Quality Assurance of Malaria Microscopy

I. Introduction


The effective treatment of malaria largely depends on the accuracy of diagnosis. Microscopy remains as the gold standard in malaria diagnosis. Quality microscopy can be achieved by implementing a quality assurance system (QAS) that ensures and maintains high accuracy, reliability and efficiency of laboratory services nationwide.

Support for early diagnosis and treatment of malaria from various sources has scaled up in previous years. Guided by the Malaria Program, microscopy services in the Rural Health Units (RHUs) and hospitals have been strengthened. Barangay Malaria Microscopy Centers (BMMCs) were also established even in remote malarious areas to provide immediate microscopy services. To ensure high quality microscopy services at various levels of health care, a quality assurance system must be implemented.

II. Objectives


This Chapter aims to guide local health managers and service providers in ensuring reliable microscopy services in their respective localities. Specifically, it aims to:

(1) describe the quality assurance system for malaria microscopy, and

(2) detail the processes and procedures in ensuring accurate and reliable microscopy services.

III. Policy Directions


Quality malaria microscopy is assured through the establishment of a 3-level microscopy quality assessment system.

1. All health facilities providing malaria microscopy services must undergo validation of blood films by qualified provincial/regional validators;

2. All provinces must have a qualified validators certified through regular proficiency assessments every 2 years; and

3. A national core group of trainers/validators certified by an independent body must be sustained by the Malaria Program.

IV. Quality Assurance System for Malaria Microscopy


Microscopy services are provided by existing microscopy centers comprising of the RHUs, hospitals, laboratory facilities and BMMCs. These are manned by microscopists who could either be a medical technologist, a laboratory technician, other health staff or community volunteer worker who underwent special training on malaria diagnosis.

Quality microscopy is provided by competent microscopist adhering to standards and protocols, with available supplies and the necessary equipment.

Assuring quality of microscopy begins at the point of service but needs to be sustained through a 3-level QAS. At first level, microscopists have to undergo the appropriate training courses provided by the National Core Group of Trainers (NCGT). In order to maintain quality microscopy services, the proficiency skills of performing microscopists must be validated by certified provincial/regional malaria microscopy validators on a regular basis (Level 2). In turn, the proficiency skills of validators must be subject to the proficiency assessment conducted by Research Institute for Tropical Medicine-National Reference Laboratory (RITM-NRL) every 2 years while the training competencies of NCGT members must be regularly assessed by an external expert through its Regional Accreditation and External Quality Assurance (EQA) Program (Level 3). The following describes the 3-level QAS of malaria microscopy.

Figure 6.1 Quality Control and Quality Assessment of Malaria Microscopy*

V. Implementing Guidelines


Level I. Training of Microscopists for Malaria Diagnosis

As a first level of quality assurance for microscopy, microscopists must first undergo the Basic Malaria Microscopy Training, and a regular refresher course every 3 years provided by the NCGT. Health facilities without a qualified malaria microscopist must be guided with the following:

1. The head of the health facility must identify and designate a staff member to perform malaria microscopy. The designated staff must undergo the basic microscopy training and must satisfy the following criteria:

If the designated staff is a:

• Medical Technologist or Non-Medical Technologist deployed in RHUs/hospitals and laboratory

(i) with good visual acuity

(ii) not more than 45 years old

(iii) in good physical and mental condition

(iv) willing to complete the course

(v) committed to serve at least 1-2 years

• Non-medical technologist: Midwife (MW)/barangay health worker (BHW) to be deployed at BMMC.

Same as above and must be able to read, write and perform numeric computations at basic level 

2. The head of the health facility must coordinate with the Provincial Health Office (PHO)/Center for Health Development (CHD) for appropriate training and schedule and make the necessary administrative and financial arrangements in support to the staff to be trained.

3. Microscopist for training will undergo training course recommended according to the category of their profession:

3.1 For medical technologists : 2-week Basic Malaria Microscopy Course

3.2 For non-medical technologists: 5 week Basic Malaria Microscopy Course

4. Trainees who obtain the passing mark of at least 80% in the training can be designated as malaria microscopist.

     4.1 Those with grades <80%:

a. Medical Technologist: to be mentored by the validator for 6 months and take

the same 2-week course. If staff fails, the head of facility needs to mobilize the services of other qualified microscopists in other facilities

b. Non-Medical Technologist: advise head of health facility to recommend another staff to be trained to perform microscopy

     4.2 Those with grades > 80%:

a. Their competencies must be assessed every 3-5 years

b. They must undergo a refresher course with a minimum of 5-day duration that gives emphasis on species identification (for all microscopists) and quantification (for microscopists assigned in RHUs/hospitals/laboratories only).

