EXPANSION OF PILOT IMPLEMENTATION OF MALARIA MICROSCOPY QUALITY ASSURANCE IN CENTRAL LUZON

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EXPANSION OF PILOT IMPLEMENTATION OF MALARIA MICROSCOPY QUALITY ASSURANCE IN CENTRAL LUZON Powered By Docstoc
					 Collaborating Center for Disease Prevention and Control
  Department of Health – Center for Health Development III




EXPANSION OF PILOT IMPLEMENTATION OF
MALARIA MICROSCOPY QUALITY ASSURANCE
          IN CENTRAL LUZON




                       Validators:

                 Jocelyn R. Pascua, RMT

               Jeffrey V. de Guzman, RMT

                  Haydn E. Aguilar, RMT

             Girlie C. Soriano, RMT (interim)

              Leonor Aquino, RMT (interim)
      The province of Zambales in Region 3 was included in the
expansion of the pilot implementation of malaria quality assurance
system (QAS). There are 13 municipalities and 1 city covered in the
QAS. Twenty-nine microscopists voluntarily participated in the
implementation. The areas were categorized into three, according to
the number of smears examined per year. There are three (3) areas at
category A (120 slides), nine (9) at category B (60 slides), and
thirteen (13) at category C (panel of 20 slides). These microscopy
centers are in different health facilities like Rural Health Units
(RHUs,13), City Health Office (CHO, 1), hospital-based (5), Barangay
Malaria Microscopy Centers (BMMC, 4), and dispensary (1, Subic Base
Metropolitan Authority).

       There are five validators who perform the activities of QAS
namely: Jocelyn R. Pascua, Jeffrey V. de Guzman, Haydn E. Aguilar,
Girlie C. Soriano (interim), and Leonor Aquino (interim). The four
validators based at the region are in- charge of planning, and
scheduling of slide submission, validation, preparation of sets of slides
for EQAS, and sending of feedback reports. The interim validator at
the province was tasked to send to the region the slides submitted for
validation, bring the panel of slides to the centers and discusses the
results of examination with the microscopists.

      As planned at the QAS orientation held in Baguio City last May
2006, submission of slides started right after the orientation in the
province which was in June. The following are the details and results of
quarter 1 implementation:

Validation or Cross-checking of slides

       I. Slide submission: 2 hospital- based laboratories did not submit
slides because they were not able to save the slides examined. Seven
(7) out of ten (10) centers were late in the submission. Some were not
able to follow the scheme of slide selection.          In quarter 2 of
implementation only five microscopists submitted slides for validation.
All were late in the submission.

      II. Percent Accuracy: Among 10 microscopists who submitted
slides for validation in quarter one, only Buhawen BMMC was not able
to achieve the acceptable accuracy of 80%. She submitted seven
slides but only three were validated because four were not fit for
examination. Her accuracy is 66.6 %. In quarter two, five (5) centers
already submitted slides. Four microscopists improved in the accuracy
with ratings from 92.86 % to 100%. San Marcelino District Hospital
submitted slides only in quarter 2. Microscopist reached an accuracy of
78.0% with two false positive reports.

Figure 1

    100
     90
     80
     70
     60
     50                                                                1st Qtr
     40                                                                2nd Qtr
     30
     20
     10
      0
           1   2   3   4    5   6   7       8       9       10 11

      III. Percent Sensitivity: Their ability to detect the parasite in a
true positive smear ranged from 33.3 % to 100.0% in quarter one. In
quarter two, so far all the centers who already submitted slides
achieved 100%.

Figure 2

     100
      90
      80
      70
      60
      50                                                                 1st Qtr
      40                                                                 2nd Qtr
      30
      20
      10
       0
           1   2   3    4   5   6       7       8       9    10   11
     IV. Percent Specificity: Their ability to detect a true negative
malaria smear ranged from 86.6 % to 100 % in quarter one while
80% to 100% so far in quarter two.


