# Presentation: 703840

##  SUDAN-NTPMicroscopy networkand AFB quality assurance

**Overview of Sudan-NTP microscopy network **
**2.****   Quality assurance on Sudan-microscopy network****.**

## Sudan NTP Microscopy network

**One TB National Reference lab.**
**22 State TB Reference lab.**
**297 peripheral TB laboratories**.

## Laboratory workload in 11 states 2002

| state  | centers | total Smear postive slides | no of smear negative slids | total  |  | SPR | Work load  |
| --- | --- | --- | --- | --- | --- | --- | --- |
| BAHR GABAL | 8 | 1098 | 9201 | 10299 | 12949 | 8.5 | 2000 |
| BLUE NILE | 6 | 759 | 7275 | 8034 | 9962 | 7.6 | 2000 |
| GEDARIF | 14 | 1437 | 13017 | 14454 | 17926 | 8 | 1000 |
| GEZIRA | 36 | 3690 | 36711 | 40401 | 50912 | 7.2 | 1000 |
| KASSALA | 16 | 1230 | 14040 | 15270 | 19290 | 6.4 | 1000 |
| KHARTOUM | 53 | 12714 | 114900 | 127614 | 157922 | 8.1 | 3000 |
| NORTH KORDOFAN | 15 | 1776 | 14946 | 16722 | 20818 | 8.5 | 1000 |
| RED SEA | 17 | 1953 | 17883 | 19836 | 24284 | 8.1 | 1000 |
| RIVER NILE | 12 | 1254 | 11748 | 13002 | 15602 | 8.1 | 1000 |
| SINNAR | 12 | 1293 | 13059 | 14352 | 17364 | 7.4 | 1000 |
| WHITE NILE | 12 | 3090 | 29562 | 32652 | 40460 | 7.6 | 3000 |

- Average Slide Positivity = rate 10%
- Average workload = 2000Average workload =
- No of slides done/
- No of laboratories

## Tasks of TB National Reference Lab:-

**1- Maintaining high proficiency in routine smears microscopy carried out at peripheral health facilities.**
**2- Training of laboratory staff involved in the national laboratory network for tuberculosis.**
**3- Surveillance of anti-tuberculosis drug resistance.**
**4- Collaboration in research activities**.

## Tasks of State TB Reference Lab:-

**1- Preparation and distribution of the stains to peripheral laboratories in the state.**
**3-  Training of local lab.assistant.**
**4- Supervision activities.**
**5- Implementation and follow up of the Quality Assurance of sputum microscopy.**

## Tasks of peripheral TB Laboratory:-

**1- Examination of sputum smears by Z.N technique .**
**2- Registration of results in lab register book.**
**3- Keep slides for E.QC.**

## Organogram of Sudan NTP network

- NTP Manager

- NPHL Director

- Decision on priority activities,research protocols,budgets...

- Utilizes supplies

- Equipments transport

## Supervision:-

**Supervision is a key element of TB control and is considered the corner stone for sustainability of different NTP activities.**
**Effective supervision will ensure sustainable,high quality services.**
**Supervision can also be seen as a tool to achieve the NTP objectives****.**

## The specific objectives of supervision in the NTP laboratory network

**Provide support to health staff in order to improve their skills and performance.**
**Monitor the implementation of NTP activities.**
**Ensure high quality performance.**
**Help solve problems related to sputum microscopy.**
**Provide on job training.**
**Share ideas.**

## Levels of supervision

**The NTP carries out supervision at the following four levels.**
**1- Central level.**
**2- State level.**
**3- province level.**
**4- Microscopy centers.**

## The Frequency of supervision is done as

**TCU                          St (Once per year)**
**St.C                           Pr.C  (Quarterly)**
**Pr.C                          TBMU (Monthly)**
**Regular supervision is vital to NTP success.Feedback between different levels of the NTP is necessary to maintain staff motivation and quality of services.**

## Training

**Objectives**** of Training:-**

**1- To train and retrain lab staff on sputum microscopy.**
**2- To implement new technique.**
**3- To exchange the experience between different levels.**

## Levels of Training :-

**1- International level:**
**sending local NTP staff to attend external courses or workshops.**
**inviting external expertise to carry out workshops to NTP staff in the Sudan.**
**2- National level: (SNTBRL).**
**3- State level: (state team in target states).**

## Quality Assurance System

## Definition of Quality Assurance

**It is a system designed to continuously improve  the reliability and efficiency of laboratory services.(WHO-IUATLD).**
**A quality assurance program for AFB smear microscopy has several components.**