If microscopist fails the refresher course, the following measures must be undertaken by the validator:

(i)  review and identify areas of weaknesses/gaps in the microscopist performance

(ii) closely mentor and supervise the microscopist

(iii)send panel of slides for practice by the microscopist

Level 2. Quality Assessment of Microscopy Services in Health Facilities

After the initial training on Basic Malaria Microscopy, performance of malaria microscopists needs to be regularly assessed in order to maintain quality microscopy services. This is done through a validation of blood films, on-site supervision, feedback and remedial interventions. The purpose of validation is not to find fault and look for deficiencies but rather to further enhance the skills of the microscopists, and help improve the support system for delivering microscopy services e.g. checking functionality of microscope, adequacy of laboratory reagents/supplies, recording system, etc. Quality assessment should cover the proficiency of microscopists on accuracy, specificity, sensitivity, species identification and parasite quantification.


     1. Blood Film Validation

Quality assessment of microscopy services at the microscopy centers must undergo regular assessment by a qualified validator as reflected in Table 6.1.

Validation is done by randomly selecting a subset of blood films examined at the microscopy centers. These are re-examined by the validator in an independent and blinded manner.

     1.1 Selection of blood films for validation
Based on the total number of reported blood films examined in the previous year, the validator adopts the appropriate selection scheme.

Scheme 1: If there are >240 blood films in a previous year, microscopist must submit 30 blood films examined per quarter regardless of the results to complete a total of 120 blood films reviewed in a year

Scheme 2: If there are 200-240 blood films in a previous year, the microscopist must submit all blood films examined in a quarter for validation regardless of the results

Scheme 3: If there are < 200 blood films in the previous year, the microscopist must submit all blood films examined in the previous 6 months regardless of the results and await the panel of blood films to be sent by the validator every year if validation result of sent blood films is < 20% error or if there are no blood film examined in the previous 6 months

     1.2. Validation Schedule and Frequency
Designated validators must inform the microscopist and head of the microscopy centers of the validation schedule and advise the microscopist to prepare the blood films appropriate for the selected scheme as shown in Table 6.1.


Malaria Microscopy QA: Validation Schemes and Frequency



     1.3 Validation of Blood Films

Scheme 1 and 2

Scheme1 is applicable to microscopist with more than 240 blood films examined in the previous year while scheme 2 applies to microscopists with 200-240 blood films examined in the previous year.

Upon receipt of blood films and the sealed envelope containing accomplished Form 1; the validator must accomplish the following within 2 weeks:

a.  Read the submitted blood films and record the result on Form 2. Malarial Blood Films Report by Validator (Annex 6.2) according to the instructions.


b.  Open the sealed envelope and copy the microscopist’s blood film results written in Columns 11, 13-15 of Form 1 to Columns 10, 11a-c of Form 2. Take note that medical technologist/laboratory technician assigned at the RHU/ hospital/laboratory facility should have accomplished Columns 14-15 of Form 1.


c.  Compare the reading with the blood film readings sent by the microscopist. Indicate in Column 13 of Form 2 the results of the comparison according to the instructions given.

     c.1 Accuracy by species identification, specificity and sensitivity

(i)Accuracy: total number of correctly-read blood films by the microscopist OVER total number of blood films read by the validator MULTIPLIED BY 100

(ii) Sensitivity: total no. of true positive blood films OVER the total number of true positive blood films PLUS false negative blood films MULTIPLIED BY 100

(iii) Specificity: total number of true negative blood films OVER the total

number of true negative blood films PLUS false positive blood films MULTIPLIED BY 100

     c.2 Parasite Quantification: Number of blood films read by microscopist with parasites counts within + 20% deviation from the count of the validator OVER the total number of positive blood films MULTIPLIED BY 100


d.  Assess the quality of thick and thin blood film and the quality of staining. Write
the findings in Columns 14a-c of Form 2 according to the instructions given.

     d.1 Quality of Blood Film. There are 2 blood films prepared for malaria diagnosis,
one thin blood film and one thick blood film per slide.

i. A good blood film is determined by the quality of the thin and thick blood films prepared in a given slide. A good quality blood film requires that both thin and thick blood films are properly prepared as described below.

