# Presentation: 318165

## SUPERVISION OF SPUTUM SMEAR LABORATORIES

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

## AIM OF SUPERVISION

- <date/time>

_**AIM OF SUPERVISION**_

**Problem solving**
**problems often there, not reported**
**suspicion from quality assessment**
**Continued education **
**Motivation**
**needs positive attitude**
**avoid false accusations & wrong emphasis on targets**
**help whenever possible**

## GENERAL ORGANIZATION 

**Who?? **
**central lab supervisors: too infrequently**
**NTP supervisors (district, region): more efficient**
**When??**
**ideally at each visit to a centre**
**at least:**
**always enquire about problems**
**take sample for quality control, give feed-back**

## GENERAL ORGANIZATION (2) 

**How??**
**needs good insight in AFB-microscopy**
**and practice: confirm positives as an exercise**
**problem-oriented for highest efficiency**
**quality assessment system = part of supervision**

## INDICATORS OF LAB PERFORMANCE

**From registers or reports**
**Have been used for internal monitoring**
**comparing smear- and culture-positivity**
**Derive from numbers for smears only?**

## TENTATIVE AFB-SMEAR INDICATORS 

**Positivity rate among suspect smears**
**Positivity rate among follow-up smears**
**Low positive case smears**
**Consistency within case series**
**Case yield of first smear**
**Number of smears per (positive) case**
**Percent positive cases registered for treatment**

## POSITIVITY SUSPECT SMEARS

**Indicates lab quality, but also**
**accessibility (financial, geographical)**
**selection of suspects**
**Normal rate: often not 10%**
**variations between NTPs: accessibility, other diseases (HIV !)**
**variations ~ level of service, i.e. 3rd line **
**seasonal variations ...**
**Extract lab quality ??**
**compare units at same level**
**gross lab deficiencies may show**

## POSITIVITY FOLLOW-UP SMEARS

**Sensitive indicator of lab quality ?**
**Normal rate may be around 10%**
**~ population: early treatment? MDR-TB? HIV?**
**~ guidelines: no. of smears first 2-3 months? **
**~ correct registration: targets!!**
**Interpretation of too low rates**
**superficial reading or bad microscope**
**and/or poor staining**

## LOW POSITIVE CASE SMEARS

**Less than 1 AFB per field/ all with AFB**
**Normal rate 25-50% ?**
**~ population: accessibility, HIV**
**requires +/- correct quantification**
**Interpretation**
**too low: superficial reading or bad microscope**
**too high: poor stain or staining**
**confirmed by their absence among follow-up smears**

## CONSISTENCY CASE SERIES

**% of cases with AFB in all 2 or 3 smears**
**Normal rate around 80% ?**
**~ population: accessibility, HIV**
**~ sampling strategy (spot more variable)**
**Interpretation**
**100%: copying results? **
**low: problems with reading, microscope, staining or specimen collection**
**isolated positives not rare = serious problem: doesn’t know AFB or unusable microscope; mislabeling**

## CASE YIELD FIRST SMEAR

**% cases with AFB in first smear**
**Similar to consistency**
**At least 85% ?**
**~ population: accessibility, HIV**
**~ sampling strategy (no. of specimens, no. of spot)**
**Interpretation: as before**
**100%: copying results? **
**low: reading, microscope, staining & smearing**
**more indicative of good specimen**

## NO. OF (POSITIVE) SMEARS PER CASE

**Compares cases registered / smears done**
**Respect of strategy and guidelines?**
**at least X negatives per SM-**
**at least 2 positives per SM+**
**Interpretation**
**proper use of lab ~ guidelines **
**SM-: gross deviations; compare diagnostic units**

## PERCENT POSITIVE CASES REGISTERED FOR TREATMENT

**Counts from lab versus treatment register**
**	****easier than cross-checking registers**
**Indicates**
**patient-friendliness at all levels, including appropriate detection strategy**
**lab: transmission of results, delay**
**(completeness of registration)**
**Normal level**
**can be >99%**
**exception: well-known TB referral centres**

## HOW TO USE THESE INDICATORS?

**Internal monitoring, charting**
**problem: fluctuations++**
**--> only larger units & selected indicators ?**

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## HOW TO USE THESE INDICATORS?

**During supervision visits**
**can be used by non-professionals**
**one value, i.e. full quarter or year**
**problem: time constraint in big units**
**selected indicators only, i.e. low positives**
**scan rather than count**
**Calculate from lab reports**
**ideal: analysis by computer**
**problem: few NTPs have lab reports!**

## PROBLEM ORIENTED SUPERVISION

**Overall impression of the laboratory**
**installations, equipment, personnel adequate ?**
**supplies sufficient ? storage conditions ?**
**safety ; waste disposal ?**
**important: cleanliness, tidiness**

## PROBLEM ORIENTED SUPERVISION (2)

**Check the lab register for:**
**completeness ? up to date?**
**plausibility of results**
**i.e. isolated positives ; proportion scanty results**
**workload: <25 smears daily?**
**indicators of performance**

## PROBLEM ORIENTED SUPERVISION (3)

**Look at smears macroscopically**
**properly identified ?**
**thickness of unstained smears ?**
**colour of stained smears ?**
**Check recent positives / (& neg.) microscopically**
**image bright, clear and stable ?**
**AFB visible ? **
**strong red colour AFB, not background?**

## PROBLEM ORIENTED SUPERVISION (4)

**Check cross-checking**
**correct sampling possible ?**
**all slides kept ?**
**no result on slides ?**
**sampling regularly done ?**
**feed-back on results received ?**
**errors ? **
**type : FN ? FP ?**
**evolution**
**need to call a specialist ?**