A comprehensive approach for Quality Improvement of TB laboratory service in resource-limited settings
A multistep plan was designed in order to improve the quality of tuberculosis laboratory diagnosis among the 18 laboratories the Institute of Human Virology of the University of Maryland School of Medicine (IHV-UMSOM) is supporting in Uganda under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).
The ability of African health care systems to respond to the growing number of cases of tuberculosis (TB) is constrainedby limitations of funding, facilities, personnel, drug supplies,and laboratory capacity. The unprecedented growth of the TB epidemic in Africa is attributable to several factors; the most important being the HIV epidemic. TB is the most common coexisting condition in people who die from AIDS and the diagnosis in settings where mycobacterium culture is not routinely available, is prevalently done by Acid Fast Bacilli (AFB) microscopy. The diagnosis of TB remains difficult, in particular in HIV positive people because of the low number of M. tuberculosisbacilli production.
A very low incidence of TB among HIV patients was observed in some laboratories according to the number of AFB positive slides reported. This seemed unusual because the same microscope and reagents were provided to all the laboratories in an effort to maintain consistency and quality.
The rationale behind this approach was to create a TB Working Group (TB-WG) within the IHV laboratory network functioning as a strategic element for sustainability. The working group comprised of laboratory technicians who performed AFB microscopy at site level. The overall quality of TB services was overseen by IHV-UMSOM in-country working group comprising a doctor, a nurse, a counsellor, a laboratory specialist and a quality improvement specialist. Firstly, a refresher course on AFB microscopy was held for the members of the TB-WG. The training was organized in collaboration with the Uganda National Tuberculosis Leprosy Program (NTLP). The Acid-Fast Direct Smear Microscopy Training Package developed by CDC was adapted. The second step was to adopt a standardized questionnaire to be used by IHV laboratory in-country specialists to assess and follow up AFB microscopy services. Each Local Partner Treatment Facility (LPTF) received technical assistance and support by IHV-UMSOM in-country working group during regular quarterly visits. The questionnaire included 53 indicators covering 10 areas (staff, microscopes and oil, small equipment and spares, staining, tools, laboratory register, quality of smears macroscopically, quality of smears microscopically using microscope at site, external quality assurance and safety in the laboratory) to be used for follow-up corrective actions. In addition, blind rechecking of sputum smears following the NTLP algorithm were conducted at every visit.
The retention of the course on AFB microscopy was evaluated with a questionnaire immediately after the training. The same questionnaire has been submitted to the same laboratory technicians every 6 months in order to evaluate the retention over time. After the pilot study to improve the performance of TB in the 18 laboratories, results showed 38.9% of the laboratories had poor human resources, tools, equipment, quality of smears, safety in the laboratory and absence of records of collected samples. The questionnaire was useful at every field visit to monitor the improvements that can be measured with the number of right answers after each visit.
This pilot phase allowed standardizing the AFB microscopy procedure across the 18 laboratories supported by IHV in Uganda. The gaps identified decreased over time and the needs promptly addressed at each site visit.
This participative approach was a fruitful learning-by-doing experience for laboratory technicians that were part of the Working Group. Tools and strategies were discussed, developed, and adopted by the Working Group during trainings. This represented a fundamental step in the efficacy and sustainability of the program. The questionnaire and the blind rechecking were effective in assessing the technical skills of the laboratory staff, while offering on-the-job training. These steps aimed at improving the performance of the laboratories in the National EQA TB program and thereby intensify TB case findings among people living with HIV.