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
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 2
https://www.currytbcenter.ucsf.edu
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)
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 3
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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
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 4
https://www.currytbcenter.ucsf.edu
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
ASA CHK CNMI EBE GUA MAJ PAL PNI YAP
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
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 5
https://www.currytbcenter.ucsf.edu
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%)
# Patients with 2 specimens
8(12%)
8(12%)
14(17%)
# Patients with 1 specimens
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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
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 7
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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
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 8
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
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
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
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
28
Impact of these issues on TB testing & results
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. Incompletely filled TB lab requisition forms
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. 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
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. Submission of 1‐2 specimen
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. 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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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Comparison of Performance Indicators across the USAPI labs: October 2017 – June 2018
37
0
5
10
15
20
25
30
ASA CHK CNMI EBE GUA MAJ PAL PNI YAP
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
ASA CHK CNMI EBE GUA MAJ PAL PNI YAP
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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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0
5
10
15
20
25
30
35
40
ASA CHK CNMI EBE GUA MAJ PAL PNI YAP
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
ASA CHK CNMI EBE GUA MAJ PAL PNI YAP
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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
ASA CHK CNMI EBE GUA MAJ PAL PNI YAP
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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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%
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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
Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigation in the Pacific November 27‐30, 2018
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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
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Thank you!!!
64