The Rapid syPhILIs TEsT ToolkiT IMPLEMENTATION 2 · 2020. 2. 11. · IMPLEMENTATION 2 Quality Management System Guide for Rapid Syphilis Testing 3 Good Laboratory Practice Embodies

Quality Management System Guide for Rapid Syphilis Testing

IMPLEMENTATION 2

The Rapid syPhILIs TEsT ToolkiT

Contents Glossary 2

abbreviations 5

preface 6

Background 7

1. a Quality Management System approach for Rapid diagnostic Tests 8

2. documents and Records 102.1Documents 102.2Records 11

3. organization and Management: Structural Set-up of Qa 123.1Responsibilitiesatthenationallevel 123.2Responsibilitiesatthesitewheretestingoccurs 13

4. Facilities and Safety 144.1Facilities 144.2Safety 14

5. personnel and Training 15

6. equipment 16

7. purchasing and inventory 177.1Responsibilitiesatthenationallevel: 177.2Responsibilitiesatthetestingsite: 17

8. Quality Control 188.1IncomingInspectionofrapidsyphilistestkits 198.2In-builtproceduralcontrol 198.3InternalQualityControl 208.4ExternalQualityAssessment 23

9. information Management 29

10. occurrence Management 30

11. assessment 31

12. process improvement 32

13. Business plan 33

14. Frequently asked Questions on Quality Systems 35

15. References 37

16. appendices 38

Contents

The Rapid syPhILIs TEsT ToolkiT 02 The Rapid syPhILIs TEsT ToolkiT

Quality Management System Guide for Rapid Syphilis Testing

hyperlinksplease note that hyperlinks within this document are indicated by text underlined and emboldening.

IMPLEMENTATION 2 Quality Management System Guide for Rapid Syphilis Testing 1

appendices

appendix 1. overview of country approaches to a Quality 38 Management System for a Rapid Syphilis Test programme

appendix 2. Summary flow chart of a Quality Management System 39in place for Rapid Syphilis Testing in country

appendix 3 . example of a Standard operating procedure: Work 40instructions for use of standard diagnostics bioline syphilis 3.0 rapid test

appendix 4 . protocol for preparation of dried tube specimen 44

appendix 5. dried Tube Specimen Testing instructions diagram 47

appendix 6. protocol for preparing Syphilis – positive Quality 48Control Materials

appendix 7. daily Record of Quality Control Results 52

appendix 8 . external Quality assessment of Syphilis Rapid Tests: 53 operational issues for re-testing

appendix 9. external Quality assessment of Rapid Syphilis Tests 55Statistical Models for Re-testing

appendix 10. example specimen Transfer log for re-testing 64

appendix 11. daily Temperature check chart 65

appendix 12. protocol worksheet used in Brazil 66

appendix 13. pictorial diagram of the manufacture of dTS in Brazil 67

appendix 14. pictorial instructions on performing rapid syphilis 67testing (in Brazil)

The Rapid syPhILIs TEsT ToolkiT 2

DefinitionsforthefollowingtermsaretheinternationallyaccepteddefinitionssuppliedbytheClinicalandLaboratoryStandardsInstitute(CLSI)initsharmonized Terminology database.Itispubliclyavailableat:http://www.clsi.org/AM/Template.cfm?Section=Harmonized Terminology_Database

Accuracy(ofmeasurement)Closenessofagreementbetweenameasuredquantityvalueandatruequantityvalueofameasurand.

AgreementTheproportionofspecimenswhereresultsobtainedusinganewtestandthoseobtainedusinganimperfectstandardagree.

AlgorithmAsetofrulesforsolvingaprobleminafinitenumberofsteps,asforfindingthegreatestcommondivisor.

AuditAplanned,independent,anddocumentedassessmenttodeterminewhetheragreed-uponrequirementsarebeingmet.

BiohazardAbiologicalagentorconditionthatconstitutesahazardtohumanbeingsortheirenvironment.

BiosafetyCabinetHooddesignedspecificallytocontainmicroorganisms.Itisdesignedtoprotectworkers,theenvironment,andlaboratoryconsumablesfromcontamination.Itcanalsobedesignedtousesmallamountsofchemicalsandtokeepproductsinthehoodclean.

CalibrationOperationthat,underspecifiedconditions,inafirststep,establishesarelationbetweenthequantityvalueswithmeasurementuncertaintiesprovidedbymeasurementstandardsandcorrespondingindicationswithassociatedmeasurementuncertaintiesand,inasecondstep,usesthisinformationtoestablisharelationforobtainingameasurementresultfromanindication.

Characterization(forareferencematerial)Determinationofoneormorephysical,chemical,biological,ortechnologicalpropertyvaluesthatarerelevanttoitsintendedenduse.Thecharacterizationprocessprovidesthevaluesforthepropertiestobequantified.

CollegeofAmericanPathologistsAccreditationProgram:AninternationallyrecognizedprogrambasedontheCAPLaboratoryAccreditationStandardsthathelpslaboratoriesachievethehigheststandardsofexcellencetopositivelyimpactpatientcare.

CorrectiveactionActiontakentoeliminatethecause(s)ofexistingproblems,defects,oranyotherundesirablesituationinordertopreventrecurrence.

DocumentAnyrecordeditemofafactualorinformativenature,eitherpaperorelectronic;writtenorelectronicallygeneratedinformationandworkinstructions.

DriedTubeSpecimenDriedserumorplasmapatientspecimenthatarecoldchainindependent,foruseasaqualitycontrolsampleorproficiencytestingprogram.

DriedBloodSpotsBloodcollectedonfilterpaperanddriedfortransportandtestingforHIVandotherdiseases.Canalsobeusedasaqualitycontrolmeasure.

ExternalQualityAssessmentEvaluationofthelaboratory’sperformanceonexaminationofsamplesofexternaloriginforthepurposesofdeterminingadequacyofthelaboratory’spre-examination,examination,andpost-examinationactivities;Themainobjectistoestablishbetween-laboratoryandbetween-instrumentcomparabilitythatis,ifpossible,inagreementwithareferencestandard(whereoneexists).Externalqualityassessmentschemesmayberegional,national,orinternational.Itissometimesalsoreferredtoas“proficiencytesting,”especiallywhentheexternalagencyisaregulatoryagency.Interlaboratorycomparisonsandotherperformanceevaluationsmayextendthroughoutallphasesofthetestingcycle,includinginterpretationofresults;determinationofindividualandcollectivelaboratoryperformancecharacteristicsofexaminationproceduresbymeansofinterlaboratorycomparison.

ExternalQualityControlExternalqualitycontrolandassuranceorproficiencytestingistheevaluationofanalyticalperformancethatincludesasampleforwhichtheanalystdoesnotknowtheexpectedmeasurementresult.

False-negativeNegativetestresultforapatientorspecimenthatisknownorsubsequentlyprovedtobepositivefortheconditionorconstituentinquestion.

FalsepositiveApositivetestresultforadiseaseorconditionwhenthediseaseorconditionisnotpresent.Apositivetestresultforapatientorspecimenthatisknownorsubsequentlyprovedtobenegativefortheconditionorconstituentinquestion.

FormApaperorelectronicdocumentonwhichtheresultsfromtheperformanceofaprocedureorotherinformationarecaptured,afterwhichitbecomesarecord.

Glossary


GoodLaboratoryPracticeEmbodiesasetofprinciplesthatprovidesaframeworkwithinwhichlaboratorystudiesareplanned,performed,monitored,recorded,reported,andarchived.GLPhelpsassureregulatoryauthoritiesthatthedatasubmittedareatruereflectionoftheresultsobtainedduringthestudy,andthereforecanberelieduponwhenmakingrisk/safetyassessments.

GoodClinicalPracticeAninternationalethicalandscientificqualitystandardfordesigning,conducting,recordingandreportingtrialsthatinvolvetheparticipationofhumansubjects.

InstructionsForUseInformationsuppliedbythemanufacturerwithaninvitrodiagnosticmedicaldeviceconcerningthesafeandproperuseofthereagentorthesafeandcorrectoperation,maintenance,andbasictroubleshootingoftheinstrument.

IntegrityAmeasureoffunctionality

InterferenceArtifactualincreaseordecreaseinapparentconcentrationorintensityofananalyteduetothepresenceofasubstancethatreactsnon-specificallywiththemeasurementsystem.

InternalqualitycontrolTheevaluationofanalyticalperformancethatincludesqualitycontrolsamplesforwhichtheanalystknowstheexpectedmeasurementresult.

NegativePredictiveValueThelikelihoodthatanindividualwithanegativetestresultdoesnothavethedisease,orothercharacteristic,thatthetestisdesignedtodetect.Thisisequaltothenumberoftrue-negativecasesdividedbythesumoftrue-negativeplusfalse-negativecases.

Point-of-careTestingperformedinanalternatesite,outsideacentrallaboratoryenvironment,generallynearerto,oratthesiteof,thepatient.

PositivePredictiveValueThelikelihoodthatanindividualwithapositivetestresulthasaparticulardisease,orcharacteristic,thatthetestisdesignedtodetect;Thisvarieswiththeprevalenceofthediseaseinthepopulationtested.

PreventiveactionActiontakentoeliminatethecause(s)ofpotentialproblems,defects,oranyotherundesirablesituationinordertopreventoccurrence.

PreventivemaintenanceScheduledperiodicworkonapieceofequipmentthatisnotaresultofmalfunctionorfailureandisintendedtoavertsuchfailure.

ProcedureSpecifiedwaytocarryoutanactivityoraprocess.

ProcessSetofinterrelatedorinteractingactivitieswhichtransformsinputsintooutputs.

ProcessControlAseriesofqualitycontrolprocessesrequiredtoproducearesultfromapatientspecimenandtohandle/manipulate/transportthespecimen.

ProcessImprovementPartofaprocessmanagementfocusedonreducingvariationandimprovingprocesseffectivenessandefficiency.

ProficiencyTestingAprograminwhichmultiplesamples(proficiencypanel)areperiodicallysenttomembersofagroupoflaboratoriesforanalysisand/oridentification,inwhicheachlaboratory’sresultsarecomparedwiththoseofotherlaboratoriesinthegroupand/orwithanassignedvalue,andreportedtotheparticipatinglaboratoryandothers.

QualitativeCharacterizationappliedtolaboratoryteststhatdetectand/oridentifyaparticularanalyte,constituent,orcondition.Whenusedtodescribeatest,meansatestthatproducesaresultthatisdescriptiveratherthannumerical.Forexample,arapidsyphilistestmightgeneratearesultof‘positive’or‘negative’.

QualityAssurancePartofqualitymanagementfocusedonprovidingconfidencethatqualityrequirementswillbefulfilled.Thepracticethatencompassesallproceduresandactivitiesdirectedtowardensuringthataspecifiedqualityofproductisachievedandmaintained.Inthetestingenvironment,thisincludesmonitoringalltherawmaterials,supplies,instruments,procedures,samplecollection/transport/storage/processing,recordkeeping,calibratingandmaintenanceofequipment,qualitycontrol,proficiencytesting,trainingofpersonnel,andallelseinvolvedintheproductionofthedatareportedpracticethatencompassesallproceduresandactivitiesdirectedtowardensuringthataspecifiedqualityofproductisachievedandmaintained.Inthetestingenvironment,thisincludesmonitoringalltherawmaterials,supplies,instruments,procedures,samplecollection/transport/storage/processing,recordkeeping,calibratingandmaintenanceofequipment,qualitycontrol,proficiencytesting,trainingofpersonnel,andallelseinvolvedintheproductionofthedatareported.


QualityControlThesetofproceduresundertakeninalaboratory,orclinic,forthecontinuousassessmentofworkperformedandevaluationofteststodecidewhetherthesearereliableenoughforreleaseofresultstotherequestinghealthcareproviderandpatient.QualityControlincludestestingcontrolmaterials,chartingtheresultsandanalyzingthemtoidentifysourcesoferror,andevaluatinganddocumentinganyremedialorcorrectiveactiontakenasaresultofthisanalysis.

QualityManagementSystemManagementsystemtodirectandcontrolanorganizationwithregardtoquality.Aqualitymanagementsystemtypicallyincludestheorganizationalstructure,resources,processes,andproceduresneededtoimplementqualitymanagement;TheseprinciplesincludecategoriessuchasDocumentsandRecords,Organization,Personnel,Equipment,PurchasingandInventory,ProcessControl,InformationManagement,OccurrenceManagement,Assessments—ExternalandInternal,ProcessImprovement,CustomerService,andFacilitiesandSafety.

QuantitativeAcharacterizationappliedtolaboratoryteststhatgiveresultsexpressinganumericalamountorlevel(concentration)ofananalyteinaspecimen.

RecombinantArtificialmethodsofproducingDNA(syntheticDNAandproteins).

ReconstitutionRestoring(aliquidinconcentratedorpowderform)tonormalstrengthbyaddingwater.

RecordDocumentstatingresultsachievedorprovidingevidenceofactivitiesperformed.

ReferencemethodAnexactlydefinedtechniquethatisusedinassociationwithaninternationallyagreedreferencepreparationtoprovidesufficientlypreciseandaccuratedataforassessingthevalidityofothermethods.

Sensitivity(ofameasuringsystem)Quotientofthechangeinanindicationofameasuringsystemandthecorrespondingchangeinavalueofaquantitybeingmeasured.Inclinicalsettings,thisisdefinedastheproportionofpatientswithawell-definedclinicaldisorder(orconditionofinterest)whosetestvaluesarepositiveorexceedadefineddecisionlimit(i.e.,apositiveresultandidentificationofthepatientswhohaveadisease).

Shelf-lifePeriodoftimeuntiltheexpiration(expiry)date.

SpecificationAdocumentthatspecifies,inacomplete,precise,verifiablemanner,therequirements,design,behavior,orothercharacteristicsofasystemorcomponent,andoften,theproceduresfordeterminingwhethertheseprovisionshavebeensatisfied.

SpecificityTheabilityofatestorproceduretocorrectlyidentifyorquantifyanentityinthepresenceofinterferingphenomena/influencequantities.Inaclinicalsetting,itisthepercentageofsubjectswithoutthetargetcondition(asdeterminedbythediagnosticaccuracycriteria)whosetestvaluesarenegative.

StabilityCapacityforaproducttoretainitscomposition,characteristics,andpropertiesduringspecifiedconditions.

StandardOperatingProcedureAsetofstandardizedanddocumentedproceduresthatformthebasisofanyspecifiedaction.

TitreThedilutionoftheantibodyatwhichaspecifiedpercentageoftheanalyteisboundunderdefinedconditions.

Traceability(metrological)Propertyofameasurementresultwherebytheresultcanberelatedtoareferencethroughadocumentedunbrokenchainofcalibrations,eachcontributingtothemeasurementuncertainty.Theabilitytotracethehistory,application,orlocationofanentitybymeansofrecordedidentifications.

ValidationConfirmation,throughtheprovisionofobjectiveevidence,thattherequirementsforaspecificintendeduseorapplicationhavebeenfulfilled.TheWorldHealthOrganization(WHO)definesvalidationas“theaction(orprocess)ofprovingthataprocedure,process,system,equipment,ormethodusedworksasexpectedandachievestheintendedresult”.

VerificationConfirmation,throughtheprovisionofobjectiveevidence,thatspecifiedrequirementshavebeenfulfilled.Confirmationcancompriseactivitiessuchas:performingalternativecalculations;comparinganewdesignspecificationwithasimilarprovendesignspecification;undertakingtestsanddemonstrations;andreviewingthedocumentpriortoissue.


Bhi:BrainHeartInfusion

Cap:CollegeofAmericanPathologists

CdC:CentersforDiseaseControlandPrevention

ClSi:ClinicalandLaboratoryStandardsInstitute

CV:CoefficientofVariation

dTS:DriedTubeSpecimen

dBS:DriedBloodSpots

edTa:Ethylenediaminetetraaceticacid

eia:EnzymeImmunoAssay

eliSa:Enzyme-linkedimmunosorbentassay

eQa:ExternalQualityAssessment

Glp:GoodLaboratoryPractice

GCp:GoodClinicalPractice

hCW:HealthCareWorker

hiV:HumanImmunodeficiencyVirus

id:Identification

iFU:InstructionsForUse

iSo:InternationalOrganizationforStandardization

MCh:MotherandChildHealth

NpV:NegativePredictiveValue

NRl:NationalReferenceLaboratory

poC:Point-of-care

ppV:PositivePredictiveValue

pMTCT:PreventionofMotherToChildTransmission

pT:ProficiencyTesting

pp:ProficiencyPanel

Qa:QualityAssurance

QC:QualityControl

QMS:QualityManagementSystem

RdT:RapidDiagnosticTest

RpR: RapidPlasmaReagin

RT:RoomTemperature

SeSai: SecretariaEspecialdeSaúdeIndígena

Sop:StandardOperatingProcedure

STi:SexuallyTransmittedInfection

Tpha:TreponemaPallidumParticleAgglutinationAssay

Tppa:TreponemaPallidumHaemagglutinationAssay

UVRi: UgandanVirusResearchInstitute

VCT:VoluntaryCounsellingandTesting

Who: WorldHealthOrganisation

abbreviations

The Rapid syPhILIs TEsT ToolkiT6

preface

WiththeexponentialgrowthofprogrammesforpreventionofmothertochildtransmissionofHIV,andwithincreasingemphasisbothonpreventionofHIVinfectionamongpersonswithconventionalsexuallytransmittedinfectionsandonbloodsafety,thesetestswillbeanessentialtoolforthediagnosisofadiseasewhichhaslargelybeenneglected.Currenttechnologiesavailableforsyphilistestingincludethestandardlaboratory-basedtestssuchastherapidplasmareagintestorenzymeimmunoassayassaytechnology.Inmanysituations,however,rapidtestsforsyphiliswillbethemostefficientandperhapstheonlyfeasiblewaytoprovideinformationaboutsyphilisstatus.

Theaccuracyandreliabilityofdiagnostic/laboratorytestingwillbecriticaltothesuccessofsyphiliseliminationprogrammes.Inordertoensurethisreliabilityandreduceerrorstoaminimum,aqualitysystemthataddressesallaspectsoftestingisessential.Thequalitysystemisimportantinanylaboratoryortestingsiteandappliestoalltestingandlabbasedactivities,includingsimple-to-performtests.Itisalsoessentialtosetupalltheelementsofaqualitysysteminsitesconductingonlyrapidsyphilistesting.

Thesimplerapidsyphilistestsdiscussedinthisdocumentaresingleuse,disposabledevicesthatmaybeusedtodirectlytestwholebloodspecimens,serum,orplasma.Althoughrapidsyphilistestsaresimpletouseandcanprovidereliableresultswhenthemanufacturer’sdirectionsarefollowed,errorscanoccuratanypointinthetestingprocess.Thesesingleusedevicespresentuniquechallenges:

Testingisoftenperformedbypersonswithoutformallaboratorytraining.

