1. Laboratory Workshop: Specimen Collection
Sean R. Toney
Immigrant, Refugee, and Migrant Health Branch
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention
Panel Physician Training Summit
March 2017
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

2. Learning Objectives Identify appropriate sputum collection areas.
After this workshop, participants should be able to:
Identify appropriate sputum collection areas.
Incorporate safety measures and fraud prevention into collection activities.
Implement proper sputum collection procedures and Follow requirements outlined in Technical Instructions.

3. Activity…. This is an interactive activity:
Participants will be divide into smaller groups
Each group moves to a designated area in the room
Each group collectively decides to arrange an indoor, outdoor, or covered outdoor collection area
Complete with applicant reception area, waiting area, collection area, and Directly Observed Therapy (DOT) area

4. Activity…. This is an interactive activity:
Each group collectively draws or sketches out the arrangement of the collection area on paper
Pros and cons of each groups’ drawing will be discussed
Participants will discuss collection processes and procedures
Participants will discuss specimen storage and transport

5. TB Sputum Collection Areas

6. Specimen Collection Area:
Indoor
Outdoor
“Covered” Outdoor

7. Specimen Collection Area:
OPTIMAL
SATISFACTORY
ADEQUATE / SUFFICIENT / MINIMAL

8. Specimen Collection Area: Indoor Requirements
Negative pressure in booths
Well-maintained ventilation system
Adequate air exchange between applicants
Booths must allow for direct observation of applicant by technologist
TIP:
If you are unsure whether negative pressure system is working, put a strip of thin tape or tissue paper at the booth’s window and see if it blows inward.

9. Sputum Specimen Collection Areas
Indoor
Source: Panel Sites: Thailand and Ukraine

10. Sputum Specimen Collection Areas
Indoor
Source: Panel Sites: Turkey and Malaysia

11. Specimen Collection Area: Outdoor Requirements
Adequate sunlight
Good ventilation
Collection from multiple applicants
Maximum 4 applicants per technologist
Minimum of 1.5 meters between applicants

12. Sputum Specimen Collection Areas
Outdoor
Source: Panel Sites: Jamaica and Vietnam, and Kenya

13. Sputum Specimen Collection Areas
“Covered” Outdoor
Source: Panel Sites: DR and Thailand, and South Africa

14. Collection Area Considerations:
Location
Rooftop / Basement
Parking lot / Hallway
Size
Service(s) provided
Setup of area
Organization
Registration
Document check
Waiting area
Bags/Personal Items
DOTs area
Entrances / Exits
Applicant volume
Flow of applicants
Fraud Prevention
Infection Control
Ventilation
UV lights
Sunlight
Exhaust Fan(s)
Sample storage
Sample transport
Waste Disposal
Job aids
(Posters / TV)
Supplies
Containers
Records/Files
Paper towels / Napkins
Hand Sanitizer
Water
Wash hands
Rinse mouth
Collectors
Tables
Chairs
Other…..??

15. Collection Times

16. Collection Times Early morning; three (3) consecutive days
Mon / Tue / Wed
Tue / Wed / Thu
Consider transport of specimens, if needed
Consider possibility of missed appointments

17. Safety Measures

18. Safety Measures Use personal protective equipment (PPE) for:
Collecting specimens
Processing specimens
Inoculating culture tubes
PPE includes:
N95 or FFP2 respirators
Disposable gloves
Disposable gowns
Dispose of infectious materials
Autoclaving
Incineration

19. Safety Measures Use personal protective equipment (PPE) for:
Collecting specimens
Processing specimens
Inoculating culture tubes
PPE includes:
N95 or FFP2 respirators
Disposable gloves
Disposable gowns
Dispose of infectious materials
Autoclaving
Incineration

20. Safety Measures Use personal protective equipment (PPE) for:
Staff
Applicants / patients
New
Follow-up
DOT
PPE for applicants includes:
Surgical / face masks

