Performance Review of Sputum Smear Microscopy 4Q08

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Performance Review of Sputum Smear Microscopy
4Q08

• Dr TV Bhalodia
• Director
• STDC-Ahmedabad

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Quality Assurance in Sputum Smear Microscopy

• Analysis of 3Q08 (4Q08)

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Annexure E 3Q08..(1)
Sl. No. MC name Annual total slide volume Annual positive slide volume Slide positivity rate (SPR) Nos. of slides rechecked during the month_at_ HFP HFN LFP LFN QE Total Number
1 Ahmedabad-R 38050 5602 15 528 0 4 0 2 0 6
2 AMC 142591 21524 15 1290 1 2 0 4 1 8
3 Amreli 34527 4241 12 597 2 0 0 1 0 3
4 Anand 52197 7749 15 645 0 2 0 4 3 9
5 Banaskantha 68869 12094 18 626 1 6 0 0 1 8
6 Bharuch 49309 6990 14 889 0 0 0 0 1 1
7 Bhavnagar 59034 10556 18 855 1 1 2 1 1 6
8 Chhotaudepur 19591 3325 17 411 1 0 0 0 1 2
9 Dahod 61462 8007 13 918 0 0 0 0 0 0
10 Dang 5315 534 10 153 0 0 0 0 1 1
11 Gandhinagar 35894 4722 13 447 0 0 0 0 1 1
12 Jamnagar 43419 5051 12 851 0 0 1 0 1 2
13 Junagadh 58631 6801 12 882 0 2 3 1 0 6
14 Kachchh 38782 5638 15 954 1 1 0 4 1 7
15 Kheda 49011 9338 19 543 0 3 0 1 0 4
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Annexure E 3Q08..(2)
Sl. No. MC name Annual total slide volume Annual positive slide volume Slide positivity rate (SPR) Nos. of slides rechecked during the month_at_ HFP HFN LFP LFN QE Total Number
16 Mehsana 47673 5937 12 669 0 1 0 0 1 2
17 Navsari 28231 3825 14 483 0 0 0 0 0 0
18 Panchmahal 71900 12951 18 777 7 4 1 2 1 15
19 Patan 31826 4596 14 474 0 0 0 0 1 1
20 Rajkot 73845 10274 14 1320 0 0 0 0 0 0
21 Sabarkantha 59469 8539 14 1146 0 0 1 0 1 2
22 Surat-R 35929 5511 15 548 0 0 0 0 1 1
23 SMC 89112 259 11 1526 0 1 0 0 0 1
24 Surendranagar 41181 6165 12 429 0 0 0 0 1 1
25 Vadodara-R 32473 4961 15 432 0 0 0 0 0 0
26 VMC 34666 6494 19 270 0 1 0 0 0 1
27 Valsad 32056 3342 10 685 0 0 0 0 1 1
28 Vyara 16801 2664 16 351 1 1 0 3 1 6
29 Pobandar 12373 1181 10 321 0 0 0 0 1 1
  TOTAL 1364217 188871 14 20020 15 29 8 23 21 96
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Consolidated District RBRC Reports (Annexure E)
summary 3Q08

• No. of districts submitting reports
  electronically on time ? ALL 29
• No. of districts reporting no errors in all three
  month ? Nil
• No. of districts reporting high false errors in
  all three months ? AMC, Banaskantha, Panchmahal
• No. of DMCs reporting high false errors
  consecutively in all three months ? Nil

