT MTB CultureDST

5

TB Testing at the Local Lab (Level 1)

11/20/2018 6

AFB Smear Microscopy(detects the infectious stage of TB)Duration of process (receipt to reporting) = 30 mins/specimen

1. Sputum smear preparation

2. Sputum smear staining (Ziel Neelsen (ZN) staining)




3. Drying of smears 4. AFB microscopy(100x objectives with oil immersion)

11/20/2018 7

AFBs(red‐pink rods)

Acid Fast Bacilli in ZN‐stained Sputum Smear

AFB Result Turn‐around‐Time (TAT) = 24hrs

AFB smear results shall be reported according to the WHO guideline as indicated below

8

AFB Counts Recording/ReportingNo AFB in at least 100 fields No AFB Seen/Negative

1 – 9 AFB in 100 fields Indicate Actual AFB Count

10 – 99 AFB in 100 fields 1+

1 – 10 AFB per field in at least 50fields

2+

>10 AFB per field in at least 20fields

3+

Genexpert TB Testing

9

1mL

Genexpert

Genexpert Result Turn-around-Time (TAT) = 2 hrs

+ test reagents




USAPI TB Lab Workload

0

50

100

150

200

250

300

ASA CHK CNMI EBE GUA MAJ PAL PNI YAP

24

141

67

93108 101

68

38

8

12

216

7054

83

140

50 42

7

43

243

64

3747

253

46 44

21

Number of patients

Total number of patients submitting TB specimens for testingbetween October 2017 – June 2018

2017‐Q4 2018‐Q1 2018‐Q210

0

100

200

300

400

500

600


40

320

128

198

368

212

168

91

2326

504

178

104

247

303

123

97

2443

550

171

81

168

467

127 112

65

Number of specimens

Total number of specimens processed between October 2017 – June 2018

2017‐Q4 2018‐Q1 2018‐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 7th 2018 15 IATA shipping trainers; 65 shippers in the

USAPI• 1 – 2 trainers per lab • 1 – 4 shippers per lab 12




TB specimen shipping to DLS, Honolulu

• On going TB shipping negligible shipping incidents• As of Aug 7th 2018 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

14

TB specimen quality status at Majuro HospitalJan – Sept 2017

Contents of CE sessions completed to enhance quality TB specimen collection (important feedback to TB Program/TB clinicians/DOT workers)

EXAMPLE

15

2017 1st Quarter 2nd Quarter 3rd Quarter

Total # TB suspects

71 68 82

# Patients with 3 specimens

60(84%)

51(75%)

56(68%)


8(12%)

8(12%)

14(17%)


3(4%)

9(13%)

12(15%)

Target = 100% of TB suspects submitting 3 specimens 0% of TB suspects submitting 2 or 1 specimen

Submission of 3 specimens from TB suspects




16

Submission of salivary sputum specimens from TB suspects

2017 1st Quarter 2nd Quarter 3rd Quarter

Total # scored as saliva

17 24 14

Suspects/Dx 14(83%)

19(79%)

10(71%)

Follow‐up/Treatment

3(17%)

5(21%)

4(29%)

Target = 0% of salivary specimens

Proper use of the sputa collection device

17

1.Demonstration by a DOT worker/TB nurse2.Demonstration by facilitator

Collection of a quality sputum sample for TB investigation

18

Recommended: Sputum collection device and container




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 ability2. ToolsHaving an adequate supply of the right tools (specimen containers, etc.) to perform the tasks at

handHaving an adequate supply of the right toolsHaving a good support system in place (internet, networking, etc.)3. TestTesting technician effectively checks quality of specimen received4. TimeConsistent timely communication among team members on status of sputum quality