Figure 3

     100

      80

      60
                                                                      1st Qtr
      40                                                              2nd Qtr

      20

       0
           1   2    3    4      5   6    7    8      9   10   11



      III. Type of Error: Most microscopists committed false negative
reports at 64.28 % followed with misidentification of parasite at
21.14 % and false positive results at 14.28%.


Figure 4


                   Mis-
               identification       False Positive
                   21%                   14%
                                                                   False Positive
                                                                   False Negative
                                                                   Mis-identification
                                False Negative
                                      65%
Results of External Quality Assurance (panel of 20 slides):

      From the last quarter last year up to this time, ten out of 14
microscopists in category C areas had already received and examined
the panel of slides. The plan to send the slides for two rounds to each
microscopist was not met due to the difficulty in preparing the slides,
and to a prolonged stay of the slides with some microscopists (they
were supposed to examine the slides for two weeks only).

       I. Percent Accuracy: Accuracy ranged from 40% to 85%. Only
three (3) microscopists reached the acceptable 80% mark. This is for
the reason that they no longer have the chance to examine positive
slides after the training because their areas are not endemic to malaria.
Validators are planning to prepare positive reference slides to these
centers to be used as practice slides for examination.


Figure 5

     90
     80
     70
     60
     50
     40                                                          Qtr 1
     30
     20
     10
      0
           1   2    3    4    5    6    7    8    9   10
       II. Percent Sensitivity and Specificity: Their ability to detect the
parasite in a true positive smear ranged from 73.68% to 92.3%. Their
ability to detect a true negative malaria smear ranged from 66.6 % to
100 %.


Figure 6

      100

       80

       60
                                                                        Sensitivity
       40                                                               Specificity

       20

        0
            1    2       3   4   5      6   7     8   9   10




      III. Type of Error: Most microscopists committed false negative
reports at 37% followed with misidentification of parasite at 45% and
false positive results at 18%.


Figure 7



                                 False Positive
            Mis-                     18%
        identification                                         False Positive
            45%                                                False Negative
                                                               Mis-identification
                                      False
                                     Negative
                                       37%
On-site Supervisory Visit

       As part of the implementation of malaria quality assurance
system in Zambales, on-site supervisory visit was conducted to assess
the present set-up and conditions of the malaria microscopy centers.
Four regional validators of the Reference Laboratory of the
Collaborating Center for Disease Prevention and Control at the Center
for Health Development 3 (CHD3) performed this activity. A checklist
developed from the national level was used as a tool to assess
different aspects of a microscopy center. The following is a summary
of findings, comments, and recommendations for all microscopy
centers. Another sheet is also attached to show the set-up of individual
laboratory.
       On-site supervisory visit will only be conducted again if a
microscopist is not performing well in smear examination. Performance
will be based on the slides submitted for validation at the CHD3 in two
consecutive periods.

Result of visit in the municipalities of Zambales

     I. GENERAL INFORMATION:

     Nineteen facilities (Hospital-4, Barangay Malaria Microscopy
Center (BMMC)- 3, Rural Health Unit (RHU)-12) were visited for on-
site supervision on malaria microscopy. There are twenty
microscopists in these facilities where four had not yet attended a
formal training in malaria microscopy.

     II. PROCEDURES:

      Generally, thick and thin smears are collected for blood smear
for malaria (BSM) examination. Quality of smear preparation and
staining, however, is not of acceptable standard. The validators did
tutoring on correct smear preparation during the on-site visit. This
must be re-enforced with practice or if budget allows, a re-training for
smear preparation.

     PERFORMANCE:

      To assess skills in microscopy, External Quality Assurance
System (EQAS) was conducted. Six BSM slides to examine were given
to each microscopist. Accuracy ranged from 50% (3/6) to 100.0%
(6/6). This may not reflect true competence of the microscopists
because of many intervening tasks while performing the examination,
and as mentioned, the others have not yet attended training.

      VALIDATIONS OF SMEARS:

      For quarter one, only Buhawen BMMC did not reach the 80%
acceptable accuracy in cross checking of slides. It will need close
supervision if performance is not improved in the next validation
period.