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DMCs with HF errors during 3Q08
Sr No. District DMCNo NAME OF DMC Total Total Total NAME OF DMC WITH REPEATETIVE HF ERRORS (FROM JAN 08 TO SEPT 08)
Sr No. District DMCNo NAME OF DMC HFP HFN Total NAME OF DMC WITH REPEATETIVE HF ERRORS (FROM JAN 08 TO SEPT 08)
1 Ahemedabad 1 Kuha 0 1 1  SANAND      
1 Ahemedabad 2 Sanand 0 1 1  SANAND      
1 Ahemedabad 3 Dhandhuka 0 1 1  SANAND      
1 Ahemedabad 4 Jetalpur 0 1 1  SANAND      
2 AMC 5 Saijpur 0 1 1  SAIJPUR    
2 AMC 6 Bagefordos 1 0 1  SAIJPUR    
2 AMC 7 Isanpur 0 1 1  SAIJPUR    
3 Amreli 8 Khambha 1 0 1    
3 Amreli 9 Jafrabad 1 0 1    
4 Anand(Petlad) 10 Sojitra 0 1 1  UNDEL  
4 Anand(Petlad) 11 Undel 0 1 1  UNDEL  
5 Banaskantha 12 Ambaji(NGO) 1 0 1    AMBAJI (NGO)      
5 Banaskantha 13 Kamboi 0 3 3    AMBAJI (NGO)      
5 Banaskantha 14 Danta 0 1 1    AMBAJI (NGO)      
5 Banaskantha 15 Jegol 0 1 1    AMBAJI (NGO)      
5 Banaskantha 16 Hadad 0 1 1    AMBAJI (NGO)      
6 Bhavnagar 17 Palitana 1 1 2  PALITANA
7 Chhotaudepur 18 Gadhboriyad 1 0 1  GADHBORIYAD
8 Junagadh 19 Delwada 0 2 2  DELWADA
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DMCs with HF errors during 3Q08
Sr. No. District DMCNo NAME OF DMC Total Total Total  NAME OF DMC WITH REPEATETIVE HF ERRORS (FROM JAN 08 TO SEPT 08) 
Sr. No. District DMCNo NAME OF DMC HFP HFN Total  NAME OF DMC WITH REPEATETIVE HF ERRORS (FROM JAN 08 TO SEPT 08) 
9 Kutchh 20 Nirona 0 1 1    
9 Kutchh 21 Bhachau 1 0 1    
10 Kheda(Nadiad) 22 Antisar 0 1 1    
10 Kheda(Nadiad) 23 Motizer 0 1 1    
10 Kheda(Nadiad) 24 Balasinor 0 1 1  
11 Mehsana 25 Cottege Hospital 0 1 1  
12 P.M 26 Santrod 2 0 2 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 27 Vadgam 2 0 2 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 28 Sarsan 0 1 1 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 29 Timba 2 0 2 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 30 Kothamba 1 0 1 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 31 Sansoli 0 1 1 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 32 Mehlol 0 1 1 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
12 P.M 33 Vardhari 0 1 1 SANTROD, VADGAM, SARSAN, TIMBA, SANSOLI               
13 SMC 34 Althan 0 1 1  ALTHAN
14 VMC 35 Yogini Vasanti Devi Hosp. 0 1 1  
15 Vyara 36 Utchchal 0 1 1    BALPUR
    37 Balpur 1 0 1    BALPUR
      Total 15 29 44  TOTAL 37 DMC (14 Old 23 new)
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Annexure M 3Q08..(1)
Sl. No. Name of District No. of TB suspectes examined for diagnosis No of TB suspects found to be positive No. of TB suspects undergoing repeat diagnosistic examination No. of TB suspects found to be positive on repeat diagnostic No. of follow up patients examin No of TB patients found to be positive Total No.of positive slide examined Total no. of negative slides examined Total No. of Negative Positive slides examined
1 Ahmedabad-R 2663 408 97 7 1214 135 1444 8229 9673
2 AMC 8769 1404 464 44 4981 724 5434 31195 36629
3 Amreli 2855 299 91 15 999 86 1022 9087 10109
4 Anand 3252 565 161 17 1783 204 2040 11061 13101
5 Banaskantha 3916 772 188 15 1976 215 2690 13225 15915
6 Bharuch 3766 526 257 16 1466 53 1321 10177 11498
7 Bhavnagar 3957 544 131 25 1863 191 1942 13349 15291
8 Chhotaudepur 1440 217 86 5 735 45 710 4735 5445
9 Dahod 5486 726 673 25 1948 196 3092 16893 19985
10 Dang 544 40 16 1 109 13 138 1370 1508
11 Gandhinagar 2562 323 123 9 1147 60 1071 9228 10299
12 Jamnagar 3424 419 120 36 1088 117 1434 10821 12255
13 Junagadh 4711 501 139 21 1789 131 1625 15669 17294
14 Kachchh 2539 368 93 11 1042 169 1413 7772 9185
15 Kheda 3908 670 170 12 1939 191 2330 13554 15884
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Annexure M 3Q08..(2)
Sl. No. Name of District No. of TB suspectes examined for diagnosis No of TB suspects found to be positive No. of TB suspects undergoing repeat diagnosistic examination No. of TB suspects found to be positive on repeat diagnostic No. of follow up patients examin No of TB patients found to be positive Total No.of positive slide examined Total no. of negative slides examined Total No. of Negative Positive slides examined
16 Mehsana 3892 478 179 21 1640 68 1551 13274 14825
17 Navsari 2374 332 64 8 997 65 1041 8185 9226
18 Panchmahal 4387 919 215 18 3022 301 3047 15221 18268
19 Patan 2479 356 102 12 1120 120 1294 7992 9286
20 Rajkot 5718 678 134 20 1949 207 2497 17744 20241
21 Sabarkantha 4535 799 170 19 2081 117 2529 14339 16868
22 Surat-R 3633 583 68 7 1402 158 2043 10245 12288
23 SMC 6284 685 304 31 2307 167 2290 20880 23170
24 Surendranagar 2794 451 88 10 981 98 1410 8919 10329
25 Vadodara-R 2562 412 48 10 1008 75 1380 8057 9437
26 VMC 2332 494 100 12 1183 118 1521 7773 9294
27 Valsad 2631 288 71 11 858 52 910 8673 9583
28 Vyara 1314 208 82 13 720 55 703 4501 5204
29 Pobandar 1018 110 74 3 452 16 341 3790 4131
  TOTAL 99745 14575 4508 454 43799 4147 50263 325958 376221
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Summery of Consolidate Monthly Lab Abstracts
Jul-Sept (Annexure M) 2nd q08