20

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




22

Complexity of a Laboratory System

•Data & Laboratory Management•Safety•Customer Service

Patient/Client PrepSample Collection

Sample Receipt and Accessioning

Sample TransportQuality Control

Testing

Record Keeping

Reporting

Personnel CompetencyTest Evaluations

3. How can you help obtain quality sputum specimens?

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

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

Clinician Laboratory

4. Coaching of patient in the sputum collection very important

24




5. The best sputum specimen

Muco-purulent sputum

Salivary sputum

YESNO

25Recommended volume: >5mL

Muco‐purulent sputumvs

Salivary sputum

Muco‐purulent sputum Salivary sputum

YES NO

Epithelial cellsWhite cells

26

AFBs clustered around or within dead white cells (pus cells)

AFBs in or around

white cells

White cells

27




Main issues for collection of quality sputum in the USAPI

1. High saliva content

2. Inadequate volume (< 5mL)

3. Over 10 days storage of sputum specimens before shipping to DLS

4. Contaminated sputum from betel nut chewers

5. Incomplete TB lab requisition forms





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 non‐sterile containers

10. Un‐refrigerated sputum specimen after collection

11. Non‐submission of 3 specimens from diagnostic/suspect TB patients






11. Non‐submission of 3 specimens from diagnostic/suspect TB patients

28

Impact of these issues on TB testing & results





5. Incompletely filled TB lab requisition forms





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

11/20/2018 29

Impact of these issues on TB testing & results






11. Submission of 1‐2 specimen






11. Submission of 1‐2 specimen11/20/2018 30

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

Low chances of recovery of Mtb




Other recommended specimen types & volumes required for AFB testing

• CSF – 3mL• Sterile body fluid – 5mL• Urine – 40mL• Stool – 1g• Gastric lavage/washing fluid –

>5 - 10mL• 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 – 8oC is transport to the lab is delayed for more than 1 hour.

• Specimen should be transported or shipped to the lab at 2 – 8oC 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 specimenFree 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 GenexpertRequest Form’

Timely delivery to the lab

32

TB lab documents & records

33




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 2019

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 2019

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-Nov2018)

• TB Lab Quarterly Workload Statistics and Performance Indicator Form (version-Nov2018)

• Group exercises

36




Comparison of Performance Indicators across the USAPI labs: October 2017 – June 2018

37

0

5

10

15

20

25

30


53

23

2

16.8

8 8

443

16

1

7.3

8

29

0

13

7

1

6

10

25

7

3 3

14

Percentage

Positivity rate among specimens between October 2017 – June 2018

2017‐Q4 2018‐Q1 2018‐Q2

Note: Yap figure not available for 2017‐Q4 38

0

2

4

6

8

10

12

14

16

18


8

2

15

2

17.9

109

5

8

3

13

2

12.5

7

14

0

87

1

13

11

15

6

4

2

9

Percentage

Positivity rate among TB patients between October 2017 and June 2018

2017‐Q4 2018‐Q1 2018‐Q2

39




0

5

10

15

20

25

30

35

40


3

19

5.5

1

37

9

2

40

18.6

5

34

89

1

15

18.8

86

28

9

Percentage

Proportion of specimens scored as saliva between October 2017 – October 2018

2017‐Q4 2018‐Q1 2018‐Q2

NOTE: CHK, ASA, MAJ, PAL, YAP – No % indicated40

109

1374

477

386

783

982

418

300

11266

100 99 85 95 97 100 8799

0

200

400

600

800

1000

1200

1400

1600


Count/Percen

tage

Total # of specimens vs average TAT % October 2017 – June 2018

Target = 100%

Total # specimens Average % TAT41

External quality assessment (EQA) for TB lab activities in the USAPI

42




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

Documents&

Records

Occurrence Management Assessment

Process Improvement

Customer Service

Facilities &

Safety

Laboratory Quality Management System

(LQMS)

ImplementingQuality Management

does notguarantee

anERROR-FREE

Laboratory

But it detects errors that may occur and prevents them from recurring

Laboratories notimplementing aquality managementsystem guaranteesUNDETECTED ERRORS

Organization Personnel Equipment

Purchasing &

Inventory

Process Control

Information Management

Documents&

Records

Occurrence Management Assessment

Process Improvement

Customer Service

Facilities &

Safety




EQA methods

Proficiency tests Rechecking/retestingOn-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

10 AFB-smeared slides per participantZiel Neelsen (ZN) stainAFB smear microscopyReported back to DLS on or before the deadline

Attain 80% 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 10% 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




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.