Theremaybenoresidualspecimenthatcanbecheckedorre-tested.

Conventionalqualitycontrolmethodscannotbeused.

Thereareparticularproblemsassociatedwitheffortstoprovideconventionalproficiencytesting.

Becauseofthis,andtoreduceanyerrorsduringtesting,thetestsitemusthaveaqualityassuranceprogrammeinplace.Thisprogrammemusttakeintoaccountalllevelsofhealthcarefacilities,fromthelargeclinicorhospitalwhereon-sitelaboratorysupportisavailabletooutreachsettingswithfewerpersonnelandresources.

Thepurposeofthisdocumentistoestablishguidelinesforapplyingqualitysystemessentialstosyphilisrapidtesting.Itisintendedtoprovideassistancetoallpersonsinvolvedintheplanningandimplementationofrapidsyphilistesting.Thedocumentshouldbeusefultogovernmenthealthofficials,thoseresponsibleforSexuallyTransmittedInfectionandMotherandChildHealthprogrammes,andthoseresponsibleformanagingHIVvoluntarytestingandcounsellingsites.Italsoprovidesinformationthatwillbeusefulfortestingpersonnel,bothtrainedlaboratorytechnologistsandthosewithnolaboratorytraining.

Assyphilisrapidtestingisinitiatedand/orexpandedintolargenumbersoftestingsites,itwillbeveryimportanttoimplementtheseguidelines,includingtheessentialmonitoringprocesses,toassurequalityandreliabilityoftestresults.

TheseguidelineshavebeendesignedinlinewiththeCentersforDiseaseControlandPreventionguidelinesfordesigningaqualitysystemforHIVrapidtestingprogramme (Guidelines for Assuring the Accuracy and Reliability of HIV rapid testing: Applying a Quality System Approach).Inaddition,theguidanceprovidedinthisdocumentcanbereadilyadaptedforuseforotherrapiddiagnostictestprogrammes.

Serologic tests to detect the presence of antibodies to syphilis in individuals play an increasingly important role in efforts to address the global epidemic of the disease.

http://wwwn.cdc.gov/dls/ila/documents/HIVRapidTest%20Guidelines%20(Final-Sept%202005).pdf




Background

Anapproachthatmonitorsallpartsofthetestingsystemisneededtoensurethequalityoftheoverallprocess,todetectandreduceerrors,toimproveconsistencybetweentestingsites,andhelpcontaincosts.Thisapproachtolaboratoryqualityiscalledaqualitymanagementsystem.Thequalitymanagementsystemincludespolicies,qualityassurance,qualitycontrol,andqualityimprovement.Inthisdocument,itisdividedintothetwelveessentialelementsdescribedintheClinicalandLaboratoryStandardsInstitutedocumentHS1-A,“AQualitySystemModelforHealthCare.

Theperformanceofrapidsyphilistestingpresentsspecialchallengeswhenyouareundertakingmeasurestoimprovetestreliabilityandaccuracy.Youneedtoconsiderthesechallengeswhendevelopingaplanfortheimplementationofaqualitymanagementsystem.

Inmanyinstances,rapidsyphilistestingwillbeconductedbyhealthcareworkerswhodonothavespecificlaboratoryexperienceorbylaycounsellorswithnoformalhealthcaretraining.Thetrainingprogrammeforthesenon-laboratorystaffmembersmustprovideallthenecessarylaboratoryskills,includingspecimencollectionandlaboratorysafety.Sufficienttimeforpracticalhands-onwork,aswellassomemeasureofcompetencyoncompletionofthetraining,isveryimportant.

all laboratory testing, including rapid testing for syphilis, consists of a series of processes and procedures that must be carried out correctly in order to obtain accurate results.

“ a quality management system, isdefinedastheorganizationalstructure,resources,processes,andproceduresneededtoimplementqualitymanagementatthelaboratoryortestingsite.

”

DriedTubeSpecimenTesting,Peru

WhataretheobjectivesofaQualityManagementSystemforRapidSyphilisTests?

Toassessthequalityofspecimen/samplecollectionandprocessing Todocumentthevalidityofthetestmethods Tomonitorreagents,equipment,andtheperformanceoftestprocedures

andpersonnel Toreviewtestresults Toprovidefeedbackforcorrectiveaction

Table 1. principal components of a Quality Systems programme

What is a Quality What is Quality assurance? What is Quality Control? Management System?

Table2providesanoverviewofthekeyactivitiesandresponsibilitiesofaQualityManagementSystemforRapidDiagnosticTests.

Anintegratedmanagementfunctionthatdealswithsettingpolicyandrunninganadministrativesystemofcontrolstoensuretheusabilityoftheproduct,andensuresthataprocessordeviceisofthequalityneededandexpectedbytheoperator.

Asystemofroutinestandardtechnicalactivitiestomeasureandcontrolthequalityoftestingagainstadefinedsetofcriteriaorstandard,ensuringcorrectoperationoftherapiddiagnostictestsandcorrectdiagnosis.

Theorganizationalstructure,resources,processes,andproceduresneededtoimplementqualitymanagementatthelaboratoryortestingsite.


1. a Quality Management System approach for Rapid diagnostic Tests

Theexpectedoutcomesofasuccessfulqualityassuranceprogrammeinclude:

Standardizedprocessoftestingforpatientdiagnosis. Improvedqualityofdiagnosisandqualityofcare. Empowermentofhealthcareworkersandenhancingtheskillsand

motivationofhealthcareworkers.


ensuring a stock management system is in place

ensuring biosafety measures are in place

ensuring all health care workers and lab personnel have received adequate training and re-training when necessary

documents and Records

ensuring correct methods of specimen collection

ensuring quality of reagents used

performing the tests with proper precision and accuracy

Audit/supervisoryvisit/on-sitemonitoring


Audit/supervisoryvisit/on-sitemonitoringExternalQualityAssessment

DocumentControl



IncomingInspectionInternalqualitycontrolExternalQualityAssessment

InternalqualitycontrolExternalQualityAssessment

HealthcareworkersLabpersonnelDistrictsupervisors/Monitors

HealthcareworkersLabpersonnelDistrictsupervisors/MonitorsHealthcareworkersDistrictsupervisor/Programmecoordinator

HealthcareworkersLabpersonnelDistrictsupervisors/MonitorsQualityOfficers

HealthcareworkersDistrictsupervisors/Monitors

HealthcareworkersLabPersonnel


interpreting the results correctly ExternalQualityAssessmentConfirmatoryre-testing


Monitoring and evaluation,Coordinating and supervising


Districtsupervisor/Programmecoordinator

Giving timely feedback Audit/supervisoryvisit/on-sitemonitoring

Districtsupervisor/ProgrammecoordinatorLabpersonnel

detecting errors in the testing process and taking corrective actions


HealthcareworkerLabpersonnelDistrictsupervisor/Programmecoordinator

activity Quality Control process applicable to

Table 2. principal components of a Quality Systems programme:


2. documents and Records

Standardized documents and records should be developed at the national level in order to assure conformity to national standards and for ease in collecting national data. documents and records must be maintained in such a way that they are always up-to-date and accurate, readily accessible by laboratory staff, and protected from damage and deterioration. Retention times for documents and records should be established. policies should be developed to ensure confidentiality when appropriate.

2.1 Documents

2.1.1 definition Documentsarewrittenpolicies,processdescriptionsandprocedures,andanyblankformsusedinthetestingprocess.Documentsdevelopedwithinthequalitysystemincludethewrittenstandardoperatingprocedures,safetypolicies,personnelpolicies,andallstandardblankforms,suchasreportingforms.

Externaldocumentswillalsobeusedandcanprovideimportantinformation.Examplesofexternaldocumentsusedinasyphilisrapidtestingsiteincludeinformationfromthekitmanufacturer,referencesfromjournals,andanyservicemanualssuchasforcentrifugesorrefrigerators.

2.1.2 Management of documentsDocumentsshouldbeconsistentwithnationalpolicy,toassureuniformityandadequacyofdata.Alldocumentsneedtobemanagedwithatrackingsystem,toensurethatalltestingsiteshavecurrentinformationonhandandthatoutdateddocumentsarearchivedandultimatelydiscardedtoavoidconfusionattheworksite.Alldocumentsandrecordsshouldhaveastandardizednumberingsystemwithversionnumbersanddatesofupdate.

Brazil In Brazil, syphilis and HIV rapid testing is carried out on a laminated A3 worksheet. The sheet is divided in two: the HIV test is placed on one half and the syphilis test on the other. This helps health care workers to avoid mixing up the tests, which look very similar. The worksheet also summarises the test procedure.

A testing and treatment algorithm for both syphilis and HIV is given on the reverse side of the worksheet.

Refer to Appendix 12 for an example of this worksheet. A pictorial worksheet is also provided. It details the steps for reconstitution and testing of Dried Tube Specimens. Refer to Appendix 13 for an example.


2.2 Records

2.2.1 definitionRecordsresultfromcarryingoutprocessesandprocedureswithinthetestingprocess.Examplesinclude:

Worksheets. Testresultreports. Labels. Temperatureandmaintenancecharts. Qualitycontrolresultsandcharts. Externalqualityassessmentactivitieswithresultsandcorrectiveaction. Inventorylists.

Therecordsincludeeverythingusedtocaptureinformation,activities,orresultswhenperformingaprocedure.Theymaybekeptonpaper,orelectronicallyusingacomputersystem.Recordsallowforthecontinuousmonitoringofthequalitysystem.

2.2.2 Management of recordsRecordsforsyphilistestingsitesshouldbestandardizedanddistributedonanationallevel.Ataminimum,worksheetsshouldinclude:

Spaceforthedateandtime. Clientidentifiers. Nameofthepersonperformingthetest. Nameandlotnumberofthekitused. Qualitycontrolresults.

Aseparatequalitycontrolchartshouldbemaintainedtoallowforanalysisandquickreviewofqualitycontrolresults.Personnelrecordsontraining,competencyevaluation,andworkinjuryshouldbekept.Alladverseoccurrences,includinganycorrectiveactiontaken,shouldberecorded.

Anexamplelistofrecordsthatcanbekeptatcentralandsitelabsforrapidsyphilistestprogrammes:

Characterizationofdriedtubespecimens(DTS)usingrapidplasmaregain/TreponemaPallidumHaemagglutinationassay.

Proficiencytestingresultsform. Qualitycontrollog(internalqualitycontrol,externalquality

assessment). Qualitycontrolfailurelog. Traininglog. AccidentReportform. IncomingInspectionform. Qualityassurancechecklistforsitemonitoringvisits.

Documentationsystemathealthcentre,Lima,Peru


3. organization and Management: Structural Set-up of Quality assurance

Strong commitment from top-level managers is essential to the success of the overall quality programme. This commitment is important at all levels, and national laboratory leaders will need both to provide strong leadership from the national level, and to motivate and help laboratory managers throughout the country to understand the system and commit to its success.

3.1 Responsibilities at the national level3.1.1 establishing a laboratory quality systemTheimplementationofaqualitysystemrequirescommitmentfromthetoplevelsofmanagement.TheMinistryofHealth,includingnationallaboratoryleaderswithappropriategovernmentauthority,shouldestablishanationalqualitysystem.Thisshouldinclude:

Anationalofficeofqualityassuranceorqualitymanagement. Theidentificationofanationalqualityofficerormanager. Theidentificationofamultisectoralworkingteam,inordertoextendthequality

systemtoallaspectsoftestingpracticesandtoavoidverticaldecisionsandassessments.

Extendthequalitysystemtoalltiers(central,regional,district,point-of-service)ofthelaboratorynetwork,andtheinvolvementofallserviceprovidersatalllevels.

Extendthequalitysystemtoalllaboratorytesting,includingserologicaltestingforsyphilis.

3.1.2 planning for the management of rapid syphilis testsAnoverall,country-wideplanforthemanagementofsyphilistesting,includingtheroleofrapidsyphilistests,isessential.Thefollowingstepswillbeneededtoestablishthisplan:

Nationalpoliciesfortheuseofrapidsyphilistestsmustbeestablished.Issuestobeaddressedinclude:

Theuseofrapidtestingasanalternativetoconventionallaboratory testingforsyphilis.Whenandwhereisthisappropriate?

Personnelissues.Whowillbeallowedtoperformsyphilisrapidtesting,andwhattrainingandcertificationwillberequired?Howwillappropriatesupervisionbeprovided?

Legalrequirementsthatmightapplytotesting.Examplesincludecountryrequirementsforexistingpersonnelcertificationaswellasexistingnationallaboratoryandsafetystandards.

Evaluationofthetestkitsthatwillbeusedinthecountryandestablishinganalgorithmtobeusedfortesting.

Linkagesbetweenconventionalserologicaltestsforsyphilisandrapidtests.


Developmentofstandardoperatingprocedurestobeusedinalltestingsites. Confidentialityissues. Requirementforcorrectiveorremedialaction.

Astrategicplanforimplementationofsyphilisrapidtestingshouldbe developed.Thisplanwillincludeprovisionfortrainingofpersonnelandfor continuousmonitoringandimprovementofthetestingprocess.Itisimportant toestablishatimelineaswellasprocessestodealwithmanyelementsofthe qualitysystem.

Monitoringprocessesshouldbeestablishedtoidentifyproblemsandconfirmthatthesystemisworking.Theremustbeaplanforsolutionstotheproblems,andrecordskeptofcorrectiveactionstaken.Section 8.4.4 ofthisdocumentandImplementation 4 oftheToolkitprovidemoreinformationinimplementingamonitoringplanforthequalitysystem.

3.2 Responsibilities at the site where testing occursProvisionsmustbemadeatthelaboratoryorpoint-of-carefacility(suchasanantenatalorSexuallyTransmittedInfectionsclinic,oravoluntarycounsellingandtestingcentre)foroversightoftesting,toensurethatthenecessarystaffandsuppliesareavailable,andtoensurethatconfidentialrecordsareestablishedandmaintained.Thereareseveralstepsinthisprocess.

Managementofthesyphilistestingprogrammeateachsitemustbeassigned tooneperson;thispersonmaybedesignatedasaqualityofficer.The responsibilityshouldbeassignedtosomeonewithauthoritytomakeand implementdecisions,whohasstrongknowledgeofsyphilistestingprocedures andacompleteunderstandingoftheessentialsofthequalitysystem.Insome settings,onequalityofficermightserveseveralsites.Thequalityofficershould haveaclearchannelofcommunicationtotheMinistryofHealthorpolicybody, aswellastoallstaffareperformtesting,sothatanychangesinprocedureor otherimportantinformationcanbesharedinatimelyfashion.

Standardoperatingproceduresmustbeestablishedateachsite.Thestep-by- stepsetofinstructionsthatoutlinesalltheprocessesforconductingtesting mustbeaccessibletoeveryonewhoperformstests.

Localmanagementmustensurethatalltestingisperformedbystaffwhohave beentrainedandcertifiedaccordingtonationalrequirements.Thequality officermustalsohaveaplanforevaluatingstaff,initiallyandonanongoing basis.Ifthereisnonationalcertificationprogramme,localmanagementmust ensurethatstaffaretrainedandcompetenttoperformrapidsyphilistesting accordingtonationalguidelines.

Oversightoftherecordkeepingsystemmustbeprovided.

Finally,thequalityofficermustensurethatallothercomponentsofthequality systemareinplacebeforetestingisbegunatasite.Notestingshouldbe conducteduntilthesitecanbedemonstratedtobeproperlyprepared.


4. Facilities and Safety

4.1 Facilities Everysitewheresyphilisrapidtestingisperformedmusthaveaphysicalspacethatisappropriateforthetesting.Thisshouldinclude:

Anadequateworkingsurfacethatcanbeeasilycleanedandmaintained Assuranceofanenvironmentaltemperaturethatdoesnotexceedthat

requiredbythetestingkit Refrigerationifneeded Facilitiesforhandwashingandcleaning.

4.2 Safety Procedurestohandlebiohazardousmaterialsafelymustbemadeclearandstaffmustfollowthem.Thesewillinclude:

Instructionsonuseofgloves,useofclosedfootwear,handwashing,handlinganddisposalofsharps,spillcontainmentanddisinfection.

Basicsafetyproceduresthatareclearlyvisibleintheworkspace.

Generalpoliciessuchas“noeating,drinking,orsmoking”or“nounauthorizedpersonsinthetestingarea”,whichmustbeenforced.

Proceduresforthesafedisposalofallspecimensandmaterialsusedintesting,whichmustbeobservedateachsite.Thisisessentialinordertoprotectworkersperformingthetestsaswellasanyotherswhomightbeexposedtodiscardedmaterials.Allspecimensandmaterialsmustbehandledasifcapableoftransmittinganinfectiousdisease.Aprocedureforworkerstofollowifthereisaccidentalexposureofstafftobiohazardousmaterial.Thisprocedure,aswellasalistofpersonstocontactinanemergency,mustbereadilyaccessibletoallfacilitystaff.ItisrecommendedthatallpersonsperformingrapidsyphilistestsshouldknowtheirserostatusforbothsyphilisandHIV.

Aprocedureforworkerstofollowifthereisaccidentalexposureofstaff tobiohazardousmaterial.Thisprocedure,aswellasalistofpersonsto contactinanemergency,mustbereadilyaccessibletoallfacilitystaff.Itis recommendedthatallpersonsperformingrapidsyphilistestsshouldknow theirserostatusforbothsyphilisandHIV.

Fullsafetyrequirementsfortestingblood/serumspecimensareverydetailed.Acompletesetofcountryguidelinesshouldbemadeavailableatanysitewheretestingisperformed.Usefulreferencesinclude:InternationalOrganizationforStandardization(ISO),WorldHealthOrganizationWHOBiosafetyguidelines,CDCBiosafetyGuidelines.

Biohazardprecautionmeasures


a standardized training programme for laboratory-based and non-laboratory staff should be developed and implemented at all levels of service delivery. Frequently, the training of large numbers of staff will be accomplished at the time when testing is widely implemented: at the same time, for example, as the inclusion of a new group of antenatal clinics or the expansion of syphilis testing in preventing Mother to Child Transmission programmes.

Thenationaltrainingplanmustmakeprovisionforthetrainingofnewstaffastheyarehiredandaddedtotheworkforce.Thisiscriticaltothemaintenanceofquality,reliabletesting.Itmayattimesbeachallenge,astrainingsessionsmayhavetobedoneforjustoneortwopersons.Nonetheless,allnewstaffshouldundertakethesametrainingprogrammethatisusedforinitialtraining

Detailedguidancefortrainingstaffontheuseofrapidsyphilistesting,includingqualityassuranceandqualitycontrolaspectsisgiveninImplementation 3 ofthisToolkit.

