# Presentation: 675986

## ORGANIZATION OF

**ORGANIZATION OF**
** *****TB***** LABORATORY SERVICES**

## Role of Laboratory in NTP?

**Estimation of demand of laboratory****services for *****NTP***
**Issues to be taken into account for****setting-up the laboratory network****for *****NTP***
**Set-up of different levels of laboratories****for *****NTP***
**Mechanism for continued improvement****of the services**

## ROLE OF LABORATORY IN THENATIONAL TB CONTROL PROGRAMME

**Definitive diagnosis:**** detection of infectious sources (****case-finding****)**
**Follow-up of**** patient’s response to****treatment**
**Participation in *****TB***** surveillance:****notification (/prevalence) of**** *****TB*****; DRS**
**Assist in selecting effective treatment regimens**

## Information requiring to estimate demand of

**    ****smear microscopy and the laboratories**
**Population: ****	****	****	****	****   ****10,000,000**
**Newly registered smear positive cases:*****new + retreatment cases (6,500+1300)******	*****	****7,800**
**Smear positive rate among suspects:****	****  ****	****  ****10%**
**Minimum number of smears for diagnosis: ****	****       ****3**
**Minimum number of smears for follow-up:       ****3X2*****smear positive/negative cases***
**Optimum number of smears per day per****worker (peripheral center):****	****	****          ****10 / 15*****% rural population, administrative division,******geography***

## Estimation of smear microscopy demand and

**  ****required number of diagnostic laboratories**
**For diagnosis: (1/0.1) x 7,800 x 3 =****	**** ****	****234,000**
**For follow-up:****     smear positive cases, 7,800 x 3 x 2 =****	****  46,800**
**     ****smear negative cases, 2,600 x 6 =****	****  15,600**
**Total smears required:****	****	****	****296,400**
**If optimum No of smears per day is 10:**
**     ****2,500 smears per year, so need =****	****       119****If optimum No of smears per day is 15:**
**     ****3,750 smears per year, so need =****	****         79**
**Population covered by a center (or worker):**
**     ****10,000,000 / 119 =****	****	****	****	****  84,000**
**     ****10,000,000 / 79 =****	****	****	****	****127,000**

## ISSUES TO BE TAKEN INTO ACCOUNT IN

**SETTING UP LORATORY NETWORK FOR**
**        *****TB****** *****CONTROL PROGRAMME**
**Reflect the local demands**
**Accessible to entire population**
**Relationship with NTP: functionally should be****integrated be reporting performance to NTP**
**Implement training and EQA (+supervision)****under NTP administration**
**Provide all the affordable services by developing****good referral system**
**Standard procedures must be carefully****selected according to the programme policy****and development**

## SETTING UP TB LABORATORY NETWORK

**☼ ****Integration into NTP****: desirable but**
**	****expensive, fragile to political****commitment & health sector reform**
**    ****(not sustainable)**
**☼**** ****Integration into general public**
** ****	****health laboratory network****: lack of good**
**    ****relationship with NTP (requires good**
**    ****coordination to make them report and**
**    ****implement training/EQA under NTP)**
**☼ ****Setting up****: NRL→PL; PL→IL →NRL**

## Classification of the

**different levels of laboratory**

** ****Administrative (jurisdictional) division**
** ****Geography/ population coverage/ rural**** population**
** ****Activities mandated: microscopy; culture/ID; DST**
** ****No. specimens examining per day**
**(4) No. staff and their types of work**
**     ****(only ****TB**** or ****TB****+other works)**
**(5) Laboratory facility and equipment**

## PHERIPHERAL LABORATORY

**Location:**** ****Peripheral TB dispensary(center);**
**                    ****Health Center; District Hospitals**
**                    ****1****st**** Referral Hospitals**
**Services:**** ****Sputum collection;**
**                    ****Z-N smear microscopy**
**Managerial:**** ****Recording/reporting;**
**                    ****Slides keeping for EQA**
**Manpower/workload****:**** ****≤ 1(2) worker(s);**
**                    ****>2-3 / <20 smears per day**
**Covering population:**** ****100-200k**