21. Medical Fraud Prevention Measures

22. Medical Fraud Prevention
Confirm identification
Passport
Photo
Verify signature
Specimen collection
Supervised
Specimen label
Side of container
Difficult to remove
Numbered or bar-coded
No names

23. Sputum Collection Procedures

24. By show of hands….
How many have collected sputum?

25. By show of hands….
How many have seen sputum collected?

26. By show of hands….
How many have regular communication with the lab or specimen collectors?

27. TB Sputum Specimen Collection

28. Sputum Collection Sputum must be collected from applicants who have:
Signs or symptoms suggestive of TB disease
Physical exam suggestive of TB disease
Chest x-ray suggestive of TB disease
HIV infection
Three fasting sputum specimens should be collected from the patient on three consecutive days
Important to collect specimens early in the morning
IMPORTANT:
Sputum specimens must be collected early in the morning on three consecutive days!

29. Sputum Collection Provide procedure instructions
Show applicant how to cough
Ensure lid is closed tightly to labeled container
Determine suitability of collected specimen
Collect at least 5 milliliters
Hold up to the light (sun, lamp) to determine if a quality specimen has been collected
Reject saliva; recollect
Refrigerate specimens if not transported within one hour to decrease culture contamination rate
IMPORTANT:
Specimen must be sputum, not saliva. Technician will check specimen quantity and quality upon collection. Laboratory must check specimen quantity and quality again upon arrival at lab.

30. Sputum Collection: Procedure for Applicant
No eating prior to sputum collection
Clear nasal passages and rinse mouth with distilled water
(Do not drink the water)
Take several deep breaths
Cover mouth with tissue while coughing deeply
Deposit sputum specimen in wide-mouthed container

31. Sputum Collection Container
Sterile / unused
10 ml - 50 ml capacity
Wide mouth (25mm – 65mm)
Screw top
Continuous thread

32. Sputum Specimen Quality
Source: Panel Sites: Vietnam and Ukraine, and Fujika 2005

33. Storage and Transport

34. Storage and Transport After sputum collected
Place upright in transport container
Styrofoam cooler / cool box / metal box
Gel / ice packs
Refrigerator (if batch collection, or delay in transport to lab)
Transport to testing laboratory within an hour
Hand-carry
Courier (motorcycle, bus, etc.)
Package Delivery Service
Source: Panel Sites: Vietnam, and Pinterest

35. Applicant Unable to Cough Despite Coaching?
Perform
Sputum induction
Gastric aspiration
Bronchoscopy (last resort)
Follow infection control precautions during all types of specimen collection
IMPORTANT:
Follow infection control precautions during all types of specimen collection

36. Sputum Induction Procedure must be supervised
An aerosol of Sterile hypertonic saline (3-15%) is inhaled
Saline thins and loosens secretions, irritates airways, and stimulates coughing
Applicants are instructed to cough into sterile container
Container should be labeled “induced sputum”
To prevent rejection by laboratory as saliva
Patients with reactive airway disease need pretreatment with a bronchodilator
NOTE:
Patients with reactive airway disease need pretreatment with a bronchodilator

37. Gastric Aspiration
Technique used to collect gastric content in young children <5 years
Inpatient or outpatient procedure
Collect 3, over 3 consecutive days
Mucus swallowed during night is aspirated first thing in morning using a nasogastric tube
Requires immobilization
Must neutralize and transport specimen to laboratory immediately
TB smears and cultures performed
~25 – 50% of children with active TB will be culture (+)

38. Gastric Aspiration Curry International Tuberculosis Center
Free online step-by-step guide to procedure
Brief demonstration video clip
Steps to Collect GA
Other helpful tips
List of tools and supplies needed
Reading material for parents
Source: Curry TB Center

39. Thank you! cdcQAP@cdc.gov http://www.cdc.gov/panelphysicians
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Visit: | Contact CDC at: CDC-INFO or
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine