+-------------------+--------------------------------------------------+
| ![](media/image1. | Module 3                                         |
| jpeg){width="1.50 |                                                  |
| 83333333333333in" | **Collection and Transport of Tuberculosis       |
| height="1.135     | Specimens**                                      |
| 4166666666667in"} |                                                  |
+-------------------+--------------------------------------------------+

+----------------+-----------------------------------------------------+
|                |                                                     |
+----------------+-----------------------------------------------------+
| **Purpose**    | To provide participants with the knowledge and      |
|                | skills for proper collection and transport of       |
|                | sputum samples for AFB microscopy                   |
+----------------+-----------------------------------------------------+
| **Prerequisite | None                                                |
| Modules**      |                                                     |
+----------------+-----------------------------------------------------+
| **Learning     | At the end of this module, you will be able to      |
| Objectives**   |                                                     |
|                | -   Describe specifications of suitable containers  |
|                |     for sputum collection                           |
|                |                                                     |
|                | -   Explain the collection strategy:                |
|                |     spot--morning--spot                             |
|                |                                                     |
|                | -   Describe and demonstrate safe and correct       |
|                |     collection of sputum                            |
|                |                                                     |
|                | -   Describe options for specimen collection,       |
|                |     handling, and transport                         |
|                |                                                     |
|                | -   List features of a good sputum specimen         |
|                |                                                     |
|                | -   Describe the requirements for a properly        |
|                |     labeled specimen.                               |
+----------------+-----------------------------------------------------+
| **Content      | -   Suitable specimen containers                    |
| Outline**      |                                                     |
|                | -   The number and timing of specimen collection    |
|                |                                                     |
|                | -   How to collect a specimen                       |
|                |                                                     |
|                | -   Specimen handling and referral                  |
|                |                                                     |
|                | -   Assessing specimen quality                      |
+----------------+-----------------------------------------------------+
| **Handout and  | Exercise: Practical collection of sputum            |
| Exercises**    | specimens---role play                               |
+----------------+-----------------------------------------------------+
| **Appendix**   | None                                                |
+----------------+-----------------------------------------------------+

**Module 3: Collection and Transport of Tuberculosis Specimens**

# SUITABLE SPECIMEN CONTAINERS

Use clean, wide mouthed, and leakproof specimen containers. Single use
disposable plastic containers (50 ml capacity) are preferred.

**THE NUMBER AND TIMING OF SPECIMEN COLLECTION**

To ensure optimal recovery of TB bacilli from sputum, collect and
process three specimens. Consult your country's NTP for specific
guidelines. At least one should be an "early morning" specimen that can
be collected by the patient upon rising. Early morning specimens have
the highest yield of AFB.

# 

When TB is suspected in a patient, collect three sputum specimens as
recommended for diagnosis. If the first two are positive then the third
sample can be omitted. For outpatients, collect one sample at the time
of presentation. This is known as the spot specimen. Give the suspect a
second sputum container for collection the following morning and
instruct the patient to deliver the morning specimen to the laboratory.
When the patient returns the morning specimen, give him or her the third
container and collect another spot specimen.

Give the patient clear instructions on the proper collection of a
specimen for TB. For hospitalized patients, collect early morning
specimens on three successive days, since such samples often contain
more bacilli and thus are more likely to be positive by microscopy.

## Sputum collection for follow-up of treatment:

For patients on treatment, collect follow-up specimens at intervals
specified by the NTP. Early morning sputum is the preferred specimen.

**HOW TO COLLECT A SPECIMEN**

Sputum collection is the most dangerous procedure in the AFB smear
microscopy laboratory and must be done in the open air and at a distance
from other people.

***Never collect sputum in the laboratory!***

Give a new sputum container to each patient from whom sputum examination
for TB is requested. Demonstrate how to use it to collect a good
specimen.

Clearly instruct the patient on

-   the importance of sputum examination for diagnosis or follow-up of
    TB;

-   how to open and close the containers;

-   the need for collecting real sputum, not saliva;

-   how to produce good sputum (i.e., by repeated deep inhalation and
    exhalation of breath followed by cough from as deep inside the chest
    as possible);

-   how to avoid contamination of the exterior of the container (i.e.,
    by carefully spitting and closing the container);

-   how to collect and safely deliver the morning sputum to the
    laboratory; and

-   the need for three sputa to facilitate diagnosis.

A good specimen should be approximately 3--5 ml. It is usually thick and
mucoid. It may be fluid and contain pieces of purulent material. Color
varies from opaque white to green. Bloody specimens will appear reddish
or brown. Clear saliva or nasal discharge is not suitable as a TB
specimen.

# 

# SPECIMEN HANDLING AND REFERRAL

# 

# Specimen handling

For optimum patient management, process the specimen as soon as possible
(i.e., \< 24 hours). For microscopic examination the interval between
collection and staining matters little. Acceptable results can be
obtained even on delayed specimens.