      III. MICROSCOPY SET- UP:

      It was noted that most facilities have a good microscopy set –
up. San Felipe and Botolan RHU I has inadequate working space while
Masinloc has an unorganized working condition. Poor functioning
microscope was observed in Botolan RHU I, and Sta. Cruz RHU and
Masinloc RHU. Med techs were advised to bring their units to the PHTO
for repair or preventive maintenance.

      IV. LABORATORY SUPPLIES:

      Most facilities have the supplies needed to perform malaria
microscopy examination, except for Masinloc RHU. Validators have
taken list of microscopy centers that lacks and with those inadequate
supplies for malaria microscopy to see the possibility of requesting the
needed supplies at the Regional Malaria Control Program.
      At the laboratory of Pres. Ramon Magsaysay memorial Hospital
(PRMM), industrial oil is used on the oil immersion objectives. This is
not recommended because it may damage the lenses after a long use.

      V. BIOSAFETY:

       It is good that most microscopists practice biosafety habits,
however, Pundakit and Buhawen BMMC do not wear laboratory gowns
and gloves because it was noted that they do not have the supplies.
Masinloc RHU and PHTO do not have separate containers for dry,
infectious, and needles and sharp wastes

      VI. DRUG DISPENSING:

     Barangay microscopists and midwife dispenses anti- malaria
drugs. The barangay microscopists follow the treatment schedule from
the National Malaria Drug Policy while the midwife at the Loobunga
Satellite Health Center dispenses the drug according to the product
instruction which may cause problem in treatment and management.


     VII. DOCUMENTATION:

      A. Record Logbook: RHUs in Candelaria, San Antonio and
Candelaria has no logbook for malaria cases because they have no
malaria cases yet. Most microscopists do not include travel history of
patients in the data entry.

      B. Forms: Some microscopy centers particularly the BMMC do
not use request, result, and referral forms.

       C. Technical Manual/ Bench Aids: Only Masinloc RHU have no
reference materials for malaria microscopy examination in the
laboratory. The medical technologist was given a Bench Aid during the
visit. Technical Standard Operating Procedure manual must also be
present in the laboratories. This will be disseminated once the national
level approves & provides the SOP.

      D. Operating Manual of Microscope : RHUs in San Antonio,
Subic, and Masinloc has no manual for its microscope. This manual is
an important reference in the proper use, repair and maintenance of
the specific model of microscope present in the laboratory.

      E. Equipment Maintenance Record (EMR):                    Twelve
laboratories do not have a regular schedule for microscope preventive
maintenance and no EMR. Validators informed the microscopists the
availability of trained personnels in microscope maintenance and repair
at the CHD and PHTO. They also showed the importance of keeping an
EMR.

     VIII. GENERAL FINDINGS:

     Eighteen out of 19 microscopy centers in Zambales are capable
of malaria microscopy examination. Masinloc RHU is not ready for
malaria microscopy examination because of untrained med tech,
unorganized facility and inadequate or lacking supplies.

     Almost all microscopy centers did not meet the standard quality
of smear preparation.

     IX. RECOMMENDATIONS:
        Suggestions and advises for improvement were given to each
facility depending on the noted or observed deficiencies.

      Encourage med techs to attend training if opportunity calls.

      There must be a re-training for smear preparation to improve
quality of smears collected. A good quality smear guarantees highly
accurate and reliable microscopy results.

      Refer slides to the Provincial validator at the PHTO for
confirmatory of results.

      Accuracy in malaria examination must be improved and
maintained by voluntarily participating in QAS activities like submitting
slides for cross-checking and or reading of unknown panel of slides
sent by the CHD vaidators. Positive slides must also be kept for
reference and practice reading.

       Quality Assurance activities must be continuous efforts in all
microscopy centers in the province and the regional level to ensure
reliable malaria microscopic diagnosis, thus, correct treatment and
management.

