1. Module 4: From Suspect to Confirmed Case

2. Learning Objectives Explain why sputum microscopy is important Describe the process for confirming a TB suspect as a TB case Describe how to collect sputum properly Explain how to properly fill-out the Suspect and Sputum Register Dispatch form and Mycobacteriology Request Form Describe the role of the Lab in processing specimens

3. Importance of Sputum Microscopy BNTP Programme Review demonstrated –high proportion of patients had inadequate diagnostics monitoring –Inability to track many specimens because of incomplete forms HCW and Lab feedback also indicates problem of sputum specimen quality

4. District TB Coordinator Role TBCO role is to understand, monitor, and train HCWs on proper procedures for Identifying TB Suspects Listing the TB Suspects in The Suspect and Sputum Dispatch Register Properly collect the sputum smear for examination Filling out “Mycobacteriology Request and Report Form” Packing sputum samples and sending to lab Recording results in the SSD Register and deciding on appropriate action when lab results are received

5. Identifying TB Suspects

6. Identifying TB Suspect A TB suspect is any person who presents with symptoms or signs suggestive of TB Sputum microscopy is the single most important test in TB diagnosis Suspect should be triaged and separated from other patients

7. Listing TB Suspects in Suspect and Sputum Dispatch Register

8. Listing TB Suspects The Suspect and Sputum Dispatch Register (SSD) is a record of –All patients identified as TB suspects at the health facility, and –All sputum samples sent to the laboratory Monitor whether results returned for sputum samples

9. Suspect and Sputum Dispatch Register (1) MH 2028

10. SSD Register: Data Elements (1) Date of suspect registration and specimen collection Patient no. –Suspect number (serial no. for a newly identified TB suspect), or –TB ID no. (District. no. / Facility no./ Serial registration no./ year) Patient name Sex, age and detailed address (to be filled in for suspects only) Dates of specimen collection and dispatch Date result received by clinic Result of bacteriological examination

11. Suspect and Sputum Dispatch Register (2) Maintained by all health facilities Completed by HCWs requesting sputum smear examination or drug sensitivity testing for tracking purposes The SSD Register combines: –registration of all TB suspects –sputum specimens submitted for examination for suspects for treatment monitoring at 2 months end of treatment, or as otherwise indicated

12. Suspect and Sputum Dispatch Register (3) SSD Register helps staff ensure that TB suspects specimens are dispatched to appropriate district lab for examination All bacteriology results for all specimens are –received back from the lab –centrally recorded – transcribed on the TB treatment card, the Patient TB card (Appointment/DOT Card) and Facility TB register All smear-positive suspects are registered and started on TB treatment

13. SSD Register: Data Elements (2) Decision Column –Complete the last (“Decision”) column with the assigned Unit TB number for confirmed smear-positive cases or the words "Not TB" –Until the ‘Decision’ column has been completed, the blank entry serves as a reminder to follow-up with lab on the results

14. SSD Register: Data Elements (3) If decision has to be postponed (e.g. if patient's condition strongly suggests TB but 2 negative sputum smear results) –Enter date of proposed re-examination (e.g. “To Come Again 12/6/05”). –When the suspect does return, re-register under date of return (e.g., “12/6/05”) but using original serial number If patient does not return, a home visit should be done

15. Collection of Sputum for Microscopy

16. Sputum Microscopy Patients with smear-positive PTB are the main sources of new infections in the community HCWs should always obtain 3 sputum specimens if TB is suspected Generally, a positive smear means that the patient has PTB However, negative smears are common among HIV + patients due to immunodeficiencies, this should be noted because it poses a challenge to TB diagnosis in HIV+ patients

17. Collection of Sputum Specimens Three sputum specimens should be collected For outpatients –SPOT- taken under the supervision of a HCW at first interview –MORNING - 2nd specimen taken by patient early next morning (before cleaning mouth and eating) –SPOT- 3rd specimen collected when patient returns with 2nd specimen For inpatients –Early morning specimens on three consecutive days