5. personnel and Training

TrainingworkshopforlaboratoryworkersinLima,Peru


6. equipment

one of the great advantages of using rapid, simple technology for syphilis testing is that little or no equipment is required.however, in some settings the use of whole blood or serum may require a centrifuge and pipetting devices. in this case, a plan for calibration and maintenance should be developed.

Theremayalsobeaneedforrefrigerationtostoresyphilisrapidtestreagentsorspecimens;ifso,temperaturecheckswithdocumentationandamaintenanceplanmustbeeffected.

RapidsyphilistestinginprimaryhealthcentreinTanzania


it is essential that dependable and reliable test kits and supplies are available. This requires a national plan for procurement and distribution, as well as careful management of supplies and reagents at the testing site.

7.1 Responsibilities at the national levelMostcountriesuseatenderprocessfortheprocurementofreagentsandsuppliesforalllaboratoriesandtestingsitesmanagedthroughtheMinistryofHealth.Itisimportantthatsuppliesandreagentsbecarefullyselectedandthattheyareorderedinsufficientquantitytolastuntilthenexttender.

Thekitspurchasedmusthaveanexpirationdatethatisfarenoughintothefuturetoallowforefficientuseandtopreventwaste.Apolicyof“firstexpired,firstout”willalsohelptoassureminimumwaste.

TheMinistryofHealth/nationalreferencelaboratorymusthavesomemeansofassessingthequalityofthekits,reagents,andsuppliesastheyarereceivedbythecentralpurchasingbody,toensurethatstandardsandspecificationsaremet.Itisrecommendedthateachlotnumberbecheckedbythenationalreferencelaboratorybeforedistribution.

Itwillbenecessarytoimplementadistributionplanthatallowsthesereagentsandsuppliestoreachalltestingsiteswithintheappropriatetimeframeandpriortoexpiry.Theplanmusttakeintoaccountemergencyorunexpectedneeds.

7.2 Responsibilities at the testing siteAninventoryrecordforkitsandsuppliesshouldbemaintained.Eachsiteshoulddeterminere-orderlevelsforeachitemintheinventorybasedonworkloadandusage.Thiswillallowfororderinginatimelymanner,sothatthetestingsitealwayshasthenecessaryreagentsandsuppliesandnointerruptionintestingwilloccur.AmethodforcalculationmaybefoundinManagement 2ofthisToolkit.

Onreceiptofnewsuppliesandreagents,theinventoryrecordshouldbeupdatedandallofthenewmaterialstoredundertheappropriateenvironmentalconditions.Management 2ofthisToolkitprovidesexamplesofformsthatcanbeusedforinventoryrecords.

Toavoidwaste,sitesshouldfollowtheprincipleof“firstexpired,firstout”.Thekitsthatexpireearliestmustbeusedfirst.

FurtherguidanceonmanagingandmaintainingstockatthehealthcentreisprovidedinManagement 2ofthisToolkit.

7. purchasing and inventory


8. Quality Control

Quality control refers to activities and techniques carried out to ensure that testing procedures are performed correctly, that the environment is suitable for reliable testing, and the test kit works as expected to produce accurate and reliable results.

Qualitycontrolusuallyincludestestingspecimensofaknownvalueusingthesamereagentsandequipmentthatareusedforthespecimensbeingmeasured.Sincerapidsyphilistestkitsaresingleusedevices,thisapproachisnotpossible.Qualitycontrolspecimensmustthereforebeusedinamannerthatmonitorsthecorrectperformanceofthetestbytheoperatorandthecapacityofthetestkitstoworkproperly.Whileitisnotpossibletotesteachkit,qualitycontrolspecimenscanbeusedtodetectdamageofanentirebatchorlotnumberofkits,whetheritiscausedbyimproperstorageorhandlingorthroughmanufacturingdefects.

Thequalitycontroltestingprocessfollowsthepathofworkflow.Thepathofworkflowisfrequentlydescribedasthestepsdonebeforetesting(pre-analytic),thosedonewhiletesting(analytic),andthestepsthatfollowtesting(post-analytic).Whenusingrapidsyphilistestkits,thereareanumberofstepsinthesethreepartsofthepathofworkflowthatareessentialinordertoassureaccurateandreliabletestresults.SomeoftheseactivitiesaredetailedinFigure1.

Figure 1. process Control activities

Checkstorageandroomtemperaturesdaily. Checkinventoryandtestkitlotsasneeded. Receiverequestsfortesting. Setuptestarea. Recordallneededdata(kitlotnumber,operatoridentity).

Followbiohazardsafetyprecautions. PerformQualityControlaccordingtoSOP. Identifypersontobetestedifpre-counseledbyanotherHCW. Specimencollection. TestProcedureaccordingtoSOPormanufacturer’sinstructions. Interprettestresults.

Re-checkpatientidentifierandreportresults. Clean-upanddisposeofbiohazardouswaste. PackageandtransportEQAre-testspecimenstoreferrallaboratory

ifneeded.post analytic

analytic

pre-analytic


Astandardoperatingprocedure(SOP)mustbedevelopedtoprovidedetailedinstructionsonallaspectsofthetesting.Itshouldinclude:

Transportofspecimens. Storageandinventoryinformation. Testrequisition. Environmentalrequirements. Specimencollectionandmanagement. Testperformance. Qualitycontrolinstructions. Testinterpretation. Thereportingandrecordingofresults. Appropriateuseofthetestingalgorithm. Anyexternalqualityassessmentrequirements.

Eachtestproductwillneeditsownstandardoperatingprocedure.Awrittenstandardoperatingprocedureshouldbeavailableateachtestingsite,andshouldalwaysbefollowedwhenconductingtests.Achartshowingasimplifiedversionoftheproceduralsteps(workinstructions)isveryusefulandshouldbeprovidedatthepointoftestingperformance.Thetestsitemusthavewritteninstructionsonallpoliciesandprocedurestobefollowedwhenconductingtests,includingpersonneltrainingandcertificationrequirements,competencychecks,confidentialitypoliciesandsafety.

SeeanexampleofaStandardOperatingProcedureforManufactureofDriedTubeSpecimensinAppendix 4.

8.1 Incoming Inspection of rapid syphilis test kitsIncominginspectiontestingiscarriedoutoneachnewlotorshipmentofrapidtestkitsarrivingin-countryfromthesupplier.Itensuresthevalidityandintegrityoftestkitsandlotsaftershipping.Arepresentativenumberoftestkitsaretestedusingaknownnegativeorknownpositivecontrolatthecentralorreferencelaboratory.Eachnewlotoftestsreceivedshouldbetestedinparallelwiththeoldbatchtoconfirmlottolotagreement.

8.2 In-built procedural controlManyrapiddiagnostictestshavein-builtproceduralcontrolsintheformofatestcontrolline.Insomekits,thesecontrolsmaybeprovidedasaseparatematerial,butwillstillbeusedwitheachtest.Thein-builtcontrolverifiesthatthespecimenwasadequateandthatthecomplexofspecimenandreagentflowedthroughthedeviceasintended.Itdoesnotvalidatethetestingprocessorthetester.Theoperatorshouldfollowmanufacturer’sinstructionsandexplanationofthelocationandfunctioningofthein-builtproceduralcontrol.


8.3 Internal Quality Control Internalqualitycontrolevaluatestheaccuracyofthetestandverifiestheoperator’sabilitytoperformthetestandinterpretthetestresultcorrectly.Itensuresreliabilityofthetestresultonthedayoftesting.Internalqualitycontrolshouldincludethetestingofatleastoneknownsyphilis-positiveandoneknownsyphilis-negativespecimen.Ifpossible,aweaklypositivesyphilisspecimenshouldalsobeincluded.

TheMinistryofHealthshouldestablishpolicyforhowandwheninternalqualitycontrolmaterialshouldbeused.Thisinformationmustbeprovidedanddescribedinthestandardoperatingprocedure.

Thefrequencyofuseofqualitycontrolmaterialisdependentonseveralfactors.Theconditionofthekitsmustbeevaluatedovertime.Itwillbeimportanttocheckkitsfairlyofteninareaswhereenvironmentalconditionscanbeextremeanddifficulttocontrol,andwheretransportationcanbechallenging.Whenrunningcontrolsforrapidsyphilistesting,itisimportanttousebothanegativeandapositivecontrol.Wheneverpossible,aweaklyreactivepositivecontrolthathasbeenvalidatedtoyieldweaklyreactiveresultsonallrapidtestkitsusedshouldbeincluded.

8.3.1 Source of quality control materials

dried Tube SpecimenDriedtubespecimens[DTS]canbeusedasanalternativetodriedbloodspots(DBS)forinternalqualitycontroland/orproficiencytesting.Driedtubespecimensareadriedformofserumorplasmawithknownserostatus.Theyarepreparedusingastandardizedprotocol(giveninAppendix 4)andcharacterizedusingthereferencestandardavailable(e.g.rapidplasmareagin,TreponemaPallidumParticleAgglutinationassay/TreponemaPallidumHaemagglutinationassay).Driedtubespecimensarecold-chain-independentandcanbeshippedtoandstoredathealthcentresinnon-refrigeratedconditions.

Zambia InZambia,rapidsyphilistestkitsarevalidatedtoconfirmthattheyareingoodworkingorderuponreceiptatthecentrallaboratoryfromthesupplier.Thisisdonebytestingarandomselectionof1%ofthekitsineachbatchoftestkitsusingknownsyphilis-positiveandsyphilis-negativespecimens.Theknownsyphilis-positiveand-negativesamplesareprovidedandcharacterizedbyCollegeofAmericanPathologists(CAP)surveys.

Thepositivesamplesaretestedonrapidplasmareagin,titratedandconfirmedonTreponemaPallidumHaemagglutinationtechnique.ThecentrallabisregisteredwiththeCollegeofAmericanPathologistsandreceivessyphilisproficiencypanels3timesayear.Thisincominginspectionprocessconfirmsthevalidityofthetestkitspriortotheirdistributiontothehealthcentres.

InternalQCpackusingDTSinPeru


Theadvantagesofusingdriedtubespecimensincludethefollowing:

Driedtubespecimensarestableatelevatedtemperaturesforatleast3-4weeks.

Theyarecold-chain-independentandcanbeeasilytransportedbymailorvehicle.

ADriedTubeSpecimenPanelcanbemadein-country,maintaininglowcostwhenspecimensarealreadyavailableandallowingthequalityoftestingtobecontinuallymonitored.

TheycanbeusedforProficiencyTestingand/orasInternalQualityControlmaterials.

TheDriedTubeSpecimenPanelusedtoevaluatethehealthcentreorlaboratory’sperformanceMUSTNOTbetreateddifferentlyfromanypatientspecimenstested.

Itisrecommendedthatqualitycontrolmaterialsbedistributedwiththetestkits.Thiswillassurethateachsitehassufficientqualitycontrolmaterialforusewiththekits.

8.3.2 Troubleshooting and corrective actions when internal quality control results are out of range

Whenaninternalqualitycontroldoesnotgiveresultsasexpectedandareoutofrange,thelaboratoryorclinicsupervisorshouldbenotified.S/hewilldecidehowthenon-conformingtestresultshouldbeinvestigated.Errorsinresultsmayoccurforavarietyofreasons.Operatorerrorintestperformanceisonecauseofdiscrepancy:thiswillrequireadditionalqualityassuranceandtrainingatthesite.Acommonsourceoferrorisatranscriptionmistakeatsomepointintheprocess.

Errorsmaybeproducedifthedriedtubespecimenswereinadequatelyreconstitutedatthehealthcentre/laboratoryortherewasanerrorinmanufacturingatthecentrallab.Inaddition,errorsmaybeproducedifthetestkitsareimproperlystoredand/ortransported.

Anypatienttestresultsthathavebeengeneratedsincethelastcontrolswererunshouldbeconsideredinvaliduntiltroubleshootingisundertakentodeterminethesourceoftheproblem.

Figure 2 detailsaprocessflowforcorrectiveactionwhenaninternalqualitycontrolisoutofrange.RefertoSection 10 ofthisdocumentforfurtherinformationonmanagingerrorsandproblemsinthetestprocess.


Figure 2 Corrective action Testing algorithm when Quality Controls are out of range

CollectonePositiveandoneNegativeQCsamplevials.

Get2cassettesfromanewboxoftestkitandlabelonePositiveandtheotherNegative.

CollectonefreshlyreconstitutedPositiveandonefreshlyreconstitutedNegativeQCsamplevials.

Get2newcassettesfromthesametestkitandlabelonePositive andtheotherNegativeandperformStep3above.

ForNegative: Draw20µLofNegativeSampleand

droponcassettelabeledNegative Addbufferandstarttimerfor20min. ReadresultandrecordinQCLog

provided.Note:ResultNegative,kitsareworkingproperly.AcceptinqualitycontrolLogandusethekits.Ifnot,pleasefollowinstructionsbelow:

ForPositive: Draw20µLofPositiveSampleand

droponcassettelabeledPositive Addbufferandstarttimerfor20min. ReadresultandrecordinQCLog

provided.Note:ResultPositive,kitsareworkingproperly.AcceptinqualitycontrolLogandusethekits.Ifnot,pleasefollowinstructionsbelow:

Step 1.

Step 4.

Step 2.

Step 5.

Step 3a.

instructions for out of specification results:

Step 3B.

peru Atthetimeofpress,areal-timestabilitystudyofrapidsyphilistestswasbeingundertakeninthevariousclimaticsettingswithinPeru.Theseinclude:theIquitosJungle(hightemperaturesandhighhumidity);thePiuraCoast(drywithhightemperatures);andtheCerrodePascoAndes(highaltitude,verycoldanddry).TestkitsinthevarioussettingswerecomparedtocontrolkitsstoredinthereferencelaboratoryinLimaat4°C(coldroom/refrigerator)and37°C(incubator)and15–27°C(storageroom).Atthetimeofthispublication,6monthsofreal-timestudydemonstratedequivocalperformanceoftestkitswithcontrolkits.

Forfurtherinformationonthisstabilitystudy,refertohttp://www.proyectocisne.org/ wherefullresultswillbepublished.

Temperature monitoring at health centre in lima, peru


8.3.3 Record-keepingAstandardizedmethodforrecordkeepingshouldbeprovidedbythenationalreferencelaboratoryorcentrallaboratory.Thisshouldincludeastandardworksheetforrecordingqualitycontroldataandacorrectiveactionalgorithmfortroubleshootinganoutofspecificationqualitycontrolresult.

AnexampleofaQualityControlRecordForm,includingloggingofcorrectiveactions,isgiveninAppendix 7.

8.4 External Quality Assessment Throughexternalqualityassessment,theperformanceofatestingsitecanbeindependentlyevaluatedfromoutsidethelaboratoryortestingsite.Methodsforexternalqualityassessmentincludetraditionalproficiencytesting,re-testingofspecimens,andcarefulon-sitemonitoringusingachecklistandknowledgeableassessors.

8.4.1 proficiency testing using a proficiency panelTraditionalproficiencytestingisorganizedandconductedbyareferencelabora-toryorcentre.Atregularintervals,apanelofspecimensofknownreactivityissenttoallparticipants,whotestthespecimensandreturnresultstotherefer-encelaboratory.Thedataisanalyzedandinformationissentbacktothepartici-patingtestingsites.

ProficiencyTestingcanbeperformedusinganyofthefollowingspecimens:

Liquidserumorplasmaspecimens Freeze-driedspecimens Driedtubespecimens

Thedisadvantagesofusingliquidserumorplasmaspecimensforanexternalqualityassessmentprogrammearethelimitationsinshippingandstorage:theyrequirecoldstorageandtransportation;thereisanincreasedriskofbio-hazardspill;itiscostly;anditisimpracticalforremotesites.

ReconstitutionofDTS


8.4.2 Scoring and follow-up of proficiency panel test resultsThedistrictsupervisororlabcoordinatorwillcollectallproficiencytestingrecordformsfromparticipatinglaboratories.Resultsshouldbeenteredinanexcelspreadsheet.Proficiencypanelsshouldbescoredandthefinalscoreconvertedtopercentagesusingthefollowingequationshownleft.Thelabordistrictsupervisorshouldfollowupwiththosetestersorfacilitiesthatobtainedlessthanthecut-offpercentageorpassinggradeandundertakethenecessarycorrectiveactionsorre-trainingtoresolveanyissues.

Proficiencytestingforrapidsyphilistestshassomelimitations.Thepanelofspecimenssenttothetestingsitewillnotnecessarilybetestedbyallstaff,sothisisnotagoodmeasureofindividualperformance.Thesamplesizeissmall,sotheabilitytodetecterrorsisimpaired.Furthermore,preparinganddistributingspecimensforproficiencytestingmaybeburdensomefornationalreferencelaboratories.Proficiencytestingisprovidedinsomelocations,andwhenavailableitisausefultoolincombinationwithon-sitemonitoring.

Zambia ThemanagementteamfortherapidsyphilistestingprogrammeinMonguandLusakainZambiahaveimplementedacorrectiveactionplanforhealthcareworkerswhoobtainafinalscoreoflessthan67%onexternalqualityassessment.Allindividualsorfacilitiesthatscoredlessthan67%overallontheDriedTubeSpecimenProficiencyPanelareaskedtotestasecondproficiencypanelasaformofre-training.

Beforetestingthesecondpanel,theinternalmonitorsorsupervisorswillvisitthefacilitiesandobserveandprovideguidanceasthehealthcareworkersre-testtheoriginalproficiencypanelsothatanyproblemswiththeweakpositivesamplescanbeaddressed.Thesecondproficiencypanelwillthenbedistributedtothefacilities,wherehealthcareworkerswilltestunaided.

Brazil DriedtubespecimensareusedforproficiencytestingamonghealthpostsintheAmazonasregionofBrazil.Thecold-chain-independencyofthedriedtubespecimenmakesitanidealformofspecimentobeshippedoverlongdistanceswithunreliablemodesoftransportandwithhightemperaturesandhumidity.Thefrequencyofdriedtubespecimentestingaspartofanexternalqualityassessmentprogrammeforrapidsyphilistestingislargelydependentontheaccessibilityoftheclinics/healthposts.Distributionismainlyopportunistic:driedtubespecimensaresentfortestingwheneveraSecretariaEspecialdeSaudeIndigena(SESAI)technicalcoordinatorismakingaroutinevisittothehealthposts.

Follow-uponresultscanbeconductedthatdayorbycellphoneorbymailiftestingisnotperformedonthesameday.