LEVEL 2Diagnostic Lab

ServicesHonolulu, HI

LEVEL 3Mycobacteriology Lab

CDC, Atlanta

LEVEL 1USAPI Labs

Genotyping/Fingerprinting

AFB smear(sedimentation)

Genexpert

Specimen packing & shipping

Overview of TB lab testing in the USAPI

AFB smear (direct)

NAAT

MTB Culture &

DST




TB Laboratory EQA Activities in the USAPI

LEVEL 2Diagnostic Lab Services

Honolulu, HI

WHO TB Reference

Lab (Brisbane, Australia)

BSR

LEVEL 3Mycobacteriology Lab

CDC, Atlanta

LEVEL 1USAPI Labs

EQAAFB PT

Panels

PIHOA Regional Lab Coordinator

EQAGenexpertPT Panels

EQAAnnual onsite visits

AFB PT Panels

GenexpertPT Panels

Comparison of TB Lab EQA Performance among the USAPI labs: 2016 - 2017

Acid-fast bacilli staining & microscopy PT Blind-slide rechecking (BSR)

Genexpert PT

0

100

200

300

400

500

600


40

320

128

198

368

212

168

91

2326

504

178

104

247

303

123

97

2443

550

171

81

168

467

127 112

65

Number of specimens

Total number of specimens processed between October 2017 – June 2018

2017‐Q4 2018‐Q1 2018‐Q2




89

0

9085 92

70

95

80

90

42

89

90

90

93 9880 83

8365

88

0

20

40

60

80

100

120

ASA CHK CNMI EBE GUA KOS MAJ PAL PNI YAP

Average Percentage

Performance trend of acid ‐fast smear proficiency testing (PT) among the USAPI labs: 2016 ‐ 2017

2016 2017

2016:‐ CHK did not participate‐ MAJ – 100% (1 participant)

2017:‐ GPHL & EBE – 100% (2 participants)

TARGET: 100% scorePASS: 80%

100%

1

0 0 0 0 0

1

0 0 0

1

0 0

1

0 0 0 00 0

1

0

3

4

3

0

9

0

2

5

0 0 0

3

0

3

0 0 0 0 0 0 0

2

1

0 0 0 0

3

0

4

0 00

1

2

3

4

5

6

7

8

9

10

Number of errors

Blind‐slide Rechecking (BSR) ‐ Overview of Results 2016 – 2017

Target: Zero errors

Major QE Minor QE False pos False neg

85 90

65

0

20

40

60

80

100

120

ASA CHK CNMI EBE GUA KOS MAJ PAL PNI YAP

Percentage score

Genexpert PT performance: 2016 – 2017Target = 100%

2016‐A 2016‐C 2017‐A

100%




References• http://www.who.int/ihr/training/laboratory_quality/10_b_eqa_contents

• http://www.who.int/ihr/training/laboratory_quality/11_cd_rom_tb_eqa_wpro.pdf

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 techsAnnual professional development (online) for USAPI TB lab techsAdoption 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 2018 EQA results)

60




Reporting of 4+ AFB smears by DLSOnly 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

Pohnpei Kosrae Palau Majuro Yap GPHL A/Samoa

1 Not always

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 sitePrepare sodium carbonate package and deliver to collection site

2. Neutralize in the labCollect and deliver GL to lab ASAPPrepare 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 [email protected] in your post-shipping email notification

For all DLS shipments: Indicate on AWB under ‘Handling Information’: “PLEASE CONTACT DLS DISPATCH UPON ARRIVAL.

TELEPHONE: 808 589-5103”

63




Thank you!!!

[email protected]

64