• No. of positive patients diagnosed out of total
  TB suspects examined in 3rd Q08 ? 14575/99475
  (14.6)
• No. of patients Undergone repeat sputum
  examination for Diagnosis ? 4508 (4.5)
• Positivity rate amongst repeat examination ?
• 454/4598 (10.07)
• Positivity rate in follow up patients? 4147/43799
  (9.46)
• Total slide positivity rate in 3rd q08 ?
  50263/376221 (13.35)

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Trend of HFP HFN Errors 1Q06 to 3Q08
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Trend of TB Suspects subjected to Repeat Sputum
examination for Diagnosis and found sputum
positive
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Trends of Sputum Positivity Rate4Q05 - 3Q08
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IRL OSE visit- Bharuch

• At present in the district only 1 post of DMC LT
  is been vacant at DMC Sagbara but almost all
  RNTCP Contractual LT is on deputation to other
  DMC to manage RNTCP work as at those DMC post is
  vacant.
• In TU Valia 4 LTs been there in 7 DMCs.
• Ensure running water supply to DMC Patlamau.
• Calculate all Single Sputum as suspect in lab
  abstract and in PMR.
• Reagents are not permitted to be preparing higher
  than 5 liter.
• 4 STLS (TU- Amod, Bharuch, Valia Rajpipla) in
  the Districts needs to be require retraining at
  State level.
• SPR is very low in DMC Dahej, Umalla, Avitha,
  Palej Sagbara.
• Newly appointed MOs are untrained in RNTCP
  modular training.
• Display diagnostic algorithm and categorization
  chart in MOs chamber. It is easier way for them
  to follow diagnostic algorithm properly.

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IRL OSE visit- VMC

• STLS needs to require refresher training whenever
  conducted at STDC as all STLSs were trained in
  2000-2003.
• Very selective referral found in all most all
  DMCs visited with low
• referral rate and SPR is very high. Needs to
  strengthen supervisory visit of STLS for referral
  from PPs and MO UHC.
• No corrections should be permissible in found in
  Lab register.
• Repair all non functioning Binocular Microscopes.
  
• Use Heavy Liquid Paraffin as immersion oil
  instead of synthetic oil.
• Retraining should be on going process when ever
  require for DMC LT as smear preparation is not
  proper in all most 50 of DMCs. It is
  responsibility of STLS to conduct on job training
  first and make a document in his/her TU-OSE
  Checklist.
• Cleanliness at DTC DMC should be improved.