RapidsyphilisandHIVtestingintheIanomamicommunityofAmazonas,Brazil

The number of correctly identified specimens/total number of vials) x 100% = score. (a cut-off percentage or passing grade should be determined as good practice by the central, or coordinating, laboratory.)

ProficiencyPanelresultsusingrapidsyphilistestsinBrazil


Uganda TheUgandanVirusResearchInstitute(UVRI)isresponsibleforthemanufactureofdriedtubespecimensforproficiencytestingandforthereviewandfollow-upofcompletedresultsfromthefacilitiesfortherapidHIVandsyphilistestingprogrammes.

ThemanufactureofdriedtubespecimensforrapidsyphilistestingisintegratedwiththatforHIVrapidsyphilistesting.Thepanelscurrentlyremainseparatebuttheschedulingformanufacture,distributiontofacilitiesandfollow-upandreviewiscoordinatedforboth.

8.4.3 Re-testing of specimensWiththisexternalqualityassessmenttechnique,serumiscollectedfromtheclientatthetimeofrapidtesting.TheserumistestedusingatreponemalsyphilistestsuchasaTreponemaPallidumParticleAgglutinationassayorEnzymeImmunoAssay(EIA),andtheresultsofthistest,or“re-test,”arecomparedwiththatobtainedfromthefinalsyphilisrapidtestresult.Acommonmodelinuseisthere-testingof5%-10%ofrapidtestspecimens,randomlyselected.

Re-testing with dried Blood Spots Withdriedbloodspots,dropsofbloodarecollectedontoafilterpaperatthetimeoftesting.Oncethedropsaredried,thefilterpapercardswiththedriedbloodspotscanbesenttothereferencelaboratoryforretestingwithatreponemalbasedsyphilisassay.NospecialstorageconditionsarerequiredforDBS.Thebenefitsofdriedbloodspotsarethattheyeasilycollectedandcorrectcollectionandstorageofsamplesrequiresminimaltraining.Fortemporarystorage,humidityshouldbecontrolledbyplacingtheDBSinplasticsealablebagswithdesiccants.Afterretesting,laboratoryresultsshouldbeenteredinExcelorcomparablesoftwaretoreviewtheperformanceofthehealthcentresovertime.Thedistrictsupervisororlabcoordinatorshouldfollowupandprovidecorrectiveactionswiththosehealthcentresthatperformbelowadeterminedpercentagecut-offlevel.DriedbloodspotsforsyphiliscanalsobeintegratedwiththeHIVormalariaqualitycontrolsystemtominimisesamplecollection,transportandeffort.Thequalitycontrolofsyphilis,malariaandHIVtestingcanbecombinedbytestingonefilterpaperforthethreedifferentpathogens.

haiti InHaiti,apanelof5driedtubespecimensofknownstatusarepreparedandsentbythecentrallabtothedifferentsitesfortestingandreportingonaquarterlybasis,.Thesespecimensaretypicallymadeupof2negative,2weaklypositiveand1stronglypositivesamples.

Thepassinggradeforaroundoftestingis80%.Labsthathaveagradeof80%orlessonanyeventmorethanonceperyearmustbeconsideredforpersonnelretraining.Thesitesmustkeeparecordoftheproficiencytestingandevaluationresults.Thesitesmustalsoprovidedocumentedevidenceofareviewofevaluationresultsandcorrectiveactionsinthecaseofanevaluationresultoflessthan100%.

DTSPanelPackusedinPeru

in the 7 study countries where a quality system approach to rapid syphilis testing was introduced, health care workers were highly motivated by the rapid testing and felt empowered by the capacity to perform patient diagnosis at the point of care and the associated responsibility. it was widely acknowledged that the quality controls built confidence around the correct operation of the test and the correct diagnosis of the patient.

Brazil Toensurethatmultipleoperatorsatahealthfacilitynevertestthesameproficiencysamplesandtoavoidsharingoftestresults,theresearchteaminBrazilprepareddifferentlotsofdriedtubespecimenpanelsforthesyphilisandHIVproficiencypanels.

4separatepanelswithindividuallotnumberswerecreatedwith6panelmemberseachbyselectingdifferentpanelmembersforeachpanellot,butalwaysensuringthateachpanellothasatleastonestrongpositive,oneweakpositiveandonenegativesample.

Sops for preparation and testing of dBSare available at:http://www.lshtm.ac.uk/itd/crd/research/rapidsyphilistoolkit/index.html

http://www.lshtm.ac.uk/itd/crd/research/rapidsyphilistoolkit/index.html


Thetablebelowsummarizesthestatisticalinformation.(Note:Thenumberofspecimenstestedisindependentoftime.)

Table 2. Re-Test Size (and percentage) needed to provide 95% confidence of detecting at least one discrepant result, when the underlying error rate is 1% or 5%e

*95%confidence

Volume (per site) 1%* error 5%* error Re-testing feasibility

Verylow50specimens

Re-test48specimens(96%)


No

Low500specimens



Possible

High5000specimens

Re-test290specimens(5.8%)

Re-test59specimens(1.2%)

Yes

Tanzania Driedbloodspotshavebeenusedovera4monthperiodforre-testingofpatientsamplesforsyphilisandHIVasaqualitycontrolmethodintheGeitadistrictofMwanza,Tanzania.ThestudywascoordinatedbytheNationalinstituteforMedicalResearch,MwanzainTanzania.Thisqualitycontrolmethodwassuccessfulinidentifyingthoseclinicsthatwereperformingwellandclinicsthatwouldrequireadditionalsupportand/orre-trainingbydistrictsupervisorsiftheyperformedbelowthedeterminedcut-offperformancelevel.Themethodwastested

inahospitalsetting,aswellasatdifferenthealthcentresanddispensaries.Protocols,guidelines,excelandEpi-infotemplatesusedduringthestudycanbefoundatthewebsitehttp://www.lshtm.ac.uk/itd/crd/research/rapidsyphilistoolkit/inazipfile.Theexcelfile(DBSresultsanalysis.xls)wasusefulforvisualisingtheperformanceofthedifferentclinics.Theexcelfilegeneratedacut-offlineofthemedian±2standarddeviation.Ifaclinicperformed2monthsbelowthiscut-off,asupervisoryvisitwasrecommendedtoperformanycorrectiveactions,suchastroubleshooting,orre-trainingonsite.

Re-testingofspecimenshaslimitations.Inmanycountriesthereislackofcapacityatthenationalreferencelaboratoryforre-testingthelargenumberofsamplesandforconductingtheneededanalysisofdata.Longdelaysincompletingthere-testingresultsindelayedidentificationofproblems.Anoutlineoftheoperationalissuesthatmustbeconsideredbeforeare-testingprogrammeisimplementedisgiveninAppendix 8andAppendix 9.Finally,statisticalanalysisrevealsthatforlow-volumesites,averylargepercentageofsampleswouldhavetobere-testedinordertodetecterrors.

http://www.lshtm.ac.uk/itd/crd/research/rapidsyphilistoolkit/


Afulldiscussionofthestatisticalmodelsispresentedin Appendix 9.

Notethatthesestatisticalmodelsshowanalysisofsite-specificdata.Aggregatedatacouldbeobtainedbycombiningdatafromseveralormanysites,andcouldbeofsomeuseinlookingattheoverallprogramme.However,aggregatedataisofnovaluewhenevaluatingsiteerrorsortakingcorrectiveaction.

Itisrecommendedthat:

Re-testingbeusedtoestablishthecompetenceofnewstafforanewtestingsite. Ifon-goingre-testingisperformed,itmustbebaseduponstatisticalconsiderationsandarecognition

thatitwillonlybefeasibleinhigh-volumetestsites. Theoutcomeofre-testingmustbeanalyzedforeffectiveandtimelyfeedback

-inordertodeterminecost-effectiveness -todetermineifcorrectiveactioncanbetakenifproblemsareidentified

Iferrorsarenotfoundasaresultofre-testing,establishedsitesshouldconsiderdiscontinuingre-testing.

8.4.4 on-site monitoringExternalqualityassessmentcanbeaccomplishedbyacarefulon-siteobservationofthetestingprocessesandproceduresbyaknowledgeablepersonorteam.Achecklistthatallowsforassessmentofallpartsofthequalitysystemisanimportanttoolforsuchvisits.RefertoImplementation 4ofthisToolkitforfurtherinformationonimplementingandconductingon-sitemonitoring,includingasamplechecklist.

Itisrecommendedthat:

Majoremphasisisplacedonon-sitemonitoringintheexternalqualityassessmentplan.Inlow-volumesitesthismaybetheonlyexternalqualityassessmenttoolthatisused.

On-sitemonitoringshouldincludeallaspectsofthequalitysystem,includingpersonnelcompetencyandtraining,equipmentpolicies,inventorycontrol,qualitycontrolpractices,recordsanddocuments,andfacilitiesandsafety.

Ifothertesting,suchasHIVrapidtesting,isperformedatarapidsyphilistestingsite,anintegratedapproachtoon-sitevisitsshouldbetakentoassessallaspectsoftestingpractices.

Thesitevisitshouldincludeobservationoftestingwithspecimensofknownreactivity(proficiencypanels). Whenpossible,directobservationofinteractionswithclientsisuseful.Othermeansofassessing

performanceoftestingpersonnelcouldincludeexitinterviewswithclientsanduseof“mysteryclients”(personswithknownsyphilisserostatuswhopresentanonymously).

Astandardchecklistmustbeusedforallvisits. Theon-siteassessmentshouldoccuratleasttwiceyearlyatestablishedsites,andatleast

quarterlyfornewsitesorsiteswithnewpersonnel.Thefrequencyofassessmentsshouldbebasedoninitialfindingsandtheneedforcorrectiveaction.

Theon-sitevisitsshouldbeinstructionalandprovideamentoringexperience.Theexperienceshouldnotbepunitive.

Aplanmustbeestablishedforcorrectiveactionrelatedtofindingsduringtheon-sitevisit.Allproblemsshouldbediscussedimmediatelywithon-sitestaff,andanyneededfollow-upactivitiesincludingtrainingshouldbeundertakeninatimelymanner.


defi

ning

C

hara

cter

istic

sin

com

ing

insp

ectio

n in

-bui

lt p

roce

dura

l co

ntro

l in

tern

al q

ualit

y co

ntro

lex

tern

al Q

ualit

y a

sses

smen

t

obj

ectiv

eEn

sure

sva

lidity

an

din

tegr

ityo

fall

new

lots

and

shi

p-m

ents

ofk

itsa

nd

cons

iste

ncy

ofn

ew

lota

gain

sta

pre

vi-

ousl

yus

edlo

t.

Anin

-bui

ltco

ntro

ltha

tve

rifie

sth

atth

esp

eci-

men

was

ade

quat

ean

dth

atth

eco

mpl

ex(s

olu-

tion)

flow

edth

roug

hth

ede

vice

as

inte

nded

.D

oes

notv

alid

ate

the

entir

ete

stin

gpr

oces

s

Eval

uate

sth

eac

cura

cyo

fthe

test

and

ver

ifies

ope

ra-

tor’s

abi

lity

top

erfo

rmth

ete

sta

ndin

terp

rett

hete

st

resu

lt.It

ens

ures

relia

bilit

yof

test

resu

lton

day

of

test

ing.

Pro

ficie

ncy

Test

ing

Ensu

res

inte

r-la

bora

tory

com

para

bilit

yan

das

sess

espr

ofici

ency

ofp

artic

ipat

ing

lab/

clin

ica

ndin

divi

dual

test

er

Res

pons

ible

pers

onne

lC

entr

al/R

efer

ence

la

bora

tory

Hea

lthc

are

wor

ker

Lab

Per

sonn

elH

ealth

car

ew

orke

rLa

bP

erso

nnel

Hea

lthc

are

wor

ker

Lab

Per

sonn

el

Freq

uenc

yEv

ery

lot/

Ever

ysh

ipm

ent

Ever

yte

stA

tlea

sto

ne/w

eek

pref

erab

lya

tbeg

inni

ngo

fwee

kN

ewo

pera

tor/

turn

over

oft

estin

gpe

rson

nel

New

loto

fkits

New

shi

pmen

tofk

itsW

hen

envi

ronm

enta

lcon

ditio

nsa

reo

utsi

dere

com

-m

ende

dra

nge

for

stab

ility

as

defin

edb

ym

anuf

ac-

ture

rL

arge

vol

ume

ofte

stin

g/an

onym

ous

test

ing

shou

ld

run

cont

rols

mor

efr

eque

ntly

T

roub

lesh

ootin

gw

hen

in-b

uilt

proc

edur

alc

ontr

ol

inva

lidat

esth

ete

stre

sult

Per

iodi

c(m

onth

lyto

qua

rter

ly)

Sam

ple

form

atSe

rum

or

Dri

ed

Tube

Spe

cim

enK

now

npo

sitiv

ean

dkn

own

nega

tive

spec

imen

Who

leb

lood

,ser

umo

rD

ried

Tub

eSp

ecim

enSe

rum

or

Dri

edT

ube

Spec

imen

Kno

wn

posi

tive

and

know

nne

gativ

esp

ecim

enD

ried

Tub

eSp

ecim

enP

anel

in

clud

ing

nega

tive,

str

ong

posi

-tiv

ean

dw

eak

posi

tive

spec

imen

s

Stor

age

re-

quir

emen

ts2

-8°

Cfo

rse

rum

Roo

mte

mpe

ratu

re

for

Dri

edT

ube

Spec

imen

2-

8°C

for

seru

mR

oom

tem

pera

ture

for

Dri

edT

ube

Spec

imen

2-

8°C

for

seru

mR

oom

tem

pera

ture

for

Dri

edT

ube

Spec

imen

Roo

mte

mpe

ratu

refo

rD

ried

Tu

beS

peci

men

Cut

-off

/out

-of-

rang

e re

sult

Any

spec

imen

not

co

rrec

tlyid

entifi

ed

requ

ires

furt

her

inve

stig

atio

nof

lot/

ship

men

tofk

its

No

visi

ble

cont

roll

ine

inva

lidat

este

str

unO

vera

llre

sults

of<

x%

agr

eem

entw

illre

quire

inte

r-na

linv

estig

atio

n(x

val

ues

houl

dbe

det

erm

ined

by

the

over

allq

ualit

ym

anag

emen

ttea

m,r

efer

toA

ppen

dix

1fo

rex

ampl

es

from

oth

erc

ount

ries

)

Ove

rall

resu

ltso

f<x

%a

gree

-m

entw

illre

quire

inte

rnal

in

vest

igat

ion

(xv

alue

sho

uld

bed

eter

min

edb

yth

eov

eral

lqua

lity

man

agem

ent

team

,ref

erto

App

endi

x 1

for

exam

ples

from

oth

erc

ount

ries

)

Table 3. key characteristics of Quality Control events


defi

ning

C

hara

cter

istic

sin

com

ing

insp

ectio

n in

-bui

lt p

roce

dura

l co

ntro

l in

tern

al q

ualit

y co

ntro

lex

tern

al Q

ualit

y a

sses

smen

t

obj

ectiv

eEn

sure

sva

lidity

an

din

tegr

ityo

fall

new

lots

and

shi

p-m

ents

ofk

itsa

nd

cons

iste

ncy

ofn

ew

lota

gain

sta

pre

vi-

ousl

yus

edlo

t.

Anin

-bui

ltco

ntro

ltha

tve

rifie

sth

atth

esp

eci-

men

was

ade

quat

ean

dth

atth

eco

mpl

ex(s

olu-

tion)

flow

edth

roug

hth

ede

vice

as

inte

nded

.D

oes

notv

alid

ate

the

entir

ete

stin

gpr

oces

s

Eval

uate

sth

eac

cura

cyo

fthe

test

and

ver

ifies

ope

ra-

tor’s

abi

lity

top

erfo

rmth

ete

sta

ndin

terp

rett

hete

st

resu

lt.It

ens

ures

relia

bilit

yof

test

resu

lton

day

of

test

ing.

Pro

ficie

ncy

Test

ing

Ensu

res

inte

r-la

bora

tory

com

para

bilit

yan

das

sess

espr

ofici

ency

ofp

artic

ipat

ing

lab/

clin

ica

ndin

divi

dual

test

er

Res

pons

ible

pers

onne

lC

entr

al/R

efer

ence

la

bora

tory

Hea

lthc

are

wor

ker

Lab

Per

sonn

elH

ealth

car

ew

orke

rLa

bP

erso

nnel

Hea

lthc

are

wor

ker

Lab

Per

sonn

el

Freq

uenc

yEv

ery

lot/

Ever

ysh

ipm

ent

Ever

yte

stA

tlea

sto

ne/w

eek

pref

erab

lya

tbeg

inni

ngo

fwee

kN

ewo

pera

tor/

turn

over

oft

estin

gpe

rson

nel

New

loto

fkits

New

shi

pmen

tofk

itsW

hen

envi

ronm

enta

lcon

ditio

nsa

reo

utsi

dere

com

-m

ende

dra

nge

for

stab

ility

as

defin

edb

ym

anuf

ac-

ture

rL

arge

vol

ume

ofte

stin

g/an

onym

ous

test

ing

shou

ld

run

cont

rols

mor

efr

eque

ntly

T

roub

lesh

ootin

gw

hen

in-b

uilt

proc

edur

alc

ontr

ol

inva

lidat

esth

ete

stre

sult

Per

iodi

c(m

onth

lyto

qua

rter

ly)

Sam

ple

form

atSe

rum

or

Dri

ed

Tube

Spe

cim

enK

now

npo

sitiv

ean

dkn

own

nega

tive

spec

imen

Who

leb

lood

,ser

umo

rD

ried

Tub

eSp

ecim

enSe

rum

or

Dri

edT

ube

Spec

imen

Kno

wn

posi

tive

and

know

nne

gativ

esp

ecim

enD

ried

Tub

eSp

ecim

enP

anel

in

clud

ing

nega

tive,

str

ong

posi

-tiv

ean

dw

eak

posi

tive

spec

imen

s

Stor

age

re-

quir

emen

ts2

-8°

Cfo

rse

rum

Roo

mte

mpe

ratu

re

for

Dri

edT

ube

Spec

imen

2-

8°C

for

seru

mR

oom

tem

pera

ture

for

Dri

edT

ube

Spec

imen

2-

8°C

for

seru

mR

oom

tem

pera

ture

for

Dri

edT

ube

Spec

imen

Roo

mte

mpe

ratu

refo

rD

ried

Tu

beS

peci

men

Cut

-off

/out

-of-

rang

e re

sult

Any

spec

imen

not

co

rrec

tlyid

entifi

ed

requ

ires

furt

her

inve

stig

atio

nof

lot/

ship

men

tofk

its

No

visi

ble

cont

roll

ine

inva

lidat

este

str

unO

vera

llre

sults

of<

x%

agr

eem

entw

illre

quire

inte

r-na

linv

estig

atio

n(x

val

ues

houl

dbe

det

erm

ined

by

the

over

allq

ualit

ym

anag

emen

ttea

m,r

efer

toA

ppen

dix

1fo

rex

ampl

es

from

oth

erc

ount

ries

)

Ove

rall

resu

ltso

f<x

%a

gree

-m

entw

illre

quire

inte

rnal

in

vest

igat

ion

(xv

alue

sho

uld

bed

eter

min

edb

yth

eov

eral

lqua

lity

man

agem

ent

team

,ref

erto

App

endi

x 1

for

exam

ples

from

oth

erc

ount

ries

)

Records may be kept either manually or usingcomputer technology. Where computer systems are available, laboratories are afforded many useful tools for managing client data as well as quality control and external quality assessment information.