ii. A good thin blood film is a properly prepared thin film which is thick at the beginning end and thin or feathered on the other end which should not reach the end of the glass slide and should have areas optimal for microscopy having red blood cells that are in a single distinctive layer.

iii. A good thick blood film on the other hand is circular film with 1 cm diameter. The ideal thickness of the blood film should allow for printed text to be readable when it is placed on it.

iv. A poor blood film is when any of the thin or thick blood film did not comply to the above description.

     d.2 Quality of Staining
A good stained blood film is determined by the quality of both the stains of the thin and thick blood films in a given slide.

i. A good stained thin blood film must have:

• a clear background free from debris
• pale grayish pink erythrocyte
• leukocytes with deep purple nuclei and well defined granules
• a deep red chromatin of malaria parasite and clear purplish blue cytoplasm
• for P vivax or P. ovale parasite, stippling shows up as schuffner’s dots and for P falciparum, the larger ring forms show Maurer’s spots in erythrocytes

ii. A good-stained thick blood film must have:

• a clean background free from debris, with a pale mottled-grey color
• deep rich purple leukocytes nuclei
• a deep-red chromatin of malaria parasite and clear purplish blue cytoplasm
• for P. vivax and P. ovale parasites, stippling in the “ghost of host erythrocytes” shows up as schuffner’s dots, especially seen at the edge of the thick film

iii. An under-stained blood film shows a too bluish or purplish film suggesting a high pH.

iv. An over-stained blood film shows a too pinkish film suggesting a low pH.

e. Total the number of inconsistent findings and analyze the results:

     e.1 If the number of blood films with error is 20% and more in any quarter, conduct the on-site visit immediately.
     e.2 If the number of blood films with error is less than 20% in any quarter, ensure to visit the facility at least once a year.


Scheme 3

Scheme 3 is applicable to microscopists with less than 200 slides examined in the previous year. The process of applying Scheme 3 would depend on the presence or absence of blood films examined in the previous 6 months prior to the validation period.

a. For microscopists with blood films examined in the previous 6 months:

     a.1 Use the same set of procedures under Schemes 1 and 2 in validating, analyzing and recording the results.
     a.2 If the results show more than 20% error, schedule at once an on-site visit to the concerned microscopist. In this regard, there is no need to send the panel of 20 slides.
     a.3 However, if the results show less than 20% error, send a panel of 20 slides to the concerned microscopists to further validate his/her microscopy proficiency.

(i). Upon receipt of the returned panel of 20 blood films and sealed envelope containing accomplished Form 1 from the microscopists, perform the same analysis as indicated in Schemes 1 and 2. The analysis though covers only accuracy and specificity of species identification and quantification (if applicable) but not the quality of blood film and quality of staining.

(ii) Based on the validation results, take actions as appropriate and submit the necessary report to the head of the facility within a month after the validation period.

b. For microscopists without any blood film examined in the previous 6 months:

     b.1 Validator should send the panel of 20 blood films to the microscopist concerned.
     b.2 Apply the same validation steps, analysis and appropriate actions as in a.3.


     1.4 Feedback and Reporting

Microscopist and his/her supervisor must be given feedback on the results of the validation as contained in the accomplished Form 2a. Validation Summary Report (Annex 6.3) within one month from the receipt of the blood films for information and appropriate action.

a. Validator provides feedback to the microscopy center specifying the level of accuracy by species, sensitivity and specificity, staining quality and smear size and labeling including recommendations.

b. The accomplished Form 2a must be sent back to the microscopist concerned together with the empty slide box. However, the discrepant blood films should be mounted and saved by the validator for discussion with the microscopist.

c. Report must also include the schedule of the next validation to be undertaken.

d. Copies of the report must be provided to the microscopist, copy furnished the head of the microscopy center, and the heads of PHO and CHD. The report must be endorsed by the head or supervisor of the validator before it is sent out to the proper recipients.

e. Validator must retain hard and electronic copies of the reports.

f. Microscopists must file the validation report for future reference.


2. On-Site Supervision

On-site supervision is an opportunity for both the microscopist and validator to directly interact and discuss the results. It also allows the assessment of the working conditions of the laboratory units and support systems in place (e.g. recording, etc) and helps institute corrective measures, as needed.