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IRL - OSE visit- Vadodara Rural

• Post of MO PHI vacant at DMC Valan.
• Lens cleaning paper should be as per
  specification. Should be procured soon.
• DMC LT Sinor is still untrained in RNTCP.
• Binocular Microscopes needs to be repaired as
  soon as possible.
• Re training of all DMC LT who was trained since
  more than 2 years duration, needs to require
  soon.
• During TU OSE Visit of STLS it is require filling
  problems identified in detail along with possible
  suggestions in the summery of the report
• During their visit write down how many number in
  percentage of slides are thin, uneven and not in
  proper size.
• Make no correction in Lab register if it happen
  make note in remarks column reason for
  correction.
• Reasons for errors should be evaluated during
  next DMC Visit and documented in TU OSE Checklist
  and same will be documented in Annexure F.

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IRL - OSE visit Surendranagar

• DTC LT should be trained for RNTCP/EQA at state
  level.
• All non functional Binocular Microscopes to be
  repaired at the earliest.
• Laboratory Technicians needs to require on job
  training and sensitization for smear preparation
  techniques in all DMCs visited.
• In DMC Chuda and DMC Lakhtar, Many single sputum
  examinations are found in last 3 months. Health
  education and proper motivation to the patients
  for 3 sputum examination by DMC LT needs to be
  strengthened and supervised meticulously by STLSs
  to reduce single sputum examination.
• All STLS are instructed to cross check 5 Positive
  5 Negative Slides for Un-blinded Cross Checking
  between their 2 TU OSE Supervisory visits. Not on
  monthly bases. District TB Officer is requested
  to supervise the same.
• All TU OSE summery should be checked and signed
  by DTO for further corrective measures and all
  Technical and Operative problems should be
  discussed in meeting with MO-TC for appropriate
  actions.
• STLSs are instructed to identify possible cause
  of error by DMC LT in RBRC in their next TU OSE
  Visit and right the information in their overall
  remarks column.
• Annexure F should contain action required and
  taken including Errors in RBRC by DMC LTs
• STLS who has undergone training in RNTCP/EQA
  before two years needs to require retraining at
  state level when ever state will conduct such
  training.

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IRL - OSE visit Rajkot

• Needs prompt supervision for corporation DMCs as
  almost 50 DMCs are non functional more than 6
  months.
• This is second time as IRL Team has found Silica
  powder has been thrown away by LTs after one
  month. It is responsibility of STLS to explain
  all DMC LT for usage of silica crystals for
  preservation of microscopes.
• Strictly no manipulation or correction in Lab
  register should be followed. (For DMC Upleta)
• Needs improvement in Smear quality and staining
  technique as per the TU OSE Checklist of all STLS
  and on job training should be given by STLS to
  DMC LTs with date of on job training mentioned in
  OSE Checklist.
• DMC Hari Krupa, not functioning since more than 6
  month and is reported in QPMR but not reported in
  RBRC and in Annexure E M. Report of non
  functioning DMCs to be submitted to state for
  further actions and without prior concern with
  State TB Cell DMC number of DMC should not be
  changed.
• DMC Dhoraji- DOTS to be given by Pharmacist not
  by TB HV as already 4 Pharmacists are available
  at Dhoraji government hospitals.
• Preserve all Control Slides in all DMC for at
  least 3 months. (For DMC Upleta)
• Conduct training of all untrained DMC LTs. Even
  LT from non DMC should be trained for smear
  microscopy work
• Still some DMCs having many single sputum need to
  motivate and educate patients for 3 sputum
  examination. (DMC Dhoraji) Repair all non
  functional Binocular Microscopes.

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IRL - OSE visit Banaskantha (1)

• It is necessary to require monitoring by all
  level staff for
• Quality of Smear Microscopy Completeness of all
  details in Lab registers with minimum
  corrections.
• Poor performing DMCs whose ANSV SPR are very
  low
• Refer for suspects are very low.
• Repeat Sputum examinations are very low.
• Diagnostic algorithm should be followed strictly
  in all DMCS.
• Training and On Job sensitization of all DMC LTs
  with HF errors.
• SOP is not displayed. (PHC Malan, Hadad)
• 5 Phenol should be prepared regularly for
  chemical disinfection of the sputum cups and
  broom sticks. (PHC Malan , Virampur)
• Instruct LTs to use burner to fix the slides
  timer during staining. (PHC Danta)
• STLSs do not know proper method for reagent
  preparation especially for Carbol Fuchsin
  preparation. Needs urgent training.
• Control slides batch numbers should be written on
  slides.