Forexample,asystemfortrackingserumspecimenscollectedforexternalqualityassurancepurposeswouldmakeitmucheasiertomanagethisaspectofthequalitysystemfunction.Ifthereiscountry-widenetworking,thepotentialtocorrelateanindividual’sclinicaldataandlaboratoryresultscountry-wideisvaluable.

Whencomputerizedinformationmanagementsystemsareavailable:

Processestoensureaccuracyandreliabilityofdata,andtoprotectdatafromdamageandloss,mustbeputinplace.

Privacyandconfidentialityofdatamustbestrictlyobserved. Staffwillneedtrainingtodevelopcompetencyinuseofcomputertools,

includinguseofthespecificlaboratorysystem,aswellasinwordprocessing,useofspreadsheets,anddatabases.

9. information Management

Zambia TheSmartCareelectronichealthrecordsystemhasbeendevelopedbytheZambianMinistryofHealthincollaborationwiththeCentersforDiseaseControlandPreventionandmanyotherimplementingpartners.ItisaclinicalmanagementinformationsystemusedatthefacilityanddistrictlevelwhichincludesdetailsonHIV/AIDStreatment,TBcare,VoluntaryCounsellingandTesting,andantenatalcareamongothers.Dedicatedpersonnelhavealoginandpasswordforaccess.Everyquarter,informationisuploadedonaflashdrive/centralhub,compiledandanalyzed.EachpatientisissuedwithaSmartCardthatstoresanindividual’shealthinformationandisallocatedwiththepatientnumber.

Thisallowscontinuityofcarebetweenvisits,healthservicesandhealthfacilities.Staffalsohaveflashdrivesforlower-technologyconnectivity.Theindividual'shealthrecordisalsostoredonthehealthfacilityinstallationdatabaseforbackupandgenerationoffacilitylevelandhealthmanagementinformationsystemreports.TheZambianMinistryofHealthhasinstalledSmartCareinover200facilities(clinicalanddistrict/provincial/nationallevels),inalldistricts,andpatientenrolmenttothesystemwasmorethan200,000in2008.


errors and problems occur in the most carefully conducted and monitored testing environments. The purpose of a quality system is to reduce and minimize errors in the total testing process. in order to meet this goal, each testing site should have a method to detect and resolve problems. it is important to understand root causes and to take corrective action.

Thefollowingstepsshouldbefollowedwhenadverseincidents,errors,andproblemsoccur:

Investigatetheerrororproblemtodeterminecause. Takeactiontoaddressthecauseoftheproblem.Correctiveactionsmayresult

inchangesinpolicyorprocedurestohelpensurethaterrorswillnotre-occur. Communicateappropriatelywithallthoseaffectedbytheerrororproblem,

forexample,nursingstaff,physicians,and/orclients. Keeparecordofallcircumstancesrelatedtotheerrororproblem.Alsokeep

arecordofcorrectiveactiontakenandanycommunicationswithaffectedpersons.Thisinformationisusefulforthosemonitoringthetesting,foranyinternalaudits,andforuseiffurtherenquiriesfrompatientsorphysicians

occur. TheQualityOfficerhastheresponsibilitytoensurethatthisprocessis

followed,includingallappropriatecorrectiveactionstaken.

10. occurrence Management


The key to a successful quality system is continuous improvement. an essential component of this process is assessment. Formal assessments may be external, performed by persons outside the laboratory or testing site, or they may be conducted by staff at the site and be internally managed.

Theregularperformanceofinternalqualityassessmentsandauditscanyieldagreatdealofimportantinformationabouthowwellthelaboratoryortestingsiteisfollowingitsqualitypoliciesandprocedures.Itcanalsohelptoidentifyproblemareas.Informationontheinternalauditprocessiswidelyavailable,andtheInternationalOrganizationforStandardizationdescribesaninternalauditprocessthatisusefulinlaboratories.Smallertestingsitescoulduseamoreinformalprocess.

Keyindicatorsthatshouldbecheckedtoassesstheperformanceofindividualfacilitieswithrespecttothequalitysystemsprogrammeinclude:

Numberoftestsorexternalcontrolmaterialsthatexpiredbeforeuseor occurrencesofexpiredtestsusedfordiagnosticorqualitycontrolpurposes.

Numberofdaysthattests/qualitycontrolmaterialswerestored/usedoutsideoftemperaturespecs.

Frequencyofexternalqualitycontroltestingcomparedwithtestsite procedure.

Frequencyofinvalid/incorrecttestresultswhenperformingexternalcontroltestingorpatienttesting.

Proportionofnegativeandpreliminarypositivepatientresults. Proportionofreactiverapidtestresultsconfirmedpositive. Healthcareworkers’abilitytomanagethecorrectiveaction(accordingtothe

localprogramme’salgorithm)followinganoutofrangeresult. Howtodocumentandverifycorrectiveaction Comparisonoftotalnumberofreactiverapidtestresultswithnumberof

confirmedpositiveresults.Ifresultingratiooffalse-positiverapidtestresultssuggeststhetestisnotperformingaccordingtothemanufacturer’sspecifications,qualityassurancemanagersshould:

- Evaluateexpirationdatesandtestingarea. - Reviewrecordsofexternalcontroltesting. - Performtroubleshootingaccordingtomanufacturer’sinstructions. - Evaluatefacilitytestingproceduresandifnecessary,modifyquality

assuranceprotocolorretrainstaff.Ifnecessary,informmanufacturer.

RefertoImplementation 4 ofthisToolkitforfurtherinformationonmonitoringthequalitysystem.

11. assessment


12. process improvement

process improvement is the action of revising a process based on information gathered and the identification and rectification of problems. as used in this model, process improvement involves identifying an area to study, collecting information, evaluating the information, and taking corrective action based on the findings. For example, a testing site might decide to study its turn-around time. Thiswouldrequirecollectingdataforaperiodoftime,analyzingthedata,evaluatingwhethertheturn-aroundtimeissufficientlyshort,andifnot,implementingsomestepstoshortenthetime.

AlltheseeffortsshouldbetheresponsibilityoftheQualityOfficer,whoshouldmanageallprocessesrelatedtoassessmentandprocessimprovement,andwhoshouldcommunicateresultsofallprojectstoboththesitestaffandtoappropriatehigherlevelmanagement.

Theadvantagesofprocessimprovementinclude:

Improvedprocessescanraisemoraleamongstaffandpatientsandcanfurthermotivatestaffinmaintainingahighlevelofqualitytestingand

diagnosis. Itcansetabenchmarkofperformancebeyondwhichsystem

improvementscanbemadecontinually. Availabledatacanbeusedtoidentifycurrentgapsthatneedtobe

addressed(evaluationofqualityindicators)


13. Business plan

decentralization of testing creates challenges in the assurance of both the quality of tests and of testing. National laboratories can play an important role in the provision of quality assurance, quality control and supervision in remote settings if adequate training can be provided on the manufacture, validation and shipment of proficiency panels in freeze-dried form. Agenericbusinessplanshouldbedevelopedtoallownationalprogrammestoestimatethecapitalinvestmentsupfrontandtherecurringcostsofmakingproficiencypanelsandmaintainingasystemofsupervisoryvisitstoremotesettingstoensurequalitytestingusingrapidsyphilistests.AsampleoutlineofabusinessplanforaQualityManagementSystemisprovidedonthenextpage.


Sample outline of a Business plan for a Quality Management System

1. What are your goals for a Quality Management System?

2. What is your design Concept for a Quality Management System?Includethefollowing:

ThetypeofQualityControlevents - Internalqualitycontrol - ExternalQualityAssessment - Re-testingofspecimens - IncomingInspection

Numberofsamplesperqualitycontrolevent Frequencyofqualitycontrolevents DocumentationsystemandDocumentControl Canitbeintegratedintoanexistingqualityprogrammeforotherdiagnostics?

3. Management & organization WhatHumanResourceRequirementsareneeded?Makealistofallpersonnelrequired,

includingroles,responsibilitiesandtimerequiredforeach: - ProgrammeManagement - LaboratoryPersonnel - Cliniclevel - Monitoringandsupervision

Doyouneedtodevelopcontractualagreementswithotherinstitutionsanddepartments(forMonitoringandEvaluation,Training,ManufacturingofDriedTubeSpecimens)?

DrawupanOrganizationChart

4. What operations requirements are needed? Locationandfacilities:

- Equipmentrequirements - Technologicaltools - Printedmaterials

Supplyanddistribution KeySuppliers HumanResourcePlan

5. Based on all of the above, draw up a Budget. What level of funding do you require for the Quality Management System? What are the financial commitments and who are they from?

6. What are your outputs for the Quality Management System? Performanceanalysis Correctiveactionsand/ortroubleshooting

7. What are your outcomes for the Quality Management System? Performancegrade,individual Performancegrade,facility

8. What are the Challenges or Risks facing a Quality Management System for your programme (e.g. high staff turnover, Regulatory changes) and list the Contingencies that can be put in place to overcome them.


WhatisaQualityManagementSystem?

Aqualitymanagementsystemtypicallyincludestheorganizationalstructure,resources,processes,andproceduresneededtoimplementqualitymanagement.TheseprinciplesincludecategoriessuchasDocumentsandRecords,Organization,Personnel,Equipment,PurchasingandInventory,ProcessControl,InformationManagement,OccurrenceManagement,ExternalandInternalAssessments,ProcessImprovement,andFacilitiesandSafety.

WhatisQualityAssurance?

WhatisQualityControl?

QualityAssuranceencompassesallproceduresandactivitiesdirectedtowardensuringthataspecifiedqualityofproductisachievedandmaintained.Inthetestingenvironment,thisincludesmonitoring:rawmaterials;supplies;instruments;procedures;samplecollection,transport,storageandprocessing;recordkeeping;calibratingandmaintenanceofequipment;qualitycontrol;proficiencytesting;trainingofpersonnel;andeverythingelseinvolvedintheproductionofthedatareported.

QualityControlisasetofproceduresundertakeninalaboratoryorclinicforthecontinuousassessmentofworkperformed.Itincludestheevaluationofteststodecidewhethertheyarereliableenoughforresultstobereleasedtotherequestinghealthcareproviderandpatient.

QualityControlincludestestingcontrolmaterials;chartingtheresultsandanalyzingthemtoidentifysourcesoferror;andevaluatinganddocumentinganycorrectiveactiontakenasaresultofthisanalysis.

WhatarethedifferentqualitycontrolprocessesthatIshouldundertakeattheclinicaspartofthequalitysystemforrapiddiagnostictesting?

internal Quality Controlistheevaluationoftestandoperatorperformancethatincludesqualitycontrolsamplesforwhichthetesterknowstheexpectedmeasurementresult.

external Quality assessment, or proficiency Testingistheevaluationoftestandoperatorperformancethatincludesasampleforwhichthetesterdoesnotknowtheexpectedmeasurementresult.Theprocessevaluatesthelaboratory’sorclinic’sperformanceonthetestingofsamplesofexternaloriginforthepurposesofdeterminingadequacyofthelaboratory’spre-test,test,andpost-testactivities.

Whatarethepossibleoutcomesofthequalitycontroltestingprocess?

Test results are within range:Recordresults:nofurtheractionisrequired.

Test results are outside range:Informthelab/healthcentresupervisor,whoshouldperformacorrectiveactiontofindthesourceoftheproblem.RefertoSection8ofthisdocumentforadviceoncorrectiveactionsandanexamplecorrectiveactionalgorithm.

Ifaninternalcontrolresultisoutsiderange,mayIcontinuereportingpatienttestresults?

No.Allpatienttestresultsgeneratedsincethelastcontrolswererunareinvaliduntiltroubleshootingtodeterminethesourceoftheproblemhasbeenundertaken.Everyeffortshouldbemadetoestablishtherootcauseoftheoutofrangetestresult,asitmaybecausedbyunstabletestreagentsoroperatorerrorsthatcanimpactonpatientdiagnosis.

14. Frequently asked Questions on Quality Systems


Whatisproficiencytesting?

Proficiencytestingisanexternalqualityassessmentprogramme,inwhichmultiplesamples(withinaproficiencypanel)areperiodicallysenttomembersofagroupoflaboratoriesorclinicsforanalysisand/oridentification.Eachlaboratory’sorclinic’sresultsarecomparedwiththoseofotherlaboratoriesandclinicsinthegroupand/orwithanassignedvalue,andreportedtotheparticipatinglaboratory/clinicandothers.

Whyisproficiencytestingimportant?

Proficiencytestingallowsfortheinternalmonitor,labdirectorandprogrammemanagertomonitorhealthcareworkerperformance.Proficiencytestinghelpstoensurethatallhealthcareworkersareabletoperformtherapiddiagnostictest,interprettheresultscorrectly,andcanhelpidentifyproblemswithhealthcareworkerperformanceoftherapiddiagnostictest.

WhatareDriedTubeSpecimens?

Driedtubespecimensareadriedformofserumorplasmawithknownserostatus.Becausetheyexistinpowderform,theyarecoldchainindependentanddonotrequirerefrigerationandsoaresuitableforproficiencytestingatparticipatinghealthcentresandlaboratories.Theycanalsobeusedasaninternalqualitycontrol.

DoItestmyproficiencypanelsamplesanydifferentlythanItestpatientspecimens?

No.Oncereconstituted,theproficiencytestingsamplesshouldbetestedinthesamemanneraspatientsamplesaretested.

MayIdiscussmyproficiencytestingresultswithanotherlaboratory/anotherhealthcareworker?

Youshouldnotdiscussyourproficiencytestingresultswithco-workers.Proficiencytestingisanassessmentofindividuallaboratories:clinicsandtestersshouldnotknowthesamplestatus.Proficiencytestingcanhelpidentifyhealthcareworkerswhomayrequireadditionalsupportortrainingfromthemonitor/supervisor.Itisimportantthattheresultsoftheproficiencytestingbehonestlyrecordedbythehealthcareworkerwhoperformedthetest.Theywillbeusedtoinformthelabdirectorandinternalmonitorsothattheycantaketheappropriateaction.

DoIneedtokeeprecordsofmyproficiencytesting?

Yes,youshouldkeepacopyoftheproficiencytestingrecordform,inadditiontoanyrecordsdetailingcorrectiveactionsperformedatyourlaboratoryorclinic.Bykeepingarecordofcorrectiveactionsperformed,similarproblemscanbepreventedinthefuture.

WhatmustIdoifIdonotgetapassingscore?

Ifaproficiencypanelspecimenfails,youwillbeinformedbythecentrallaboratoryandstepsshouldbetakentofollowuptherootcauseoftheproblem.Thisdoesnotmeanthatthehealthcareworkerdoesnotknowhowtoperformthetest,butthatthetestingprocedurewasnotoptimal.Proficiencytestingmayhavebeendoneduringhourswhentherewaslesslight,theremaynothavebeenenoughsampleadded,ortheremayhavebeenaanerrorinwritingthetestresultisthecorrectcolumnontherecordform.

WhatisIncomingInspectionandwhyisitimportant?

Incominginspectiontestingiscarriedoutoneachnewlotorshipmentofrapidtestkitsthatarrivein-countryfromthesupplier.Itensuresthevalidityandintegrityoftestkitsandlotsaftershipping.Testingcanbecarriedoutatthecentralorreferencelaboratoryandatthehealthcentretore-confirmvalidityfollowingshipment.

WhatshouldbetestedduringIncomingInspection?

Testkitsshouldbevisuallyinspectedtoensurethattherehasbeennodamagetothepackagingorleakages.Lot/Batchnumbersandexpirydatesshouldbecheckedandathereshouldbeavisualchecktoensurethatallreagentsandconsumablesareprovided.Inaddition,toensurethatthetestkitsarestillvalidfollowingshipmentfromthesupplier,arepresentativenumberoftestkitsshouldbetestedusingaknownnegativeorknownpositivecontrolatthecentralorreferencelaboratory.


CDC/WHO, 2005. Guidelines for Assuring the Accuracy and Reliability of HIV Rapid Testing: Applying a Quality System Approach

ManualonQualityAssuranceforLaboratorydiagnosisofmalaria:RapidDiagnosticTests.Availablefrom:

http://nvbdcp.gov.in/Doc/SOP-Quality-Assurance-RDT.pdf

CLSI GP26-A2 “Application of a Quality System Model for Laboratory Services

ISO 19011:2002 - Guidelines for Quality and / or Environmental Management System Auditing

Clinical Laboratory Improvement Amendments (CLIA) regulation requirements brochure. Available at: https://www.cms.gov/CLIA/05_CLIA_Brochures.asp#TopOfPage

15. References



http://nvbdcp.gov.in/Doc/SOP-Quality-Assurance-RDT.pdf

http://www.clsi.org/Content/NavigationMenu/Resources/QualityManualThirdEdition.pdf

http://www.iso.org/iso/catalogue_detail?csnumber=31169

http://www.iso.org/iso/catalogue_detail?csnumber=31169

https://www.cms.gov/CLIA/05_CLIA_Brochures.asp#TopOfPage


appendix 1. overview of country approaches to a Quality Management System for a Rapid Syphilis Test programme

Tanz

ania

peru

Uga

nda

Bra

zil

Zam

bia

inte

rnal

Qua

lity

Cont

rol

Wha

ttyp

eof

sam

ple

isu

sed

for

inte

rnal

qua

lity

cont

rola

tthe

clin

ic?

Drie

dTu

beS

peci

men

Nea

tPat

ient

Ser

um(l

iqui

d)+

Drie

dTu

beS

peci

men

Drie

dTu

beS

peci

men

Nea

tPat

ient

Ser

um(l

iqui

d)N

eatP

atie

ntS

erum

(liq

uid)

Wha

tis

the

freq

uenc

yof

inte

rnal

qu

ality

con

trol

dis

trib

utio

nto

clin

ics?