     2.1 The timing of the on-site supervision depends on the extent of errors detected.

a. If error is > 20%, the on-site supervision must be done immediately

b. If error is < 20%, on-site supervision must still be done once a year

     2.2 The following are the steps in on-site supervision:

a. Planning. Set schedule for the visit and integrate this schedule with the over-all monitoring plan. Send communication informing the microscopist/s in advance on the date of the visit to ensure his/her presence and prepare records and other materials for the evaluation;

b. Conduct the visit.

     b.1 Pay courtesy call to head of facility:

Hospital - Chief of Hospital

RHU - Municipal Health Officer/Officer-in Charge

BMMC - Barangay Captain / Catchments Midwife

     b.2 Assess the working conditions of the laboratory unit using Form 3. On-site Supervisory Checklist (Annex 6.4)

     i.Interview microscopist on general information.

     ii.Review records and blood films. Randomly select at most 10 blood films from the slide box and validate reading and quality of blood film.

     iii.Inspect microscopy set-up, laboratory supplies/materials, reagents, equipment, records, biosafety and waste disposal.

     iv.If results of earlier validation indicate poor performance of blood film and staining procedures, request microscopist to demonstrate staining and smearing procedures and observe how he/she performs said procedures.

     v.Analyze results of assessment, act on issues presented and make necessary recommendations for further action/s.

c. Feedback and Reporting

     c.1 Discuss findings, comments and recommendations with the microscopist and the head of the facility.

     c.2 Submit the written report to the microscopist and head of the microscopy center not later than 2 weeks from the conduct of the on-site visit, duly signed by the validator supervisor, copy furnished the PHO and CHD.

3. Consolidation of Validation Results Among Health Facilities

3.1 Validators must consolidate the results of validation undertaken among different health facilities under his/her assignment using Form 4. Consolidated Validation Report (Annex 6.5).

3.2 Report must include a brief analysis of results summarizing the key findings, actions taken and recommendations to be further acted upon.

3.3 Submit copies of consolidated reports to CHD, PHO, Provincial Health Team Office (PHTO) and Municipal Health Office (MHO) within 1 month after the validation period.

4. Further Review and Validation by Supervising Validators


In situations where there are disagreements in the results of the validation, a member of the NCG of Trainoirs/Validators within the region should conduct further assessment/review and make the final decision.


Level III. Proficiency Assessment of Provincial/Regional Validators
and Certification of National Core Group of Trainers/Validators


The Level 3 of the QAS requires all provincial/regional validators to undergo proficiency assessments every 2 years by the (RITM-NRL), and the accreditation of the NCGT through the WHO Regional Accreditation and EQA Program every 2-3 years.

1. Proficiency Assessment for Regional/Provincial/Municipal Validators

Validators play a vital role in monitoring the performance of microscopists to ensure that high level of proficiency and high quality of microscopy services are maintained at each level of health care. It is therefore essential for validators to undergo regular proficiency assessment. Each province should identify a candidate validator for proficiency assessment. If there are no candidates, the PHO must coordinate with the CHDs to provide a validator for the province. PHO/CHD-candidate validators must pass the Proficiency Assessment for Validators conducted by RITM-NRL.

     1.1 Candidate medical technologist (regional, provincial and municipal health offices/facilities and other private institutions) for becoming a validator must meet the following minimum requirements:

a. Medical Technology graduate

b. Must have passed the Basic Malaria Microscopy Training conducted by any of the following DOH offices: Infectious Disease Office (IDO), CHD, RITM-NRL within the past 3 years

c. At least 3 years experience working as malaria microscopist

d. Willing to accept responsibility as validator

e. Endorsed by the IDO/CHD/PHO/MHO/Chief of Hospital

f. Holding a permanent position

     1.2 Proficiency Assessment Mechanism

a. Participants read a set of 48 reference slides over a period of 4 days in an independent and blinded manner.

b. Participants are graded on species identification and parasite quantification against the reference readings and classified accordingly as follows:

Grade of >90%                                   

Recommendations:

     Qualified as validator

      To undergo regular assessment every 2 years

Grade of < 90%                                    

Recommendations:

     Continue performing microscopy under the supervision of the regional/provincial validator.

     Recommend for re-assessment after 1 year

2. Certification of National Core Group of Trainers/Validators

     2.1 Certified Regional/Provincial Validators can become a member of the NCG of Trainers/Validators if they meet the following criteria:

a. Endorsed by the IDO/CHD/PHO

b. Willing to accept responsibility as a national validator and trainer

c. Officially designated by the head of office

     2.2 NCG of Trainers/Validators must undergo certification through the WHO Regional Accreditation and EQA Program every 2-3 years to increase and maintain their level of proficiency.

