Transcript 4.0 From Suspect to Confirmed Case.ppt

Module 4:
From Suspect to Confirmed Case
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
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
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
Identifying TB Suspects
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
Listing TB Suspects in
Suspect and Sputum
Dispatch Register
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
Suspect and Sputum
Dispatch Register (1)
MH 2028
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
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
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
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
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
Collection of Sputum
for Microscopy
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
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
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
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
Specimen Quality
Poor quality sputum
Better quality
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
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
Mycobacteriology Request Form
and Transporting Sputum
Specimen
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
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
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
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
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
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
The Role of the TB
Laboratory
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 shortcourse treatment for sputum-smear positive
Standardized recording and reporting systems
The DOTS Partnership
Labs
Clinics
Laboratory services are a key
component in TB Control
NO LABS
NO DIAGNOSIS
NO TREATMENT
NO DOTS
NO TB CONTROL
TB suspects
MICROSCOPY
positive
TB
cases
negative
NOT TB
Lab and Clinic Services
Depend on Each Other
Specimen
Lab Skill
Result
poor
poor
poor
poor
good
poor
good
poor
poor
good
good
good
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
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