## Objectives of External Quality Assurance by blind rechecking

**Quality Control of routine smears.**
**Continuous motivation and education.**
**Improve quality by screening for unaccepted performance and problem solving.**
**Complementary to on-site evaluation.**

## NTP LABORATORY QUALITY ASSURANCE System

**SYSTEMATIC INTERNAL MONITORING OF WORK (INCLUDING TECHNICAL procedures,equipments TS AND STAINS **

**Analysis of smear microscopy(to remove obstacles  towards  success**

## Q.A system in Sudan NTP

**In last five year the SNRL collect 100% (all) positive slide and 10% from negative slide then all slides rechecked again by SNRL staff .**
**Now the SNTP implemented QA system by Blind Rechecking of slides**

## Steps of E.QA by Blind Rechecking of Slides

**1.Slides keeping:- **
**Keep all slides whatever the result (representative) **
**Each slide must be identified by number of slide and number of patient as obtained in the lab register book of TBMU.**
**No result must be appear on slides (Blindness).**
**Slides should be kept according to their number.**
**Once a sample was collected, the remaining slides should be discarded**

## 2. Taking a sample(I)(State QCC

**Quarterly from slides of previous quarter**
**Sample(random) size is a fixed number, according to LOTS quality assurance sampling technique it depends on frequency of smear negative and slides positivity rate **
**First identify sample slides in lab register book: start with a random number each time**
**Use the master form(form1) to list these slides identification numbers(ID) and their results and make another copy without results.**

## 2. Taking a sample(II) (State QCC)

**Collect slides from the slide boxes, mark missing slides as such in the remarks column and replace them by the next slide**
**Arrange slides in the transportation box according to their ID**
**Bring slides to state lab. Coordinator with a copy of master form without results**

## 3. Blind rechecking(state lab.coordinator -first controller)

**Should clean all slides with Xylene**
**Restaining to all selected slides**
**Recheck all selected slides, reviewing the same number of fields as should have been done in the TBMU**
**List the results on the master form and gives results to state quality control officer.**

## 4. Identification of discordants (State QCC)

**Add state TB lab coordinator results to form 2, and compare with TBMU results using the errors cross-table**
**Identify all slides with discordant results**
**Make a list of those per TBMU on the discordants form, alternating column from time to time ( so part of TBMU and part of state TB lab coordinator results in each of the first two columns)**
**Request these slides from the state TB lab, and send them to National TB reference lab together with the discordants list(form 3)**

## 5. National reference laboratory( second controller)

**Controller are given slides plus discordants list to guide their work; these controllers must have plenty of time**
**All discordant slides must first restained**
**Readings should then be added to discordants list(form3) and then returned to each state with the slides.**

## 1

**FILL 2 COPIES OF FORM 1. ONE OF THEM WITHOUT RESULTS**

**GIVE SAMPLE SLIDES TO STATE LAB COORDINATOR (1****ST**** CONTROLLER)+COPY OF FORM 1 WITHOUT RESULTS TO BE FILLED**

**DOWNLOWD BOTH READINGS INTO FORM 2**
**(one COPY for each microscopy center)**

**Identify discordant slides from each TBMU**

**Fill form 3(one copy for the whole state) and send it with discordant slides to TB reference lab(2****nd**** controller)**

**TB reference lab to complete form 3 and return  it with slides to states**

**Complete form2 for each TBMU and discuss results with state coordinator and TBMU personnel **

- 2

- 3

- 4

- 5

- 6

- 7

- 8

**HOW TO CONDUCT LAB QUALITY ASSURANCE BY BLIND RECHEKING**** **

## 7.Quarterly feedback to TBMU (State QCC)

**Send to TBMU a copy of (form2) together with slides with serious errors for review.**
**No Error of any type                         optimal performance .**
**Major Error : HFP or HFN                      Unacceptable Performance****                                        (Evaluation and Corrective Action) .**
**Minor Errors : Quantification errors , LFP or LFN         should  not exceed predetermined level.           **

## SUDAN NTP

**Peripheral microscopy centers**

**random sample**
**State Q A Coordinators**

** ****intermediate level**
**First level controls:**
**States Q A Laboratories**

**5-10 % discordant**

**National level**
**Second level countercheck:**
**TB reference lab**

**SUDAN NTP**

**Feed-back**

**Feed-back**

**Organogram explain different Levels of E.QA**

## Obstacles:-

**1- Labeling and keeping of slides.**
**2- Collection of slides from TBMU.**
**3- Sending of discordant slides from states to NRL.**
** **