18. Sputum Collection Techniques (1) Sputum collection should be done outside or in an empty room with very good ventilation Use sterile glass or plastic containers, 5 – 6 cm deep, with screw cap

19. Sputum Collection Techniques (2) The health worker should explain and demonstrate procedure The health worker should supervise, but should NOT stand in front of the patient –Collect away from other people Only sputum (2-5 ml) should be accepted as a good specimen Saliva (white, watery, frothy) should not be accepted because it will yield useless and misleading results

20. Specimen Quality Poor quality sputum Better quality

21. Patient Instructions: Sputum Collection (1) 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

22. Patient Instructions: Sputum Collection (2) Instructions Rinse mouth and throat with water two to three times, and drink some water to wet throat (for easy spitting of viscid sputum) Inhale deeply 2-3 times, breathe out hard each time Keep the body inclined to front Cough deeply from the chest Open the container and keep it near mouth and spit sputum in Close lid securely Wash hands after handling sputum container Bring container to HCW

23. Mycobacteriology Request Form and Transporting Sputum Specimen

24. Packing and Transportation of Sputum Specimen (1) Label specimen with patient’s name, clinic name, sputum collection date –Label should be on container and NOT on lid Place sputum container in leak-proof plastic bag to prevent contamination Include Mycobacteriology Request Form Place specimens in rigid container with cooler bags to prevent higher temperatures (which may kill bacteria) during transportation Enter the specimen data into SSD register before dispatch

25. Transportation of Sputum Specimen (2) Dispatch the specimens as soon as possible as specimens degrade quickly During transportation, specimens should be protected from exposure to direct sunlight If dispatch is delayed, store specimens in a fridge (do not freeze) or in a cool dark corner of room until they can be sent

26. Mycobacteriology Request and Report Form Must be completed by HCW for each specimen submitted to lab –smear microscopy –TB culture –drug sensitivity testing Must accompany specimen to lab Lab will –process specimen –complete “REPORT” section on form’s lower half –return to requesting HCW or treatment unit

27. Mycobacteriology Request and Report Form: Data Elements (1) To be completed by the requesting HCW District, Facility, Patient Registration #s, and Year Patient name Patient Omang Age and sex Requesting Doctor’s name and signature Type of specimen and Investigation request ( AFB microscopy, or culture and DST) Specimen collection period Patient category Treatment regimen Any previous drug sensitivity test result

28. Mycobacteriology Request and Report Form: Data Elements (2) Result section to be completed by Lab Lab Reference Number and Date rec’d Smear result Culture result Drug Susceptibility Results Preliminary or Final Lab tech. signature Date completed

29. Mycobacteriology Request and Report Form Once received back in the clinic The receiving HCW should record the results –in the Suspect and Sputum Dispatch Register –and Facility TB Register as appropriate

30. The Role of the TB Laboratory

31. DOTS Strategy for TB Control Government and political commitment to fund and sustain NTP Microscopy services for detecting sputum-smear positive cases Regular and uninterrupted supply of drugs Direct observation of standardized short- course treatment for sputum-smear positive Standardized recording and reporting systems

32. The DOTS Partnership Clinics Labs

33. Laboratory services are a key component in TB Control NO LABS NO DIAGNOSIS NO TREATMENT NO DOTS NO TB CONTROL

34. TB suspects MICROSCOPY positivenegative NOT TB TB cases

35. Specimen poor good Lab Skill poor good poor good Result poor good Lab and Clinic Services Depend on Each Other

36. Tuberculosis Laboratory Register (1) Kept at all laboratories Lab tech must enter required information for each smear to be examined District TBCO must check regularly whether patients with positive smears Tuberculosis Laboratory Register are entered in Facility and District Tuberculosis Registers

37. Tuberculosis Laboratory Register (2) Register contains: –Serial number –Date of examination –Name of patient –Name of treatment unit –Name of MO/staff requiring examination –Result of examination