## INTERMEDIATE LABORATORY

**Location:**** ****Regional (TB) Health Institutions**
**                    ****including hospitals **
**Services to clinics:**** ****FM/ZN smear microscopy;**
**                    ****Culture / ID of *****MTB*****; referral services**
**Supports to PLs:**** ****Supply of reagents/materials**
**                    ****for smear microscopy; Training;**
**                    ****Supervision; EQA of smear microscopy**
**Manpower****: ****2-3 workers (only for TB works)**
**Covering population:**** ****500-1,500k**

## TB LABORATORY NETWORK(fully integrated into NTP)

***           ******LEVEL***

***INTERMEDIATE***
***(REGIONAL/***
***PROVINCIAL)***
*** ******LEVEL***

***CENTRAL***
***(NATIONAL)***
***  ******LEVEL***

** ****TB**** Clinic or**
**TB**** Dispensaries**

**  ****TB**** Center/**
**TB**** Unit/Ward**

**National**** ****TB**
**Control Center**

** ****Peripheral**
**(multipurpose)**
**laboratories**

** ****Intermediate**
**laboratories**

**National**
**reference**
**laboratory**

**Supplies**
**Supervision**
**   ****EQA**

**Reports/**
**Referral**
**services**

**TB**** LABORATORY NETWORK(fully integrated into NTP)**

**Reports/**
**Referral**
**services**

**Supplies**
**Supervision**
**    ****EQA**

**    ****Central**
**supervisory**
**       ****team**

**Supervisory**
**     ****teams**

**Notes:**
Laboratory organization varies greatly from country to country. The country having a good NTP organization has fairly similar one with what you are seeing in this slide. Usually the laboratories working for TB could be divided by 3 levels, peripheral laboratories, which are usually integrated into general laboratory services and examine few specimens only by smear microscopy which is most important laboratory procedure for NTP. They will refer specimens for culture or DST to higher levels. Their quality of works will be assured or supervised by the higher level laboratories.
Some country establish NRL first and then peripheral laboratories but some countries the other way. Depending the laboratory organization and relationship between the different laboratories, QA system may be different. 

## TB LABORATORY NETWORK (separated from NTP)

***           ******LEVEL***

***INTERMEDIATE***
***(REGIONAL/***
***PROVINCIAL)***
*** ******LEVEL***

***CENTRAL***
***(NATIONAL)***
***  ******LEVEL***

**TB**** Clinic**
**in Health**
**Institutions**

**  ****TB**** Unit/ward**
**In Health**
**Institutions**

**National**** ****TB**
**Control Center**

** ****Peripheral**
**multipurpose**
**laboratories**

** ****Intermediate**
**(multipurpose)**
**laboratories**

**Central**
**reference**
**laboratory**

**TB**** ****LABORATORY NETWORK (separated from NTP****)**

**    ****Central**
**supervisory**
**       ****team**

**Supervisory**
**     ****teams**

**Laboratory**
**coordinator**

**Laboratory**
**coordinator**

**Supplies**
**Supervision**
**   ****EQA**

**Supplies**
**Supervision**
**   ****EQA**

**Reports/**
**Referral**
**services**

**Reports/**
**Referral**
**services**

**Notes:**
Laboratory organization varies greatly from country to country. The country having a good NTP organization has fairly similar one with what you are seeing in this slide. Usually the laboratories working for TB could be divided by 3 levels, peripheral laboratories, which are usually integrated into general laboratory services and examine few specimens only by smear microscopy which is most important laboratory procedure for NTP. They will refer specimens for culture or DST to higher levels. Their quality of works will be assured or supervised by the higher level laboratories.
Some country establish NRL first and then peripheral laboratories but some countries the other way. Depending the laboratory organization and relationship between the different laboratories, QA system may be different. 

## TB LABORATORY SPACE & DESIGN BY LEVELS

**                               ****Room             Functional**
**	****	****       ****Space               sections**
**	****     ****	****	****	****Smear microscopy**
**Peripheral****	****	****1      ****	****(specimen reception/**
**laboratory****                             ****	****smear prep./stain./**
**	****	****	****      ****	****microscopy/recording)**
**Intermediate ****           1-2****	****Smear microscopy**
**laboratory ****               (3)****	****Culture**
**	****	****	****      ****	****Sterilisation/washing**
**	****	****	****      ****	****Microscopy**
**National****	****          ****	****	****Media preparation**
**reference****	****          4-5****	****Culture**
**laboratory****	****	****      ****	****Sterilisation**
**	****	****	****      ****	****Storage**