Ev

ery

mon

thEv

ery

mon

thto

eve

ry2

mon

ths

Ever

yw

eek

Varia

ble,

dep

endi

ngo

nav

aila

ble

tran

spor

t

Sam

ples

wer

eal

iquo

ted

into

one

use

vi

als

and

dist

ribut

edo

nce

toc

over

a6

m

onth

per

iod.

Wha

tis

the

mod

eof

tran

spor

tfor

di

strib

utio

nof

inte

rnal

qua

lity

cont

rols

fr

omth

ece

ntra

llab

orat

ory

toth

ecl

inic

?

Car

Via

netw

ork

coor

dina

tor

byp

ublic

tr

ansp

ort

Car

Airp

lane

and

boa

tC

ar

exte

rnal

Qua

lity

Cont

rol

Mat

eria

ls fo

r d

TS M

anuf

actu

re:

Wha

tis

the

sour

ceo

fpos

itive

and

ne

gativ

esa

mpl

es?

Patie

nts

ampl

esPa

tient

sam

ples

and

vol

unte

ers

Blo

odd

onor

clin

ics

cree

ned

atp

ublic

he

alth

labo

rato

rySa

mpl

esfr

omp

rison

inm

ates

Com

mer

cial

RP

Rc

ontr

ol

Wha

ttyp

eof

sam

ple

iso

btai

ned?

Seru

mW

hole

blo

oda

nds

erum

Seru

mW

hole

blo

odSe

rum

IsR

PR

use

dto

con

firm

ser

ums

ampl

est

atus

?Ye

sYe

sYe

sN

oYe

s

IsT

PPA

use

dto

con

firm

sam

ple

stat

us?

Yes

Yes

Yes

Yes

Yes

Isc

urre

ntte

stm

etho

d(o

rte

stu

nder

ev

alua

tion)

use

dto

con

firm

sam

ple

stat

us?

Yes

Yes

Yes

Yes

No

dTS

pro

ficie

ncy

pack

Con

tent

s

Wha

tis

cont

aine

din

the

DTS

P

rofic

ienc

yPa

ckth

atis

sen

tto

the

clin

ic?

4D

TSv

ials

,1x

via

lPT

buffe

r2

xpl

astic

tran

sfer

pip

ette

s1

xin

stru

ctio

nsh

eet,

1x

repo

rtin

gfo

rm

2D

TSv

ials

for

IQC

,4D

TSv

ials

for

EQA

1x

vial

PT

buffe

r,1

xp

last

ictr

ansf

er

pipe

tte1

xin

stru

ctio

nsh

eet,

1x

repo

rtin

gfo

rmC

asse

ttes,

glo

ves,

cap

illar

ies,

te

ckno

por

rack

4D

TSv

ials

1x

vial

PT

buffe

r5

xpl

astic

tran

sfer

pip

ette

s1

xin

stru

ctio

nsh

eet

1x

repo

rtin

gfo

rm

6D

TSv

ials

1x

vial

PT

buffe

r2

xpl

astic

tran

sfer

pip

ette

s1

xin

stru

ctio

nsh

eet

1x

repo

rtin

gfo

rm

6D

TSv

ials

1x

vial

PT

buffe

r2

xpl

astic

tran

sfer

pip

ette

s1

xin

stru

ctio

nsh

eet

1x

repo

rtin

gfo

rm

How

man

ysc

hem

esfo

rdi

strib

utio

nto

he

alth

cen

tres

are

pla

nned

per

yea

r?6

2-

124

Opp

ortu

nist

ic1

oth

er

How

man

yD

ried

Tube

Spe

cim

ens

per

profi

cien

cyp

anel

?4

2-

44

66

How

man

yvi

als

ofe

ach

pane

lmem

ber

are

prep

ared

ato

neti

me

atth

ece

ntra

lla

bora

tory

?60

Max

imum

:250

5015

020

How

long

doe

sit

take

tom

anuf

actu

rea

ba

tch

ofD

TSs

peci

men

s?3

days

3da

ys1

day

2da

ys2

days

Who

sco

res

the

reco

rdfo

rm?

Lab

tech

nici

ans

atc

entr

alla

bIn

tern

alm

onito

rIn

tern

alm

onito

r/D

istr

ictL

ab

supe

rvis

orLa

bte

chni

cian

sat

cen

tral

lab

Lab

tech

nici

ans

atc

entr

alla

b

Wha

tis

the

cut-

offa

vera

ges

core

be

low

whi

chc

orre

ctiv

eac

tions

mus

tbe

carr

ied

out?

≤75%

100%

≤7

5%≤

90≤

67%

Wha

tare

the

corr

ectiv

eac

tions

whe

na

heal

thc

are

wor

ker

scor

esle

ssth

an

the

acce

ptab

lele

velo

fagr

eem

ent

stat

edin

D6.

15?

On-

the-

job

re-t

rain

ing

byin

tern

al

mon

itor

Con

sulta

tion/

Cou

nsel

ling

Re-

test

us

ing

fres

hre

agen

tsR

e-tr

aini

ngR

e-te

stu

sing

fres

hre

agen

ts

Re-

trai

ning

Re-

trai

ning

Re-

trai

ning

Wha

tis

the

expi

ryd

ate

follo

win

gD

TS

man

ufac

ture

ifs

peci

men

sar

eke

pta

tro

omte

mpe

ratu

re)?

1m

onth

n/a

1m

onth

1m

onth

6m

onth

s

iNCo

MiN

G iN

SpeC

Tio

N

Isin

com

ing

insp

ectio

npe

rfor

med

at

the

cent

rall

abor

ator

yfo

rea

chn

ew

ship

men

tor

loto

fkits

toe

nsur

eth

eir

valid

ity?

Ever

ylo

tEv

ery

ship

men

tEv

ery

ship

men

tN

otP

erfo

rmed

Ever

ysh

ipm

ent

How

man

ysa

mpl

esa

rete

sted

for

inco

min

gin

spec

tion?

1Po

sitiv

e,1

Neg

ativ

e1

Posi

tive,

1N

egat

ive

,1w

eak

posi

tive

2Po

sitiv

e,2

Neg

ativ

e,2

wea

kpo

sitiv

en/

a4

Posi

tive,

4N

egat

ive

Wha

tis

the

repr

esen

tativ

enu

mbe

rof

te

std

evic

este

sted

?1%

ofa

llte

sts

rece

ived

Ther

eis

no

reco

rdfo

rth

isb

utit

cou

ld

bea

roun

d3-

5%1%

ofa

llte

sts

rece

ived

n/a

1%o

fall

test

sre

ceiv

ed

Isa

pro

port

ion

ofe

ach

kitl

ot/s

hipm

ent

reta

ined

atc

entr

alla

bora

tory

?N

oYe

sYe

sn/

aYe

s

Ifye

s,w

hat%

ofs

tock

isre

tain

ed?

1%1

test

kit

n/a

1%


appendix 2. Summary flow chart of a Quality Management System in place for Rapid Syphilis Testing in country

Cen

tral

labo

rato

ryM

onito

r/

Supe

rvis

or/

Coo

rdin

ator

Clin

ic/h

ealt

h po

st

DTS

Man

ufac

ture

Obt

ain

neat

se

rum

Rec

ordi

ng

resu

lts

Cha

ract

eriz

esa

mpl

esu

sing

re

fere

nce

met

hod

Pre

para

tion

of

pool

eds

erum

Aliq

uotD

TSin

B

SC

Pac

kage

DTS

se

rum

for

dist

ribu

tion

Inco

min

gin

spec

tion

Inte

rnal

QC

1kn

own

nega

tive

1kn

own

posi

tive

Seru

m

Rec

onst

itutio

n

Rec

ordi

ngre

sults

Rec

ordi

ngre

sults

Test

ing

Test

ing

Rec

onst

itutio

n

DTS

DTS

Exte

rnal

Qua

lity

As-

sess

men

t/P

rofic

ienc

yP

anel

(Dri

edT

ube

Spec

imen

)

Col

lect

sub

seto

fpo

sitiv

e&

neg

ativ

esp

ecim

ens

(5-1

0%)

for

re-t

esta

tce

ntra

llab

Rev

iew

of

Qua

lity

Con

trol

R

ecor

ds

1kn

own

nega

tive

+1

know

npo

sitiv

eon

are

pres

enta

-tiv

esa

mpl

eof

in

com

ing

kits

EQA

Re-

Test

(With

refe

r-en

cem

etho

d)

Tra

nspo

rtD

TSfr

omc

entr

alla

bto

cl

inic

Ret

urn

spec

imen

sto

lab

from

clin

icfo

ran

alys

isC

olle

ctio

nof

pos

itive

&n

egat

ive

pa-

tient

ser

aat

clin

icfo

rre

-tes

tatc

entr

al

lab

(EQ

A)C

olle

ctio

nof

qua

lity

cont

rolr

ecor

ds

from

clin

icto

cen

tral

lab

and

com

mu-

nica

tes

core

sfr

omc

entr

alla

bto

clin

icC

orre

ctiv

eAc

tions

&T

roub

lesh

ootin

gfo

rno

n-co

nfor

min

gre

sults

per

form

ed

atc

linic

acc

ordi

ngto

adv

ice

from

ce

ntra

llab

Feed

back C

orre

ctiv

eac

tion


intended Use

TheSDBiolineSyphilis3.0testisasolidphaseimmunochromatographicassayforthequalitativedetectionofantibodiesofalisotypes(IgG,IgM,IgA)againstTreponemapallidum.Thistestmethodisintendedforprofessionaluseasanaidinthediagnosisofsyphilis.

principle of the procedure

TheSDBiolineSyphilis3.0containsamembranestripwhichispre-coatedwithrecombinantTreponemapallidumantigens(17,15KDa)onthetestbandregion.Whenthepatientsamplewithsamplediluentisaddedtothesamplewell,itmoveswiththerecombinantTreponemapallidumantigen-colloidgoldconjugate(17,15KDa)alongthemembranechromatographicallytothetestregion(T)andformsavisiblelineastheantigen-patientantibody-antigengoldparticlecomplexforms.Theformationofavisiblelineinthetestregion(T)indicatesapositiveresultforthedetectionofTreponemapallidumspecificantibodies(IgG,IgAandIgM).WhentheTreponemapallidumspecificantibodies(IgG,IgAandIgM)areabsentinthesample,thereisnovisiblecolourbandinthetestregion(T).

kit Contents

■■ SDBioline3.0testdevice■■ EachtestdevicecontainscolloidalgoldconjugatedtorecombinantT.pallidum

antigen(17,15KDa)ontestlineandcontrolline■■ 1bottleofAssayDiluent■■ Disposablespecimendroppers■■ InstructionsForUse

Materials required but not provided with the kit

■■ Gloves■■ Timerorstopwatch■■ Bloodcollectiondevices(lancets,capillarytubes,testtubes)

Storage and Stability

1. Thetestdeviceshouldbestoredatroomtemperature.2. Thetestdeviceissensitivetohumidityandheat.Performthetestimmediately

afterremovingthetestdevicefromthefoilpouch.3. Donotusebeyondtheexpirationdate4. Theshelf-lifeofthekitisindicatedontheouterpackage.5. Donotusethetestkitifthepouchisdamagedorsealisbroken.

appendix 3. example of a Standard operating procedure: Work instructions for use of standard diagnostics bioline syphilis 3.0 rapid test


precautions

1. TheSDBiolineSyphilis3.0Testisintendedforinvitrouse.DONOTRE-USEtestdevice

2. Theinstructionsforusemustbefollowedexactlytogiveaccurateresults.Personnelperformingthetestmustbetrainedinitsuseandmustbeexperiencedinlaboratoryprocedures.

3. Collectwholebloodusingasuitablecoagulant,andcentrifugewholebloodtoobtainplasmaorserumspecimen.

4. Ifspecimensarenotimmediatelytested,theyshouldberefrigeratedat2-8°C.Forstorageperiodsgreaterthanthreedays,freezingisrecommended.Theyshouldbebroughttoroomtemperaturebeforeuse.

5. Specimenscontainingprecipitatemayyieldinconsistenttestresults.Suchspecimensshouldbefilteredpriortoassaying.

6. Wholebloodmaybeusedfortestingimmediatelyormaybestoredat2-8°Cforuptothreedays.

7. Testresultsarenotaffrectedbyanticoagulantssuchasethylenediaminetetraaceticacid(EDTA),heparinorcitrate.

8. Interferencefromhaemolyticsamples,rheumatoidfactor-containedsamples,lipemicsamplesandictericsamplescanimpairtestresults.

9. Useseparatedisposablepipettesorpipetteyipsforeachsamplesinordertoavoidcrosscontaminationofsamples,whichcouldleadtoerroneousresults.

10. Donoteatorsmokewhilehandlingspecimens.11. Wearprotectivegloveswhilehandlingspecimens.Washhandsthoroughly

afterwards.12. Avoidsplashingoraerosolformation.13. Cleanupspillsthoroughlyusinganappropriatedisinfectant.14. Decontaminateanddisposeofallspecimens,reactionkitsandpotentially

contaminatedmaterialsasiftheywereinfectiouswasteinabiohardouscontainer.

15. Donotmixandinterchangedifferentspecimens.16. Careshouldbetakentoavoidcontaminationoftheendofthebottlewhen

droppingassaydiluentintosamplewell.

Quality Control

GoodLaboratoryPractice(GLP)requirestheuseofcontrolspecimenstoensureproperdeviceperformanceatleastoncedaily.

Abuiltinproceduralcontrolonthetestdeviceindicatesthatthetestisfunctioningcorrectly.Apurplebandshouldalwaysappearatthecontrolwidow.

InternalandExternalcontrolsshouldberundailypriortoanalyzingpatient/clientspecimens.Resultsshouldberecordedonthequalitycontrollog.Patient/clientreportsshouldonlybereportedifqualitycontrolresultsareacceptable.


Test procedure

1. Removethetestdevicefromthefoilpouch,andplaceitonaflat,drysurface.2. Transferthespecimenbypipetteordropper:

a.Touseapipette:Transfer10µlofserumorplasma(or20µlofwholeblood)tothesamplewell(S)ofthetestdevice,thenadd3-4dropsofassaydiluent(approximately110µl)andstartthetimer.b.TouseaDisposableSpecimenDropper:Holdthedroppervertically,drawthespecimen(serumorplasma)uptotheFillLine(approximately10µl).Transferthespecimentothesamplewell(S)ofthetestdevice.Inthecaseofwholeblood,drawandtransferthespecimenbythesamemethodtwice(approximately20µlintotal)andthenadd3-4dropsofassaydiluent(approximately110µl)andstartthetimer.

3. Asthesamplemoveschromatographicallyalongthetestmembrane,apurplecolourcanbeseenintheresultwindowlocatedinthecentreofthetestdevice.

4. Theresultshouldbeinterpretedwithin5-20minutesofadditionofthesample.Apositivesamplewillnotchangeonceithasbeenestablishedafter20minutes.However,inordertopreventanyincorrectresults,theresultshouldnotbeinterpretedafter20minutes.

5. Whenwholebloodisused,thetestresultshouldbeinterpretedwithin10minutes.Caution:Theaboveinterpretationtimeisbasedonreadingthetestresultatroomtemperature.Ifroomtemperatureissignificantlylowerthan10°C,theinterpretationtimeshouldbeextendedtoafurther10minutes.

interpretation of Test Results

6. Acolourbandwillappearintheleftsectionoftheresultwindowtoshowthatthetestisworkingproperly.ThisbandistheControlBand(C)

7. Therightsectionoftheresultwindowindicatesthetestresult.ThisistheTestBand(T).

Negative Result:ThepresenceofonlyonepurplecolourbandintheControl(C)regionoftheresultwindowindicatesanegativeresult.positive Result:IfacolourbandappearsinControl(C)regionandTest(T)region,thetestresultispositiveforTreponemaPallidumantibodies.

invalid result:IfthepurplecolourbandisnotvisibleintheControl(C)regionafterthetesthasbeenperformed,theresultisdeemedinvalid.Itisrecommendedthatthespecimenbere-tested.


limitations of the Test

1. SDBiolineSyphilis3.0testprocedureandinterpretationofresultsmustbefollowedcloselywhentestingforthepresenceofsyphilisantibodiesinserum,plasmaorwholeblood.

2. TheSDBiolineSyphilis3.0testwillonlyindicatethepresenceofTreponemaPallidumantibodiesinthespecimenandshouldnotbeusedasthesolecriteriaforthediagnosisofTreponemaPalliduminfection.

3. Aswithalldiagnostictests,allresultsmustbeinterpretedalongsideotherclinicalinformationavailabletothephysician.

4. Ifthetestresultisnegativeandclinicalsymptomspersist,additionaltestingusingotherclinicalmethodsisrecommended.AnegativeresultdoesnotatanytimeprecludethepossibilityofTreponemaPalliduminfection.


1.0 Purpose

Thisprocedureprovidesinstructionsonthemanufactureofdriedtubespecimenstobeusedasaqualitycontrolaspartofaproficiencytestingprogramme.

2.0 Equipment and Materials

2.1 equipment

■■ Multi-channelPipettes■■ Biosafetycabinet(BSC)■■ Timer■■ RPRRotator

2.2 Materials

■■ 2.0mLconicalbottomSarstedttubes■■ TrypanBluedye(0.1%stocksolution)■■ Pipettetips■■ Disposabletransferpipettes■■ Freezerboxes■■ Tuberacks■■ Cryolabels■■ Storagebottles■■ Ziplockbags■■ Labels■■ 5mLdisposablesyringes■■ Disposablefilterunit0.2µl■■ Rapidplasmareaginkits■■ TreponemaPallidumParticleAgglutinationassay/TreponemaPallidum

Haemagglutinationassaykits■■ PhosphatebufferedsalinewithTween20(Sigma)

3.0 Handling Conditions

■■ Wearprotectiveclothingwhilehandlingdriedtubespecimens■■ Handledriedtubespecimensasifcapableoftransmittinganinfectiousagent■■ Donotinterchangevialcaps,asthismayleadtocrosscontaminationof

specimens■■ Leavethedriedtubespecimensinthebiosafetycabinet(BSC)for

overnightdrying

appendix 4. protocol for preparation of dried tube specimen


4.0 Procedure

4.1 plasma/Serum selection

■■ Obtainrejectedplasmaunitsfromthelocalbloodbank,serafromthediagnosticlaboratorywithahighsyphilistitre(RPRtitre±1:128)andsomeRPRnegatives.Storespecimensat2-8°Cuntilfurthertestinghasbeenconducted.■■ VerifythedilutionsusingTreponemaPallidumParticleAgglutinationassay/

TreponemaPallidumHaemagglutinationassayandrapidplasmareaginaccordingtomanufacturers’instructionsandincludingpositiveandnegativecontrolsinthetestrun.