If the peripheral health centre does not perform microscopy, there are
several options. Each has advantages and disadvantages. Depending on
local circumstances, one or more options may apply:

-   Refer the patient to a health centre where microscopy is performed

-   Collect a sputum specimen and refer it to the microscopy centre.

# Patient referral

Ideally, you can refer a patient to the microscopy centre so that a
specimen can be collected under monitored conditions. If an
unsatisfactory specimen is submitted, then a repeat sample can be
obtained immediately. The disadvantage of this option is that the
patient may find it expensive or impractical to travel to the microscopy
center. Patients may be reluctant to seek help and diagnosis may be
delayed.

# Specimen referral

Alternatively, the peripheral health center can supervise the patient in
collecting an appropriate specimen, which is then forwarded to a
microscopy center. Transport specimens once or twice each week, although
in some remote settings this may not always be possible. Package
specimens carefully to prevent leaks and breaks. Clearly label each
specimen with the patient identification and include a completed request
for sputum examination.

# Slide referral

Time delays for slide referrals may occur. There are, however, several
advantages. Fixed sputum smears are less infectious than sputum
specimens are and require less packaging for transport.

# ASSESSING SPECIMEN QUALITY

Upon arrival in the laboratory, assess the quality of samples. TB sputum
can have various colors and aspects. If the sample is liquid and as
clear as water, without particles or streaks of mucous material, process
the sample but ensure that the poor quality of the sample is reported on
the result form. When possible, encourage the patient to try again. Even
saliva can yield positive results. All specimens should be processed,
except for broken or leaking containers which should be discarded and
another specimen requested.

Accept very small quantities if the patient has difficulty producing
sputum and if the aspect is right. Blood-streaked sputum is suitable,
but pure blood should not be examined. Refer patients producing pure
blood specimens to a medical officer or doctor.

+-----------------+----------------------------------------------------+
| **Key message** | -   Good quality sputum samples are important for  |
|                 |     the diagnosis of pulmonary TB.                 |
| ![](m           |                                                    |
| edia/image2.wmf | -   Early morning specimens provide the biggest    |
| ){width="1.1701 |     yield of AFB.                                  |
| 388888888888in" |                                                    |
| height="0.83194 | -   For patients on treatment, collect follow-up   |
| 44444444445in"} |     specimens at intervals specified by the NTP.   |
|                 |                                                    |
|                 | -   Never collect sputum specimens in the          |
|                 |     laboratory.                                    |
|                 |                                                    |
|                 | -   Provide patients with clear instructions on    |
|                 |     the collection of good quality samples.        |
|                 |                                                    |
|                 | -   Patient referral, specimen referral, and slide |
|                 |     referral are options for peripheral health     |
|                 |     centers not performing microscopy.             |
|                 |                                                    |
|                 | -   Assess the quality of all specimens submitted  |
|                 |     to the laboratory for microscopy.              |
+-----------------+----------------------------------------------------+

+-----------------+----------------------------------------------------+
| > ![](m         | Module Review: Module 3                            |
| edia/image3.wmf |                                                    |
| ){width="1.0in" |                                                    |
| >               |                                                    |
| height="0.96041 |                                                    |
| 66666666667in"} |                                                    |
+=================+====================================================+
| > Find out how  |                                                    |
| > much you have |                                                    |
| > learned by    |                                                    |
| > answering     |                                                    |
| > these         |                                                    |
| > questions.    |                                                    |
+-----------------+----------------------------------------------------+
| > What is the   |                                                    |
| > benefit of an |                                                    |
| > early morning |                                                    |
| > specimen?     |                                                    |
| >               |                                                    |
| > \_\_          |                                                    |
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+-----------------+----------------------------------------------------+
| > Why should    |                                                    |
| > sputum never  |                                                    |
| > be collected  |                                                    |
| > in the        |                                                    |
| > laboratory?   |                                                    |
| > \_\_\_\_      |                                                    |
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| _\_\_\_\_\_\_\_ |                                                    |
+-----------------+----------------------------------------------------+
| > What are the  |                                                    |
| > important     |                                                    |
| > instructions  |                                                    |
| > that should   |                                                    |
| > be given to   |                                                    |
| > patients for  |                                                    |
| > the           |                                                    |
| > collection of |                                                    |
| > good quality  |                                                    |
| > sputum        |                                                    |
| > specimens?    |                                                    |
| >               |                                                    |
| > \_\_\_        |                                                    |
| \_\_\_\_\_\_\_\ |                                                    |
| _\_\_\_\_\_\_\_ |                                                    |
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| _\_\_\_\_\_\_\_ |                                                    |
| \_\_\_\_\_\_\_\ |                                                    |
| _\_\_\_\_\_\_\_ |                                                    |
+-----------------+----------------------------------------------------+
| > How should    |                                                    |
| > salivary      |                                                    |
| > specimens be  |                                                    |
| > handled in    |                                                    |
| > the           |                                                    |
| > laboratory?   |                                                    |
| >               |                                                    |
| > \_\_\_        |                                                    |
| \_\_\_\_\_\_\_\ |                                                    |
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+-----------------+----------------------------------------------------+