title: Integration of external quality assessment for microscopic diagnosis of malaria and tuberculosis : feasibility in Kano State, Nigeria
Creators: name: Sarkinfada, Faruk
Publisher: name: University of Liverpool Repository
Year: 2023

description: Background: Tuberculosis (TB) and malaria are endemic and are major public health burdens in Nigeria. Sputum smear microscopy for AFB and malaria microscopy are important for laboratory diagnosis and management of TB and malaria respectively. The \Vorld Health Organization has recommended the integration of malaria microscopy Quality Assessment (QA) with that of other microscopically diagnosed diseases, but there is no published evidence about the feasibility of implementing this policy in a resource poor setting in sub-Saharan Africa. Hypothesis: It is feasible to develop a model Quality Assessment (QA) system for malaria microscopy built on the existing TB microscopy QA system, in the context ofthe Nigerian health system. Objectives: To assess the feasibility oflinking malaria microscopy quality assessment into the existing AFB microscopy quality assessment system in Kano, Nigeria. Materials and methods: Five TB microscopy centres were selected for implementing the integrated TB and malaria microscopy QA scheme in the state. A model system was designed based on the Lot Quality Assurance System for selecting and blinded rechecking ofTB and malaria slides from these laboratories. Supervision and evaluation was conducted at 3 monthly intervals for 24 months. Results: Microscopy tests made up 21% of the laboratory tests conducted in one year in Kano state. The proportion of malaria and AFB microscopy among the microscopy tests was 35.1% and 27.2% respectively. To implement the model the five laboratories selected for implementing TB and malaria microscopy quality assessments had at least one microscope and two microscopists covering both TB and malaria. Full integration of the QA for TB and malaria microscopy was achieved in two laboratories, and partial integration in two other laboratories. The system improved the quality of TB and malaria microscopy results, particularly specificity. The average specificity of TB microscopy from the five laboratories increased from 80% to 97.9% and for the two laboratories in which malaria microscopy QA was fully integrated it increased from 76.0% and 66.7% to 100%. The average specificity of malaria microscopy from the two laboratories increased from 77.8% to 80.0%. On average, the concordance rate of TB microscopy results increased from 81% at baseline to 91.0% at the final assessment. For malaria microscopy the concordance rate increased from 69.2% at the baseline, to 83.3% at the final assessment in . one laboratory, but decreased from 100% to 83.3% in the other laboratory due to 16.7% false positive results. Increases in the concordant TB and malaria microscopy results were positively associated with the ability of the laboratories to prepare and stain the TB and malaria slides. There was a decreased false positivity and false negativity rates of TB microscopy results in all the five laboratories. Conclusions: It is feasible to integrate the QA system for TB and malaria microscopy and the assessment improved the quality of both services. However, a lot of advocacy is needed to engage all the relevant stakeholders and the integrated system needs testing out in different settings in order to be able to develop sound recommendations to guide the complex scaling up process.