4.2 dilution of serum/plasma

■■ Selecttheserum/plasmafromahightitresource■■ Titratetheserumusingrapidplasmareagin,initiallyby10-folddilutions,then

by2-folddilutioninanegativeserum■■ Makea4-folddilutionofthestrongestpositiveseruminnegativeserumto

yieldamediumpositive■■ Makea4-folddilutionofthemediumpositiveinnegativeserumtoyielda

faintpositiveserum■■ Notethedilutionsgivingtheseresults■■ VerifythedilutionsusingTreponemaPallidumParticleAgglutinationtest/

TreponemaPallidumHaemagglutinationtechniqueandrapidplasmareaginaccordingtomanufacturers’instructionsandincludingpositiveandnegativecontrolsinthetestrun.■■ Selectdilutionsthatrepresentahightitredandalowtitteredsample,based

onthesample/cut-offratios.

4.3 preparation of dried Tube Specimens

4.3.1 Preparea1:1000dilutionofTrypanBlue:Serum,e.g.add1µLofdyeto1mLofspecimen.Vortexthespecimentomixthedye.4.3.2 Transfer20µLofTrypanblue-serum/plasmasolutiontoeachSarstedttube.Tubesshouldbelabelledwithspecimenidentificationandexpirydate.4.3.3 Leavethetubesuncappedandallowtodryovernightinabiosafetycabinet,ensuringthatdifferentspecimensarekeptinseparateracksintheBSCThefollowingday,ensurethatallspecimensarethoroughlydriedbeforecappingeachtube.4.3.4 Avisiblecolouredpelletshouldhaveformedinthebottomofthetube.Storethecappeddriedtubespecimensat2-8°Cuntilreadyforshippingtoparticipatinglaboratories.


4.4 preparation of dST buffer (pBS/Tween-20)

4.4.1 DissolveonefoilpouchofphosphatebufferedsalinewithTween20,Ph7.4in1Lofdeionisedwater.4.4.2 Filterthesolutionthrougha0.2µmfilterflask4.4.3 Prepare1.8mLaliquotsofProficiencyTestingbufferinpre-labelled2mlscrewcappedtubes4.4.4 Labelthetubestheidentification“ProficiencyTestingbuffer”,withanexpirydateof1year.

4.5 preparation and packaging of dried Tube Specimen panels

4.5.1 Createapanelofatleast6samplesfromthecharacterizedspecimenswithacombinationofgradesofreactivityforsyphilis,includingtrulyhightitrepositivesandnegatives.4.5.2 Carefullyblindthepanelassigninganewidentification(ID)toeachsample,e.g.DTS-A1toDTS-A6.EnsurethereistraceabilitybetweentheoriginalIDandnewID.4.5.3 LabeleachtubewiththeappropriatenewID.Dependingonthenumberoflaboratoriesenrolledintheproficiencytestingprogramme,prepare10to20extrasetsandstoreatthecentrallaboratory.4.5.4 Proficiencypanelsforshippingtoparticipatinglaboratoriesshouldcontain:–Onememberofeachpanel–OnevialofProficiencyTestingbuffer–Twoplastictransferpipettes(dropper)–Oneinstructionsheet–Onereportingform4.5.5 Putallcontentsintoaziplockbaglabelledwithidentification,expirydateandstorageconditions.4.5.6 ThebaggedProficiencyPanelscanbestoredat2-8°Cuntilshipmentordeliverytotestingsites.

4.6 Reconstitution of dried Tube Specimens

4.6.1 Tapthedriedtubespecimentubegentlytoensurethatthecoloredpelletfallstothebottomofthetube.4.6.2 Usingthedropperprovided,add7dropsofproficiencytestingbuffertoeachdriedtubespecimentobetested.Coverthetube,tapgentlyandleaveovernightatroomtemperature.4.6.3 Thefollowingday,mixthespecimenbygentlytappingthetube.Testthere-constituteddriedtubespecimenwiththeappropriatesyphilistests.Reporttheresultsusingthereportformprovided.

4.7 Results analysis

4.7.1 Collectreportfromallparticipatinglaboratories.4.7.2 EnterdataintheExcelspreadsheet.4.7.3 Analyzethedataandsubmitfinalreporttoalltheparticipatinglaboratories.4.7.4 Followupwithsupervisorand/oradditionaltrainingforthoselaboratorieswhodonotreceivea100%agreement.


appendix 5. dried Tube Specimen Testing instructions diagram


1.0 Purpose

Thisprocedureprovidesinstructionsformakingasupplyoftreponemalantibodypositivesamplesatthedesiredreactivitylevel,tobeusedasadailycontroloraspartofaproficiencytestingpanel.

2.0 Equipment and Materials

2.1 equipment

■■ MagneticStirrer,Non-Heated■■ SinglechannelPipettes(0.05–20µl,50-200µl)■■ Multi-channelPipettes(0.5–20µland50-300µl)■■ VacuumPump■■ TubingforVacuumPump■■ Waterbathorincubator■■ Thermometer■■ TreponemaPallidumParticleAgglutinationassay/TreponemaPallidum

Haemagglutinationassay/Enzyme-linkedimmunosorbentassay(ELISA)equipment:e.g.reader,washer

2.2 Materials

■■ Unit(BloodTypeGroupO)oftreponemalantibodypositiveserum■■ Unit(BloodTypeGroupO)oftreponemalantibodynegativeserum ■■ SterilizingFilters,.22micron■■ Cryogenicvials,polypropylene,1.0ml(forstorageofaliquots)■■ Cryovialstorageboxes■■ BrainHeartInfusion(BHI)Broth(readytouseintubes)orBrainHeart

Infusionpowderandmaterialstopreparetubesofbroth.■■ Sterilescrewcaptubes,16x125(forBrainHeartInfusionbroth,ifneeded)■■ Non-sterileplastictubes,polypropylene12x75(forserialdilutions)■■ GlassStir-rods■■ Pipettetips■■ IndividuallyWrappedSterilePipettes(1.0,5.0,10.0,25ml)■■ Discardorwastecontainers■■ Disinfectant■■ Autoclavebags■■ Glovesandlabcoats

3.0 Handling Conditions

■■ Unitsoftreponemalantibodypositiveserumshouldbestoredat2-8oC.■■ Followgoodlaboratorysafetypracticeswhenhandlingallsamples■■ Properlydisposeofcontaminatedwasteaccordingtoestablishedwaste

disposalprocedure.

appendix 6. protocol for preparing Syphilis – positive Quality Control Materials


4.0 Overview of Process

4.0.1 Calculatesufficientvolumerequiredforoneyearsupplyofready-to-usealiquots,andanadditionalbulkvolumeforfreezingandstoringforfutureuse,e.g.,250mlofserumwillyield500aliquotsof0.5ml.4.0.2 Obtaintreponemalantibodypositiveandtreponemalantibodynegativesera.ConsidertheNationalBloodTransfusionServiceasonepotentialsourceofsera.4.0.3 Heatinactivatepositiveseraandnegativesera4.0.4 Filterandsterilizepositiveandnegativesera4.0.5 Titratetreponemalantibodypositivesera4.0.6 Toselectdesiredtitreofsample,performTreponemaPallidumHaemag-glutinationtechnique/TreponemaPallidumParticleAgglutinationtest/Enzyme-linkedimmunosorbentassaytest4.0.7 Preparebulkvolumeofselectedtitre4.0.8 Validateresultsofbulkvolume4.0.9 Aliquot,label,andstore4.0.10 Performhomogeneityandstabilitytesting4.0.11 Maintaindatalogsandrecords

5.0 Stepwise Procedure

5.1 Calculate volume required

Calculatethetotalvolumeofsamplerequiredbeforebeginningproductiontoensurethatsufficientmaterials/reagentsareavailable.Thevolumerequiredmaydependonanumberoffactors:

■■ Howlongthepooledserumisneeded,e.g.12months■■ Howoftenthesyphilistestisperformed■■ Thesamplevolumerequiredbythetest■■ ThenumberofparticipatinglaboratoriesinyourProficiency

TestingProgramme■■ Approximately10%overagefordetermininghomogeneityandstabilitytesting

5.2 obtain syphilis positive and negative sera

ObtainaunitofsteriletreponemalantibodypositiveandtreponemalantibodynegativeserumfromTypeOdonors.Note:Oneunityieldsapproximately400mlofserum.

■■ BothunitsshouldbenegativeforHepatitisBsurfaceantigen(HBsAg)andHIVantigen.■■ Bothunitsshouldbenon-haemolysed,non-lipaemic,andfreeof

particulatematerial.■■ ThetreponemalantibodypositiveunitshouldhaveahighTreponema

PallidumHaemagglutinationtechnique/TreponemaPallidumParticleAgglutinationtest/Enzyme-linkedimmunosorbentassayantibodytitre(6–8Xtestcut-off).


5.3 heat inactivate treponemal antibody positive and negative sera

5.3.1 Heat-inactivatethetreponemalantibodypositiveandnegativeunitsat62°Cfor20minutesinawaterbath.5.3.2 Ifawaterbathisnotavailable,placetheunitofseruminsidealargeglasscontainerofwaterinanincubatorsetto75°Cfor20minutes.5.3.3 Placeathermometerinthewaterandmonitorariseintemperatureto62°C.5.3.4 Placetheunitoftreponemalantibodypositiveseruminthewater.5.3.5 Continuetomonitorthetemperatureofthewaterandwhenitagainreaches62°C,timefor20minutes.

5.4 Filter and Sterilize sera

5.4.1 Usingsteriletechnique,filtertheheat-inactivatedserumthrougha0.22micronsizedsterilefilterintoasterileenclosedpolypropylenecontainer.5.4.2 Usingsterilepipettesandsteriletechniqueinoculate3-4tubesofBrainHeartInfusionBrothwith100µloftheheat-inactivated,filteredserumandincubateat37°Cfor7days.5.4.3 Storetheremainderofthetreponemalantibodypositiveheat-inactivated,filteredserumat2-8°C.5.4.4 Usingsteriletechnique,filterthetreponemalantibodynegativeserumthrougha0.22micronsizedsterilefilterintoasterileenclosedcontainer.5.4.5 Usingsterilepipettesandsteriletechnique,inoculate3-4tubesofBrainHeartInfusionBrothwith100µlofthefilteredtreponemalantibodynegativeserumandincubateat37°Cfor7days.5.4.6 Storetheremainderofthetreponemalantibodynegativefilteredserumat2-8°C.5.4.7 Attheendof7days,checkthebrothsforturbidity.Ifnoturbidityexistsinanytubes,begintitrationofthetreponemalantibodypositiveserum.

5.5 Titrate treponemal antibody positive sera (determine desired dilution)

Atitrationisconductedasfollows:5.5.1 Makeaninitial10-folddilutionoftheantibodypositiveserumbyadding0.1mlofthepositivesera,and0.9mlofnegativeserumtotube1.5.5.2 Pipette0.50mlofantibodynegativeserumintotubes2-12.5.5.3 Make2-folddilutionsintubes2-12bymixingandtransferring0.50mloffromtube1totube2.5.5.4 Continuemixingandtransferring0.50mlthroughthelasttube,endingwithadilutionof1:20,480.

5.6 perform a Treponema pallidum haemagglutination assay/ Treponema pallidum particle agglutination assay or enzyme-linked immunosorbent assay test to select desired titred sample

5.6.1 PerformaTreponemaPallidumHaemagglutinationassay/TreponemaPallidumParticleAgglutinationassay/treponemalEnzyme-linkedimmunosorbentassayfollowingthemanufacturer’sinstructionsandyourstandardoperatingprocedure.5.6.2 Inaccordancewiththemanufacturer’sinstructions,includekitpositiveandnegativecontrolsinthetestrun.


5.6.3 Testeachtitratedsample,andtheoriginalsamplefromwhichdilutionsweremade,intriplicate.5.6.4 BasedontheSample/Cut-offratiosobtainedinEnzyme-linkedimmunosorbentassaytestsorthetitreobtainedinTreponemaPallidumHaemagglutinationassay/TreponemaPallidumParticleAgglutinationassayscalculatedforthetreponemalantibodypositivedilutedsamples,selectdilutionsthatrepresentahightitreandalowtitresample.Generally,alowtitrepositivehasanS/Coratioof2–3andahightitrepositivehasanS/Coratioof5–6whenELISAtestingisusedandtitresof1:160–1:320,and1:1280-1:2560.5.6.5 Plottheresultsobtainedagainstthesampledilutionsandcalculateappropriatedilutionstoobtainlowandhightitrepositivesera.5.7 prepare Bulk Volume

5.7.1 Choosetheappropriatedilutionsforhightitreandlowtitrepositivesamplestodeterminethevolumeofsamplesuitableforyourpurpose.Forexample,if500mlisneededandthe1:2560dilutionwasselectedasthehightiteredsample,add200µlofthebulkantibodypositiveserumto512mloftheantibodynegativeserum.Useasterilecontainerwithalidtocontainthedilutionsforthebulksamples.5.7.2 AddapreservativesuchasBronidox(0.5%),tothefinaldilutedserum,e.g.0.5mlsto500mlsofdilutedcontrol.Checkthepackageinsertoftheassayforwhichthequalitycontrol/proficiencytestingsampleistobeused,toensurethatthepreservativeisappropriateandwillnotinterferewiththeperformanceoftheassay.5.7.3 Placethedilutedserumonamagneticstirrerinabiohazardcabinetandmixforatleastonehourtoensurehomogeneityofthedilutedserum.

5.8 Validate results of pooled serum

Re-testusingthesametreponemalassaytovalidatetheresultsofthedilutedbatchesofserum.ComparetheseresultsofthebatchwiththeinitialTreponemaPallidumHaemagglutinationtechnique/TreponemaPallidumParticleAgglutinationtest/Enzyme-linkedimmunosorbentassayresults.

5.9 aliquot, label, and Store

5.9.1 Ifresultsofthere-testareacceptable,aliquotappropriate(smallworking)volumes,e.g.0.5-1.0mlfromthehighpositiveandthelowpositivebatchesintosterileinternalthreaded,polypropylenevialswithsiliconO-ringsinthecaps.5.9.2 Storethevialsandremainingbulkvolumeinwelllabeledcontainersat-80°Cuntilneeded.Aliquotsstoredat4°Cshouldbediscardedafteroneweek.

5.10 perform homogeneity and stability testing

5.10.1 Toensurethatthepooledserumhasbeenwellmixedandhomogenous,randomlyselectapproximately10%oftotalaliquots.Testthesesamples,andcompareresultswithtargettitres.ThebatchofpooledserumisacceptableiftheCoefficientofVariationoftheresultsislessthan15%.5.10.2 Tovalidatethestabilityofthelevelofreactivityofthepooledserum,placealiquotsofthesampleat-20°C,4°C,androomtemp(15-25°C),Testthesamplesat7,14,21,and28days.Reviewtheresultsobtainedateachtemperature.Thebatchofpooledserumisconsideredstableifthetitresfallwithin±2standarddeviationsoftheoriginalresults.


k

it: _

____

____

____

___

lot #

:___

____

____

____

_ ex

pira

tion

dat

e: _

____

____

____

___

dat

eN

egat

ive

Con

trol

R

esul

t

Neg

C

ontr

ol

lot #

acc

epta

ble?

Y / N

posi

tive

Con

trol

R

esul

tlo

w p

os

pos

pos

Con

trol

lot #

slo

w p

os

pos

acc

epta

ble?

Y / N

initi

als

Rev

iew

ed b

y&

dat

e

Cor

rect

ive

act

ions

dat

ea

ctio

n Ta

ken

initi

als

Rev

iew

ed b

y &

d

ate

appendix 7. daily Record of Quality Control Results


Ifre-testingisusedasawaytoconductexternalqualityassessmentforrapidsyphilistesting,thereareanumberofaspectstobeconsideredwhendeterminingandimplementingnational(orlocal)policy.

Collection of samples for retesting

Appendix8providestablesandguidancefortheselectionoftheappropriatesamplesizeforre-testing.Thenumbersshowninthetablescanbeappliedtoanytimeperiod:countrieswillneedtoselecttheappropriateperiod,balancingtheneedforareasonablere-testsamplesizeagainsthowfrequentlyperformanceneedstobeevaluated.Forexample,optingtodoyearlyre-testsmaymakeitfeasibleforareferencelaboratorytotesttherequirednumberofspecimens,butitseemsunreasonablyspreadoutforthepurposeofdetectingpotentialperformanceproblems.Anintervalofthreemonthsbetweenre-testsmay,insmallersites,resultinaverylargenumberofrepeatspecimens,butitwouldprovideamorefrequentsnapshotoftheperformanceofthesite.Insummary,there-testsamplesizerequiredforstatisticalvalidityandthetimeperiodtobeusedformeasurementmustbedeterminedbaseduponpracticalityandsustainability.

Whereverpossible,thesamplescollectedforre-testingshouldberandomlyselectedanddistributedthroughoutthetestingperiod.Thiswillallowthere-testingexternalqualityassessmenttobemorerepresentativeofthetestingprocess.

Inasitewheremultiplestaffperformtesting,itislogisticallydifficulttoarrangetohaveaseparatesampleforeachindividual.Butifthere-testingistoberepresentativeoftheperformanceoftheentiresite(i.e.ofallpersonswhoperformtesting),itisimportanttoensurethatsamplescollectedforre-testingrepresentasmanystaffmembersaspossible.

Insomeareas,avenousspecimeniscollectedfortestingwitharapidplasmareaginorrapidsyphilistestkit.Inthisinstance,therecanberetrospectiveselectionofspecimensforarandomsample.

Whenthismethodisused,allspecimensmaybealiquotedandstored.Later,arandomselectionprocessisusedtodeterminewhichspecimenstore-test.Alternatively,theselectionmaybedonefirst,andonlytheselectedspecimensaliquotedandstored.

Venousbloodcollectionmayalsobecarriedoutatsitesthatperformsyphilisrapidtestingwithafingerprick.Inthiscase,prospectiveidentificationoftheclientstobetestedisrequired.

Recording information and transporting re-testing samples

Itisimportanttomaintainpatientconfidentialityinthere-testingprocess.Itisrecommendedthatalaboratoryregisterorspecimennumberbeusedwhensendingsamplesfromtheoriginaltestingsitetothereferencelaboratoryforretesting.

appendix 8. – external Quality assessment of Syphilis Rapid Tests: operational issues for re-testing


Distributingthere-testingworkloadforthereferencelaboratorywillhelptoavoidworkoverloadanddelaysinreturningresultstothetestingsite.Thiswillrequireapreplannedscheduletoensurethatre-testspecimensreachthereferencelaboratoryatspacedintervals.Frequenttransport,acontinuousre-testingprocessandpromptfeedbackofresultswillhelptoassuretimelymonitoringofperformanceandpromptalertswhenproblemsaredetected.

