SUPERVISION OF SPUTUM SMEAR LABORATORIES

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SUPERVISION OF SPUTUM SMEAR LABORATORIES

• AIM OF SUPERVISION
• GENERAL ORGANIZATION
• INDICATORS FROM THE REGISTERS
• PROBLEM ORIENTED SUPERVISION

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ESTABLISHING A MICROSCOPY NETWORK

• PYRAMIDAL STRUCTURE
• DECIDE ON THE REQUIRED DENSITY
• DECIDE ON METHODS / TECHNIQUES
• ENSURE LAB SAFETY
• CHOOSE ESSENTIAL EQUIPMENT
• ORGANIZE SUPPLIES
• ORGANIZE TRAINING

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STRUCTURE OF MYCOBACTERIOLOGY SERVICES

• Pyramidal structure recommended
• to maintain proficiency
• e.g. susceptibility testing
• but also smear!
• for maximum efficiency and cost-effectiveness
• depending on the economical situation
• e.g. culture up to which level?

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PYRAMIDAL STRUCTURE

• Three main levels
• (national) reference lab, specialised
• intermediary level district, region, province
• peripheral laboratories
• additionally
• peripheral treatment centres sputum sent up
• supra-national reference laboratories quality
  assurance

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PYRAMIDAL STRUCTURE (2)

• Role of the reference laboratory
• decisions on technical issues, with NTP
• e.g. equipment, supplies
• e.g. appropriate threshold for smear-positivity
• organization of, participation in
• training
• supervision
• quality control of smear microscopy
• training, supervision, quality control cultures
• (all) susceptibility tests, surveys
• (operational) research
• routine smears, cultures.. for its capture area

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PYRAMIDAL STRUCTURE (3)

• Intermediate level labs
• with NTP supervisors
• main level for
• training of microscopists
• supervision of smear laboratories
• quality control of smears
• supplies to peripheral laboratories
• preparation, distribution of stains
• routine tasks
• including culture?

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PYRAMIDAL STUCTURE (4)

• Peripheral laboratory network
• only AFB-microscopy
• eventually catering to subcenters

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DECIDE ON THE REQUIRED DENSITY

• On average 1 center per 100,000 population
• Factors to consider
• workload and proficiency
• case-detection of sm TB per 100,000
• accessibility /- 25 km radius ?
• area/2000 (sq. km)
• existing infrastructure (survey)
• Find a balance
• referral of patients or samples
• big specialized centers

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DECIDE ON METHODS AND TECHNIQUES

• Ziehl-Neelsen still the most appropriate
• technically simple, but tough
• prefer hot over cold method
• decide on cut-off for positivity
• Concentration techniques to increase sensitivity
  (HIV) ?
• quality of technician most important
• Fluorescence microscopy reference centers
• much more efficient human factor

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ENSURE LAB SAFETY

• Transmission of TB aerosols
• main danger patients !!
• never collect sputum indoors
• stirring, pipetting, centrifugation of sputum
• use of gloves ??
• Safety cabinets for smears??
• unproven risk RR in high prevalence countries?
• expensive dangerous if not well maintained
• self-made cabinets ?
• UV lamps rarely useful
• lighted only after the work

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ENSURE LAB SAFETY (2)

• Emphasis on light, ventilation, safe practices
• careful handling of sputum and unstained smears
• exhaust fan during work (cold climates)
• laboratory coats
• disinfection of working surface, paper covers
• Insist on safe disposal of infectious waste
• best by autoclaving(?), or burning
• disposables, e.g. bamboo sticks for smearing

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CHOOSE ESSENTIAL EQUIPMENT

• Good microscopes needed, no false economy
• free of fungus and provisions to keep it so!
• protect from dust and sand in dry climates
• Also essential
• good table and chair for comfortable work
• slideboxes for quality control
• waste receptacle
• with cover also to be used for burning
• Not absolutely needed
• safety cabinets / laminar flow cabinets
• bacteriological loops, timers

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ORGANIZE SUPPLIES

• Preparation of stains
• needs additional equipment and skills
• centralize at intermediate level
• precautions against contamination
• distilled water, absolutely clean glassware
• test and date each batch of stains
• low positives, 1 staining cycle
• negatives, 2-3 staining cycles
• Prefer non-drying immersion oil over cedar-oil
• Foresee bulbs and spares for microscopes
• Ordering and distribution system

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ORGANIZE TRAINING

• Selection of people!
• motivation more important than education
• Emphasis on practice
• Duration of the course will be limited
• teaching of theoretical part
• correct practice
• Count on an in-service period
• all positives checked on the spot
• quality control for negatives
• Expertise can be acquired quickly in a
  high-prevalence situation

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