# Presentation: 055993

## Module 3:Collection and Transportation of Tuberculosis Specimens

## Learning 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
- Assess quality of collected sputum specimen
- Outline requirements for a properly labeled specimen

## Content Overview

- Suitable specimen containers
- The number and timing of specimen collection
- How to collect a specimen
- Specimen handling and referral
- Assessing specimen quality

## Specimen Collection Container:  Specifications

- 50 ml capacity
- Translucent or clear material
- Single-use combustible material
- Screw-capped with a water-tight seal
- Easily-labeled walls

##  Specimen Collection

- Three (3) specimens optimal for identifying infectious cases of tuberculosis
- Make collection convenient and efficient for both patient and laboratory worker

## Timing of Specimen Collection

- 	**Spot–Morning–Spot****  **
- 	  WHO/IUATLD Recommendation
- Spot	initial visit to the clinic
- Early morning   first sputum in the morning
- Spot	second visit to the clinic

## Spot-Morning-Spot 

**Advantages**** **
- Requires only two visits (convenience to the patient)
- A spot specimen is available in case the patient does not return with the morning specimen

**Disadvantages**
- Two out of three specimens may be of poor quality
- High risk of missing a case if only the first specimen is properly examined

## Collection Considerations 

- Yield decreases rapidly after three specimens
- Morning specimens on average better
- Collect three morning specimens from hospitalised patients
- Two good examinations may be most efficient with high workload
- Follow NTP guidelines for exact specimen collection strategy

## Follow-up Specimens for Monitoring Treatment

- Collected during and at end of treatment
- Early morning specimen
- Consult NTP guidelines for exact collection frequency

## Country NTP

- Discuss the country related NTP guidelines for specimen collection

## Specimen Collection: Safety

- The  patient is a greater danger to staff than the specimen!
- Instruct patient to cover the mouth when coughing
- Never collect sputum in the laboratory!
- Collect OUTSIDE
- Collect away from other people
- Do not stand near patient during specimen collection

## Advantages of Open Air Collection

- Rapidly dilutes aerosols
- UV light rapidly inactivates the bacilli

## Specimen Collection Guidelines

- Explain clearly to patient
- Why sputum is needed
- Three samples required
- Spot–morning –spot
- What is a good sample and how to obtain it
- Opening and tight closing of containers
- Not to soil the exterior of the container
- Transport of sputum containers
- The need to return to the clinic

## Patient Education: Collection

- Best specimen comes from the lung
- Saliva or nasal secretions are unsatisfactory
- Remove dentures and rinse mouth with water
- Need for three sputum samples for optimal diagnosis

## Patient Instructions: Collection

- Inhale deeply 2–3 times, breathe out hard each time
- Cough deeply from the chest
- Place the open container close to the mouth to collect the specimen

## Optimum Collection Location:  Microscopy Centre

- Specimen is fresh
- Collection supervised
- Immediate recollection, if necessary

## Microscopy Not Performed at Health Centre:  Referral Options

- Patient Referral
- Specimen Referral
- Smear Referral

## Patient Referral: Disadvantages

- Expense of travel to diagnostic centre
- Family and work commitments
- Reluctant to seek help
- Diagnosis may be delayed

## Specimen Referral

- Peripheral health centre staff supervises patient collection of specimen.
- Specimen then forwarded to a microscopy centre.
- Consider:
- Frequency of transportation and packaging
- Potential for leakage and breakage

## Specimen Referral: Disadvantages 

- The microscopy centre has no direct control over the specimen collection process
- Higher risk with transporting specimens
- Requires a safe, fast and regular transport system for specimens and results
- Follow-up and quality assurance of the process may be needed

## Slide Referral 

- Smears require less safety precautions for packaging
- Peripheral centres must be trained in collection and smear preparation
- Disadvantages
- Risk of poor specimen and poor smear
- Slides are more fragile

## Request for Sputum Examination Form Should Include: 

- Patient’s name, sex, age, and address
- Date of collection
- Name of Health Institution
- Reason for examination

## Request for Sputum Examination Form

**Request for Sputum**** Examination Form**

## Labeling Specimen Container

**Labeling Specimen Container**

## Specimen Receipt at Laboratory

- Check specimens for quality:
- Volume (at least 3–5 ml)
- Describe sputum consistency (mucoid, purulent, bloody, or watery)
- Register the specimen and allocate a laboratory serial number

## Specimen Quality

**Specimen Quality**

**Purulent**

**Mucoid**

## Specimen Quality

**Specimen Quality**

**Saliva or Induced sputum (?)**

**Blood stained**

## Obtaining adequate good quality specimens is critical to ensure accurate and reliable AFB microscopy results

**Obtaining adequate good quality specimens is critical to ensure accurate and reliable AFB microscopy results**

## Role Play:  Sputum Collection

_**Process**_
- Work in groups of 3
- Decide roles: (1) health worker, (2) TB suspect patient, (3) observer
- The health worker instructs the TB suspect patient while the observer provides feedback.
- Switch roles and repeat the process until everyone has taken on each role once.

_**Purpose**_
- To practice educating TB suspect patients on the importance of a properly collected sputum specimen
- To practice providing instructions on how to collect a sputum specimen to a TB suspect patient.
_**Total Time**_
- 30 Minutes

## Role Play Debrief 

- Did the healthcare worker follow procedure:
- COMPLETE a *Request for Sputum Examination *form.
- LABEL sputum containers.
- EXPLAIN to the TB suspect how to collect sputum and the importance of a properly collected specimen.
- ASK the TB suspect to produce a sputum sample.
- ASK the TB suspect to collect another sample in the morning and then bring it to the diagnostic centre.
- Did the TB suspect understand instructions?
- What suggestions for improvements did the observer note?

## Summary

- What is the significance of spot–morning–spot collection?
- Why is sputum never collected in the laboratory?
- What are the three options for handling sputum specimens at peripheral health centres not performing microscopy?
- What are the features of a good quality specimen?
- How should you label a sputum container?