# Presentation: 463017

## SUPERVISION OF SPUTUM SMEAR LABORATORIES

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

## 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**

## 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?**

## 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**

## 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**

## 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?**

## PYRAMIDAL STUCTURE (4)

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

## 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**

## 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**

## 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**

## 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**

## Slide 12

## 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**

## Slide 14

## Slide 15

## Slide 16

## 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**

## X

## Slide 19

## Slide 20

## 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**

## Slide 22

## Slide 23