Result of Visit in Olongapo City

      I. GENERAL INFORMATION:

       Four facilities (Hospital-1, Barangay Malaria Microscopy Center
(BMMC) - 1, City Health Office (CHO)-1, Subic Dispensary- 1) were
visited for on-site supervision on malaria microscopy. There are seven
microscopists in these facilities where four had not yet attended a
formal training in malaria microscopy.

      II. PROCEDURES:

      SMEAR PREPARATION:

      All med techs prepare thick and thin smears for malaria
microscopy examination except in James Gordon Hospital where thin
smear only is prepared for malaria parasite examination at the
Hematology and Blood Bank Sections. The med tech that has not
attended training yet was advised to make a standard smear for
malaria, which is to prepare thick and thin smears on the same slide.
The validators did tutoring on the correct preparation of smears to the
microscopists during the on-site visit for them to improve the quality
of smear preparation and staining. This must be re-enforced with
practice or if budget allows, a re-training for smear preparation.

     PERFORMANCE:

      To assess skills in microscopy, External Quality Assurance
System (EQAS) was conducted. Six blood smears for malaria (BSM)
were given to each microscopist to examine during the visit. Accuracy
ranged from 50% (3/6) to 100.0% (6/6). This may not reflect true
competence of the microscopists because of many intervening tasks
while performing the examination, and as mentioned, the others have
not yet attended a formal training.

     VALIDATIONS OF SMEARS:

      For quarter one, all microscopists (CHO & BMMC) who submitted
slides for validation attained the 80% acceptable accuracy in malaria
microscopy diagnosis.



     III.   MICROSCOPY SET- UP:

     It was noted that most facilities have a good microscopy set – up
except in           New Cabalan BMMC. It has no separate area for
microscopy and storage of               supplies.

     IV.    LABORATORY SUPPLIES:

      Most facilities have the supplies needed to perform malaria
microscopy examination. Validators have taken list of microscopy
centers that lacks and with those inadequate supplies for malaria
microscopy to see the possibility of requesting the needed supplies at
the Regional Malaria Control Program

     V.     BIOSAFETY:

      It is good that most microscopists practice biosafety habits,
however, New Cabalan BMMC does not wear laboratory gown and
gloves because it was observed that he does not have the supplies.
     VI.    DRUG DISPENSING:

      The barangay microscopist dispenses anti- malaria drugs. He
follows the treatment schedule from the National Malaria Drug Policy.

     VII.   DOCUMENTATION:

      A. Record Logbook: Most microscopists do not include travel
history of patients in the data entry.

      B. Forms: New Cabalan BMMC does not use any form in the
laboratory

      C. Technical Manual/ Bench Aids: All have reference
materials for malaria microscopy examination. Technical Standard
Operating Procedure manual must also be present in the laboratories.
This will be disseminated once the national level approves & provides
the SOP.

      D. Operating Manual of Microscope: Subic Dispensary
laboratory has no operating manual for its microscope. This manual is
an important reference in the proper handling, repair and maintenance
of the specific model of microscope utilize in the laboratory.

      E. Equipment Maintenance Record (EMR): The CHO and
BMMC have no schedule for periodic preventive maintenance of their
microscope. Validators informed the microscopists the availability of
trained personnel in microscope maintenance and repair at the CHD
and Provincial Health Team Office (PHTO). They also showed the
importance of keeping an EMR.

     VIII. GENERAL FINDINGS:

     All microscopy centers in terms of supplies, facility, equipment
and personnel are capable of malaria microscopy examination.

     Almost all microscopy centers did not meet the standard of
smear preparation.


     IX.    RECOMMENDATIONS:

        Suggestions and advises for improvement were given to each
facility depending on the noted or observed deficiencies.
      Encourage med techs to attend training if opportunity calls.

       Accuracy in malaria examination must be improved and
maintained by voluntarily participating in QAS activities like submitting
slides for crosschecking and or reading of unknown panel of slides sent
by the CHD3 validators. Positive slides must also be kept for reference
and practice reading.