Finally,caremustbetakentoassurethatspecimensaretransportedinsuchawaythatthereferenceorre-testinglaboratoryreceivesthemingoodcondition.

Re-testing of samples

Generally,re-testingofsampleswillbecarriedoutbyoneorseveralreferencelaboratorieswithinthecountry.Whendealingwithvenousblood,thereferencelaboratoryorlaboratoriesshouldassurequalityoftestingbyappropriatevalidationoftheEnzymeImmunoAssayorTreponemaPallidumHaemagglutination/TreponemaPallidumParticleAgglutinationtechnologyemployed.Inaddition,alllaboratoriesperformingthisreferencetestingshouldparticipateinexternalqualityassessmentforsyphilistesting.

Followingre-testing,itisnecessarytodefineyourapproachtotheinvestigationofanydiscrepanciesbetweentheoriginalrapidtestingandthecomparatortreponemallaboratorytest.Errorsordifferencesinresultsmayoccurforavarietyofreasons.Operatorerrorintestperformanceisonecauseofdiscrepancy,andthiswillrequireadditionalqualityassuranceandtrainingatthesite.Anothercommonsourceoferrorisatranscriptionmistakeatsomepointintheprocess.Errorsmaybeproducedifthesamplesforre-testingareimproperlystoredand/ortransported.Veryslightdifferencesarealsoobservedbetweenrapidtestsandcomparatortests,withneitherbeingmoreaccuratethantheother.Alldiscrepanciesrequireinvestigation.Apolicymustbedevelopedfortheresolutionofdiscrepancies,andanacceptablelevelofdiscrepancymustbedetermined.

Reporting and corrective action

Theresultsofthere-testingshouldbereportedtotheoriginaltestingsiteandtothedesignatedqualityofficerwhereapplicable.Thequalityofficeratthetestingsiteshouldevaluateallresultsreceivedfromre-testing,andtakeappropriatecorrectiveactionwhenperformancegoalsarenotmet.

Inmostcountries,theMinistryofHealthwillalsobearecipientofinformationontheresultsofre-testing.Resultsshouldbecollectedsystematicallyandusedtoevaluatetestingperformanceonanationalbasis,aswellastoinitiateappropriatecorrectiveactionwhenneeded.


External Quality Assessment of Syphilis Rapid Tests: Statistical Models for Re-testing

Re-testingofsampleshasbeenusedtomonitorrapidsyphilistestinginlieuofconventionalExternalQualityAssuanceorproficiencytesting,whichisoftenunavailabletolaboratoriesandtestingsites.Thisdocumentlooksatthestatisticsthatapplytothisre-testing,andprovidesinformationthatwillbeusefulindeterminingappropriatemodelsforexternalqualityassessmentre-testing.

Current Situation

Currentlythereareavarietyofexternalqualityassessmentre-testingschemesinplaceinvariouscountries.Examplesinclude:■■ Re-testing5%ofallsamplesandthefirst40samplestestedbyeach

technicianwhorunstests.■■ Re-testing10%ofallsamples.■■ Re-testingallpositivesandvaryingpercentageofthenegatives.

Otherconsiderationsareasfollows:■■ Inallcasesre-testingisdonewithaconfirmatorytreponemallaboratorytest

(TreponemaPallidumHaemagglutinationtechnique,TreponemaPallidumParticleAgglutinationtestorEnzyme-linkedimmunosorbentassay).■■ Currentre-testingschemesdonotaccountforthenumberofsamplestested

ateachsite.Thiscanvarywidely,between50and1000testspermonth,orbetween500and10,000peryear.■■ CurrentnationalratesofsyphilisprevalencevaryfromlowtoveryhighThe

rateofpositivitymaybemuchhigher(orlower)thanthenationalprevalenceinaparticularsite.Rateofpositivityintestingsitesishighlyvariable.■■ Dataontheagreementbetweenrapidsyphilistestingmethodsisbecoming

morewidelyavailableasnationalrapidsyphilistestevaluationsaretakingplace.Thealgorithmsusedrequireconfirmationofallpositivetestsbyatleastonedifferentmethod.Inmanycases,negativesalsohavetobenegativeontwokits(insomecountriesinitialnegativesarenotconfirmed).Incaseswherethefirsttworesultsdonotagree,athirdkitisusedandthisisconsideredconfirmatory(severalvariationsexist,butthisissufficientforthepurposesofthisdiscussion).■■ Thesampleforre-testingmustbeobtainedatthetimeofinitialtesting.

appendix 9. external Quality assessment of Rapid Syphilis Tests Statistical Models for Re-testing


Otherconsiderations(continued):■■ Errors(disagreementwithcomparatorlaboratorytests)canoccurfora

varietyofreasons,including− Useofoutdatedkits− Improperstorageofkits− Lackoftechnicalcompetence− Clericalerror− Insensitivityofthekit

■■ Informationoncurrentagreementratesforre-testedsamplesisnotavailableforuseinthisdocument.Itwouldbeveryusefultoknowthedistributionbyagreementonpositiveandnegativesamples,theagreementratesatdifferentsites,andtheagreementratefornewtechnicians,inadditiontotheoverallagreementratesthatarefound

objectives

Themodelshouldconsiderthefollowingvariables:■■ Trueerrorrate(unknown)■■ Positivityrate■■ Populationsize(numberofcasesperstudyperiod)■■ Probabilityofdetectionoferrors■■ Numberofre-testedcases,ortheproportionofcasestobere-tested■■ Decisionrule:actonasinglediscrepancyormultiplediscrepancies?

Therecommendedre-testingschemeshouldachievethefollowingobjectives:■■ Provideastatedlevelofconfidencethatlowerrorrateswillbedetected.■■ Beindependentofpositivityrate.■■ Accommodatedifferentnumbersoftestsperformedinthetimeperiod

(50-10,000).■■ Assumethatevenasingledisagreementwillleadtoinvestigation.■■ Assumethatre-testingisperformedwithouterror.

Model assumptions

Themodelpresentedbelowcouldbeappliedequallytosamplesthatarepositiveandnegativeoninitialtesting;oritcouldbeusedonalltests,nomatterwhattheinitialresult.Therecommendedquantityofsamplescouldbedrawnindependentlyfrompatientswhoareinitiallydiagnosedaspositiveandfromthosethatareinitiallydiagnosedasnegative;oritcouldbechosenrandomlyfromallpatients.Insomeinstancesitwouldbedifficulttobasere-testingontheinitialresult,sotheeasiestre-testingschemewouldcomefromarandomsampleofallpatients.

Themodelassumesthatanydiscrepantresultisasignalforaction.Whatevertheactionsarefor“suspect”resultsfromtestsites,theseactionswouldbeinitiatedonthediscoveryofasinglediscrepantresult,nomatterwhatthesamplesizeorpositivityrate.


Thesuggestedmodeleliminatestheneedtoconsidertherateofsyphilisseropositivity,butthereremainfourimportantdimensionstotherecommendations:■■ Populationsize■■ Samplesize■■ Trueerrorrate■■ Confidencelevel

Positivityratewouldnotaffecttheestimatesinthefollowingtablesandfigures,butitwouldaffectthe“power”oftheprocedure(itsabilitytodetecterrors)iftherearedifferentprobabilitiesforfalsenegativesandfalsepositives.Thepositivityrateandtheclinicalimpactoffalsepositivesandfalsenegativescouldleadtodifferentre-testingproceduresforpositivesandnegatives.

Model

Thehypergeometricdistributioncanbeusedtopredicttheprobabilitiesofdetectionforanygivensamplesize.Inthismodel:■■ Eightdifferentsizesoftestswerechecked(thiscouldbenumbersof

negativesorpositives,orboth):50,100,200,500,1,000,3,000,5,000,and10,000.■■ Threedifferentpossibleerrorrateswereinvestigated:1%,3%,and5%.■■ Threelevelsofconfidencewerechecked:90%,95%,and99%.■■ Threedifferentre-testingrateswerechecked:5%,10%,and20%.■■ Forsmallsamplesandlowerrorratesitwasnecessarytoassumeatleast

1error;forexample,50sampleswith1%errorratewasassumedtohave1error,anda5%sampleproduces3cases.Thiscandistortthepercentagesinthetables.

Themodelwasappliedinthreedifferentwaystoanswerthreequestions:1. Forgivennumbersofcasesandgivenerrorrates,whatsamplesizeisneeded

toensureastatedconfidenceofhavingatleast1discrepantresult?Thesenumberscanthenbeconvertedtopercentagesofthenumberofcases.(SeeTable1a-c.)

2. Forgivennumbersofcases,givenre-testingratesandgivenerrorrates,whatistheprobabilityofobservingatleastonediscrepantresult?ThiscanalsobecalledthePowerofthere-testinganddecisionrule.(SeeTable2a-c.)

3. Forgivennumbersofcasesandgivenre-testingrates,whatisthelowesterrorratethatcanbedetectedwithastatedconfidence?ThisistheupperlimitoftheConfidenceIntervalfortheerrorrate(thelowerlimitiszero).(SeeTable3a-c.)


TABLE1a:Re-testsize(and%)neededtoprovide90%confidenceofdetectingatleastonediscrepantresult,whentheunderlyingerrorrateis1%,3%,or5%E

Number 1%e 3%e 5%e

50 45(90%) 34(68%) 27(54%)

100 90(90%) 54(54%) 37(37%)

200 137(64%) 63(32%) 41(21%)

500 184(37%) 71(14%) 43(8.6%)

1000 205(21%) 73(7.3%) 44(4.4%)

3000 221(7.4%) 75(2.5%) 45(1.5%)

5000 224(4.5%) 76(1.5%) 46(.92%)

10000 227(2.3%) 77(0.77%) 47(0.47%)

Example:Ifthereareapproximately1,000casesinthetimeperiod,and90%confidenceisacceptablefordetecting5%errors,thena4.4%re-testwillsuffice(44samples).

TABLE1b:Re-testsize(and%)neededtoprovide95%confidenceofdetectingatleastonediscrepantresult,whentheunderlyingerrorrateis1%,3%,or5%E

Number 1%e 3%e 5%e

50 48(96%) 39(78%) 31(62%)

100 95(95%) 63(63%) 45(45%)

200 155(78%) 78(39%) 51(26%)

500 225(45%) 90(18%) 56(11%)

1000 258(26%) 94(9.4%) 57(5.7%)

3000 284(9.5%) 97(3.2%) 58(1.9%)

5000 290(5.8%) 98(2.0%) 59(1.2%)

10000 294(2.9%) 99(1.0%) 60(0.60%)

Example:Ifthereare200casesandtheobjectiveistohave95%confidenceindetectinganerrorrateof3%ormore,thenthenumberofre-testedcaseswouldbe78,or39%ofallcases.


TABLE1c:Re-testsize(and%)neededtoprovide99%confidenceofdetectingatleastonediscrepantresult,whentheunderlyingerrorrateis1%,3%,or5%E

Number 1%e 3%e 5%e

50 50(100%) 45(90%) 39(78%)

100 99(99%) 78(78%) 59(59%)

200 180(90%) 106(53%) 73(37%)

500 300(60%) 131(26%) 83(17%)

1000 368(37%) 141(14%) 86(8.6%)

3000 425(14%) 148(4.9%) 88(2.9%)

5000 438(8.8%) 149(3.0%) 89(1.8%)

10000 448(4.5%) 150(1.5%) 90(0.90%)

Example:Ifitisdesiredtohave99%confidencethatanerrorrateof1%ormorecanbedetected,inasituationwith50(orfewer)cases,then100%ofresultsneedtobere-tested.

TABLE2a:Probabilityofobtainingatleastonediscrepantresultwithre-testingratesof5%witherrorratesof1%,3%,and5%E

Number 1%e 3%e 5%e

50 .06 .12 .17

100 .05 .14 .23

200 .10 .27 .41

500 .23 .54 .73

1000 .40 .79 .93

3000 .79 .991 1.0

5000 .92 1.0 1.0

10000 .994 1.0 1.0

Example:Ifthereare5,000casesanda1%errorrate(50errors),thenif5%ofcasesarere-tested(250cases)thereisa.92probabilityofselectingatleastoneoftheerrors(power).Ifthereare1000cases(50re-testcases),thereisa.93chanceofdetecting5%errors.


TABLE2b:Probabilityofobtainingatleastonediscrepantresultwithre-testingratesof10%witherrorratesof1%,3%,and5%E

Number 1%e 3%e 5%e

50 .10 .19 .28

100 .10 .27 .42

200 .19 .47 .66

500 .41 .80 .93

1000 .65 .96 .996

3000 .96 1.0 1.0

5000 .995 1.0 1.0

10000 1.0 1.0 1.0

Example:Ifthereare1,000cases,anerrorrateof3%andare-testrateof10%,thenthereisaprobabilityof.96thatatleastoneresultwillbediscrepant.

TABLE2c:Probabilityofobtainingatleastonediscrepantresultwithre-testingratesof20%witherrorratesof1%,3%,and5%E

Number 1%e 3%e 5%e

50 .20 .36 .50

100 .20 .49 .68

200 .36 .74 .90

500 .67 .97 .997

1000 .89 .999 1.0

3000 .999 1.0 1.0

5000 1.0 1.0 1.0

10000 1.0 1.0 1.0

Example:Ifthereare500casesanda20%re-sampling(100re-samplecases),thenthereisa.67probabilityofhavingatleastonefailureinthesamplewhentheerrorrateis1%.


TABLE3a:Lowesterrorratethatcanbedetectedwith90%confidencewiththestatedre-testingrates(%ReT)andgivennumberofcases

Number 5%ReT 10%ReT 20%ReT

50 54% 36% 20%

100 37% 20% 10%

200 21% 11% 5.5%

500 8.6% 4.4% 2.2%

1000 4.4% 2.2% 1.1%

3000 1.5% 0.73% ‹.5%

5000 0.90% ‹.5% ‹.5%

10000 ‹.5% ‹.5% ‹.5%

Example:With3,000cases,itwouldrequire10%re-testing(300re-testcases)todetecta1%errorrate(tableentry0.73%),with90%confidence.Ifnoerrorsarefound,the90%confidenceintervalfortheerrorrateis(0to0.73)

TABLE3b:Lowesterrorratethatcanbedetectedwith95%confidencewiththestatedre-testingrates(%ReT)andgivennumberofcases


50 62% 44% 24%

100 45% 25% 13%

200 26% 14% 6.5%

500 11% 5.6% 2.8%

1000 5.7% 2.9% 1.4%

3000 1.9% 0.97% ‹.5%

5000 1.2% 0.58% ‹.5%

10000 0.58% ‹.5% ‹.5%

Example:If10%of50slidesarere-tested(5re-testcases),andnoerrorsarefoundinthesample,thenthe95%confidenceintervalfortheerrorrateis:(0to.44).


TABLE3c:Lowesterrorratethatcanbedetectedwith99%confidencewiththestatedre-testingrates(%ReT)andgivennumberofcases


50 90% 78% 34%

100 59% 36% 19%

200 37% 20% 10%

500 17% 8.4% 4.2%

1000 8.6% 4.3% 2.1%

3000 3.0% 1.4% 0.70%

5000 1.8% 0.88% ‹.5%

10000 0.90% ‹.5% ‹.5%

Example:Witha20%re-testrateand200slidesinthepopulation(40casesselected),theerrorratehastobeatleast10%(20errors),ifwearetohave99%chanceofincludingatleastoneoftheerrorsinthere-testedcases.Ifnoerrorsarefoundinthere-testcases,the99%confidenceintervalforerroris(0to.10).


observations

1. Theestimatesabovecanbeappliedtoanysubsetoftestingsituations,oranycombinedgroup,includingalltestsdoneinayearoralltestsdonewithaspecifickit.ThenumbersinTables1-3canbeusedtoestimatethesamplesizesneededtoassurelevelsofperformanceofspecifictestingcentres,technicians,orkits.

2. Traditionalproficiencytestingandre-testingarebothusefulexternalqualityassessmentmethods;theyservesimilarpurposesinsomeways,butdifferintheirabilitytodetecterrorsandintheservicestheyprovide.Bothsystems:− Monitorperformancetodetectsystematicerrors.− Motivatelaboratoryandtechniciantopayattentiontoquality.− Assureresponsibleoversight.

Theydifferinthat:− Re-testingprovidesmoresamplesthanproficiencytestingandisthereforemoresensitivetoerrors.Sinceerrorratesofconcernareexpectedtobe‹5%,largesamplesarerequiredtodetecterrors.

− Proficiencytestingprovidescontrolledsamplesandroutineinterlaboratorycommunications,withmanageableoperation.

3. Currentfielddataorre-testdatashouldbeminedforadditionalinformation,suchasagreementbetweenkitsandthenumbersof“tie-breakers”requiredbyatechnicianorafacility.Thesecouldbeimportantqualityindicators.Forexample,thereshouldberoutinerecordingofalltie-breakercases,includingkitnames(andlots)andtie-breakerresult.

4. a.Insiteswithlownumbersofcases(‹500),thelikelihoodofdetectingerrorsisverylowunlesslargepercentagesarere-tested.Thiswouldapplytoprogrammesthatrequirere-testingofallpositives(lowerrorrate,highpowerrequired).b.Insiteswith500ormorecasesthereareopportunitiesforreasonablepowerforerrordetection,withfeasiblebutlargenumbersofre-testcases.c.Insituationsinvolvingverylargenumbersofcases(3,000ormore),thenumberofre-testedcasescanbecapped.Are-testof200to250caseswouldseemtoprovidehighpowerfordetectinglowerrorrates,sore-testingratescouldbesetaccordingly.


[InsertNameofReferringTestingSite,ContactName,AddressandPhoneNumber]

date: Refering Test Site: Contact Name:

address: Telephone:

Specimen Tracking Number

Test Sub-ject id*

Final Result (Testing Site)

date Specimen Collected

Specimen Type(dBS or Serum)

Collected by

Referral lab Req† Completed (✓)

date to referral lab

date Conf Result Received

Result of Re-test

*ID=Identification†LabReq=LaboratoryRequisition

appendix 10. example specimen Transfer log for re-testing


daily Temperature Check Chart for Refrigerator/Freezer/incubator #:

Thermometer#: TempSet: Month: Year:

date Temp observed initials Comments

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Supervisor(initials): Name: Date:

Binder# StorageLocation:

appendix 11. daily Temperature check chart


appendix 12. protocol worksheet used in Brazil


appendix 13. pictorial diagram of themanufacture of dTS in Brazil

appendix 14. pictorial instructions on performing rapid syphilis testing (in Brazil)