1. Laboratory ‘Network’ Update New York State Department of Health
Max Salfinger
New York State Department of Health
Princeton October 24, 2006

2. not pieces of silver and gold’
‘It is health
which is real wealth
not pieces of silver and gold’
Mahatma Gandhi,

3. 3 questions
Survey
Systems thinking

4. History / physical exam
Adherence/Cure
3 Time to negativity?
2 RIF resistance?
1 Tuberculosis?
sees a
doctor
Chest x-ray
History / physical exam

5. 1.Tuberculosis yes or no ? Identification Growth detection Microscopy
Nucleic acid amplification

6. 2. RIF res. yes or no ? Egg based AST Agar based AST
Clinical course
Egg based AST
Agar based AST
Radiometric / Non-rad.
rpoB analysis (line probes)

7. Testing concentrations:
Drug 460TB MGIT 7H10 7H11
INH 0.1/ / / /1.0
RIF
EMB 2.5/ /10 7.5
SM 2/6 1/4 2/10 2/10
PZA N/A N/A

8. What gets captured in the TB database?
Result - susceptible; resistant?
Method - BACTEC 460; MGIT, etc?
Concentration tested?
Percent resistant colonies?
Mutation found, type?

9. 3. Time to negativity
Follow up specimens until 2 consecutive specimens are culture negative...
Initial cavitation & mo-2 culture pos: extend INH/Rif from 4 to 7 months
Repeat susceptibility testing after 3 mo
Pos mo-4: Treatment failure

10. CT, DE, IN, MA, MI, NJ, NYC, NYS, PA, VT, WV
Survey [N=11]:
CT, DE, IN, MA, MI, NJ, NYC, NYS, PA, VT, WV

11. NAA:
YES: 6
NO: 5

12. DST:
Bactec 7
MGIT 2
7H10, ESP ea 1

13. DST - screening:
SIRE-PZA 5
4 drugs 4
3 drugs 1

14. DST - 2nd-line:
YES 6
NO 5

15. Quantiferon:
YES 2
NO 9

16. Work days:
7 days: 1
6 days: 1
5 days: 8

17. Biggest concerns: Not enough resources Federal TB grant reduction
Gamma Interferon assays: PHL or hospital-based labs
Ability to keep high level of testing
Delayed delivery of specimens and isolates
Loosing 40+ years of experience (retirement)
Staff shortage
Time and money
Maintaining staff competency
Reduction of Federal $$$

18. Success stories: FAST TRACK program Being a member of the LIMS RFQ
Moving into better lab space
Implementation of NAA (homeless case)
NAA turnaround time
Staff cross-training
Surpassing CDC turnaround time guidelines
Improving TAT & client relationship with less staff
Molecular identification and drug susceptibility

20. Peter Senge in The Fifth Discipline, 1990
Systems Thinking
‘We tend to focus on snapshots of isolated parts of the system, and wonder why our deepest problems never seem to get solved.’
Peter Senge in The Fifth Discipline, 1990

21. Did you hear Claudia’s husband?

22. If you suspect DR, MDR, or XDR TB you have a moral responsibility to get the results in the shortest TAT possible!

23. $$$

25. ?

26. Laboratory standards
New York: NAA mandatory for newly diagnosed patients whose sputum tested AFB smear positive.

27. Reference Laboratory System

29. T B
Think Big

30. Be
Bold !

31. Picasso: Peace Dove

33. WE can do it !

34. Thank YOU
for
Working TOGETHER!

35. The Journey sets the Destination see you ALL in Tallahassee, FL !