      There must be a re-training for smear preparation to improve
quality of smears collected. A good quality smear guarantees highly
accurate and reliable microscopy results

      Refer smears to the provincial validator at the PHTO for
confirmation of results if doubts arise.

       Quality Assurance activities must be continuous efforts in all
microscopy centers in the province and the regional level to ensure
reliable malaria diagnosis, thus, correct treatment and management.


EXPANSION OF MQAS TO OTHER SIX PROVINCES IN REGION 3:

       Since the other six provinces of Region 3 are also endemic to
malaria, it was deemed necessary to extend the MQAS to these areas.
The orientation workshop was held last November 2007. It was
attended by microscopists from the MCP in the provinces and the
trained med techs (MT) at the LGUs with endemic areas. Provincial
malaria coordinators and municipal health officers (MHO) also eagerly
participated in the orientation.

      There are 11 facilities in category A, three in category B and 12
in category C.

       Aside from the discussion of MQAS, a technical operating
procedure was presented and proposed to the microscopists to
standardize the practices in malaria laboratory techniques because
some microscopists especially from the MCP has undergone training
many years ago without updates or refresher trainings recently. It
was understood that if the National Program shall issue and provide an
official SOP, this will used instead in their laboratories

       Slide submission and sending of panel of slides commenced on
the first quarter of this year.
      On- site supervisory visits will be conducted starting next week
to observe the present set-up of the malaria microscopy centers.
Most microscopists requested laboratories supplies that they do not
have in their laboratories. These were listed down and a purchase
request of supplies is now being processed.

PLAN AND BUDGET OF ACTIVITIES FOR 2007

  I.   Retraining on Blood smear preparation for BSM examination:
     Objective: To improve the skills of microscopists, FAW, BHW in
  BSM collection for better microscopy results.
       Target Dates         :-----------
       Target Participants: Microscopists, FAW, BHW
       Number of Pax        : 30 in 2 batches
       Number of days       : 3 (?)
       Food and accom : PHp 136,000 ( 38 pax x 1200x 3)
       Materials             : PHp 60,000 ( 30 pax x 2,000)
       Transportation        : PHp 38,000 ( 38 pax x 1,000)
       Per diem ( 2 days) : PHp 30, 400 ( 38 pax x 800)
       Total                 : PHp 265,200.00

  II.      Evaluation of MQAS Implementation and Feedback/
           Discussion of Results:
        Objective: To give feedback on the results of slide validation,
        EQAS performance and on-site supervisory visits.
                    To elicit reactions and views from microscopists
        regarding MQAS implementation.

     One- day meeting
     Budget: PHp 71, 402.00 (based on the orientation last June
2006)
      Target Pax: Microscopists, MHOs,CHO, PHO,MCP, validators and
coordinators

  III. Refresher Training on Basic Malaria Microscopy:
     Target pax: Cat C microscopists trained 2 years ago who
  performed poorly in the EQAS and MCP personnel in other endemic
  provinces.
     Objective: To improve the knowledge and skills of microscopists
  on malaria microscopy diagnosis.

  Number of pax :            16
  Number of facilitators:     4
  Resource speakers :         2
Number of days       :   7 (?)
Food and accommodation: PHp 184,800 ( 22 pax x 1,200 x 7)
Materials            :    PHp 64,000 ( 16 pax x 4,000)
Transportation      :     PHp 22,00 ( 22 pax x 1,000)
Per diem ( 2 days) :     PHp 17,600 ( 22 pax x 800)
Total               :    PHp 288,400.00
 Add’l 10% contingency fund : 317,240.00


IV.    Collection and Preparation of Positive slides for Category C
       centers:
      Objective: To be used as practice slides.
       Number of centers: 26 ( Zambales- 14, Reg 3- 12)
       Number of slides/ center : 5
       Budget: estimated at PHp 10,000 for materials and supplies.

				
DOCUMENT INFO
Description: The narrative report of the expansion of pilot implementation of malaria microscopy quality assurance in Central Luzon.