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IRL - OSE visit Banaskantha (2)

• Strengthening of supervisory visit strictly needs
  to be followed and supervised by DTO, MO DTC MO
  TUs, on day to day bases and during their visit
  to DMC check all data of TU OSE Checklist of the
  same DMCs whether it is functioning according to
  guidelines or not.
• Signature and Remarks of DTO require in any TU
  OSE Summery report for the respected DMCs.
• In Panel Testing for efficiency of STLSs, Out of
  6 STLSs, results of only 2 STLSs are correct and
  6 Low False Negative error found. Training of all
  STLS who fails I n panel testing should be
  required on urgent bases.
• Water bath should be procured urgently and make
  available at DTC for reagent preparation.
• Blinding procedure should be supervised by DTO.
• Motivation to the patients for how to collect
  good quality sputum is not instructed by any DMC
  LTs.
• Visual appearance of sputum was not written in
  Lab registers. In all DMCs visited
• Sputum for AFB request forms are not completely
  filled. (DMC Khalgadh)
• Lab register contains many corrections in results
  in almost all DMCs visited.

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IRL - OSE visit Anand

• Binocular microscopes needs repairing in
  following DMC
• DMC Sojitra- 100 X is hazy
• DMC Mehlav- Coarse adjustment is tight
• DMC Ras- Stage is not moving properly
• DMC Karamsad Medical College- 100 X is hazy
• DMC LT Umreth seems to be not willing to work in
  RNTCP. Since smear preparation is very poor and
  more no of HFN (5 HFN in last 6 months) found it
  is better to change LT to non DMC.
• LT was absent at 1.30 pm on 5th July so team has
  visited the DMC on 2nd day but LT was undergone
  for leave by that time.
• Expiry date of reagent should be 4 month, not 1
  month.
• In summery report of STLSs TU OSE Checklists, in
  remarks column signature of DTO is required and a
  copy of same will be forwarded to DMC along with
  Annexure D.
• Equipments for reagent preparation are not
  sufficient. Needs to require at least 3 conical
  flasks, 2 measuring cylinders 2 separate glass
  funnel for each stain.
• 5x eye piece lens should not be used for sputum
  microscopy. 10x should be preferred. (Tarapur)
  2nd time problem identified by IRL team.

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Various pending EQA reports from the Districts.
Report Districts
IRL OSE Action Taken Report Surendranagar, Anand, Banaskantha (3Q08), Jamnagar, Surat Rural, Patan (4Q08)
Annexure E M (of the month November 2008) Anand (Due date 21st Dec)
Annexure E M (of the month December 2008) Chhotaudepur, Porbandar, Gandhinagar, Jamnagar (Due date 21st Jan 2009)




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Recommendations - 1

• Standard reagents with dye content as per
  Annexure-H should be available at all DTCs
• Standard equipment for preparation of reagents
  should be available at all DTCs Water Bath,
  Weighing Balance, Measuring Cylinder, Flask etc.
• All lab logistics forms formats should be
  available at all DMCs
• Ensure completeness and correctness of monthly
  lab abstract Annex E with reasons for any HF
  errors in remarks column
• Ensure correctness of data of QPMR with monthly
  lab extract report in regard to suspect examined
  and smear positive found
• 5 phenol/ phenolic compounds should be used as
  disinfectant
• Strengthen biomedical waste management
• 5 Heavy Liquid paraffin is preferred as an
  immersion oil
• 15 watt bulb or silica gel should be used for
  care of microscope lenses at all DMCs

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Recommendations - 2

• RBRC must be done under strict supervision of DTO
  / MODTC only separate area for RBRC should be
  made available.
• Blinding Coding register STLS roster register
  should be maintained at DTC
• IQC need to be strengthened and reagent
  validation register / control slide usage
  registers to be maintained at DTC level and
  control slide logbook at DMC level.
• Analysis of reasons and corrective actions for
  false results on monthly basis as per Annexure K
• Annexure D should be sent to all DMCs. Discrepant
  RBRC slides should also be sent to concerned
  DMCs
• Ensure completeness and correctness of TU OSE
• Action taken report (ATR) for IRL OSE EQA
  feedback should be sent to IRL within a month
• Take corrective actions for DMCs having ANSV lt500
  / or SPR lt5 as per Annexure L
• Annexure-F should reflect total evaluation of all
  DMCs of the districts in regard to RBRC and
  TU-OSE

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- Fighting TB is the responsibility of every
citizen.
Thank You