     2.3 NCG of Trainers/Validators must obtain a mark of 90% on detection of parasitemia, 90% on species ID and 50% of the blood films read that fall within + 20% of the true parasite count.


Malaria Microscopy Quality Assurance Forms

Source: Department of Health - Malaria Control Program Manual of Procedures, Guidelines in the Quality Assurance of Malaria Microscopy

Training on HIV Proficiency for Medical Technologists, January 24, 2011 – February 1, 2011 (Full Course)

By Jeffrey V. de Guzman

I happened to be selected as one of the participants in the training on HIV Proficiency that will be held at STI-AIDS Central Laboratory (SACCL), San Lazaro Compound, Manila.

This will be conducted by the Department of Health through the National AIDS STI Prevention and Control Program (NASPCP) which have funding support from the Global Fund Round 6 HIV Project. This is part of the strategy to continuously improve quality of health service delivery to Most at Risk Populations (MARP).

Below is the list of selected participants:

1. Baccay, Sheryll Aleth - Tuguegarao
2. Cabusas, Zherina Jesca - Butuan
3. Prior, Eunice S. - Butuan
4. Kho, Suzette C. - Butuan
5. Tacardon, Reynaldo S. - Zamboanga Sibugay
6. Laberos, Eden D. - Negros Occidental
7. Tallafer, Mariano P. - Negros Occidental
8. Niego, Fay Marie P. - Iloilo
9. Nismal, Marygrace C. - Iloilo
10. Ypil, Cheryl D. - Cebu
11. Dablo, Genevieve B. - Pagadian
12. Lidres, Mayflor R. - Pagadian
13. Camina, Janice R. - General Santos
14. Quintero, Jacqueline - QC PGH
15. De La Paz, Zenaida B. - QC PGH
16. Mahilum, Maria Lourdes M. - Caloocan
17. Bernales, Leticia F. - Manila
18. Ramis, Antonio Z. - Manila
19. de Guzman, Jeffrey V. - Pampanga
20. Mamaed, Juvimil F. - Nueva Ecija
21. Benter, Lucia Jacinta S. - Benguet
22. Mangansakan, Norhan P. - Cotabato
23. Buelis, Lea L. - Davao
24. Dy, Edmon J. - Davao
25. Fillarca, Anna Liza P. - Cagayan de Oro

The following are the Resource Speakers/Facilitators:

1. Dr. Gerard Belimac - NASPCP NCDPC
2. Dr. Jasmin T. Peralta - NASPCP GF Project
3. Dr. Elizabeth Telan - SACCL San Lazaro Hospital
4. Dr. Rosario Jessica Abrenica - SACCL
5. Dr. Ann Joy Aguadera - SACCL
6. Ms. Razel Kawano - SACCL
7. Dr. Arlan Lopez - SACCL
8. Ms. Luz Ramos - SACCL
9. Mr. Marco Hernando - SACCL
10. Dr. Rontgene Solante - SACCL
11. Mr. Carlo Sangco - SACCL
12. Ms. Prisca Susan Leano - SACCL
13. Ms. Amelia Cabatic - SACCL

Secretariat:

1. Ms. Helen D. Paano - NASPCP GF Project
2. Mr. Marries Concepcion - AIDS Society of the Philippines

The hotel accommodations would be at Fersal Hotel (Andalucia - Fersal Hotel - Manila #1455 A. Mendoza Street corner Alvarez Street, Sta. Cruz, Manila, Philippines).  

Arrival would be on January 23, 2011 and check-in at Fersal would be from 12 in the afternoon.

Transportation expenses (from home to airport to hotel, hotel to SACCL, from hotel to airport to home) should have proper documentation (travel voucher, receipt form, bus tickets, etc.) of exact value (as required by Commission on Audit). Non-compliance would be denied reimbursement.

To avail of land transportation reimbursement the terminal fee and boarding pass (Manila - Home flight) must be sent via courier (to serve as proof of travel).

Non-flight participants are allowed the weekends off, but travel expense will be shouldered by the participants.

Per diems one (1) day before and one (1) day after of participants and other incidental expenses shall be borne by the respective sending agency, subject to the usual accounting and auditing rules and regulations.


See also: 

• Requirements for Renewal of HIV Proficiency Certificate

Training for Drug Testing Laboratory Analysts, Feb. 2 to 4, 2011

The Seminar/Workshop on the Manual of Operations for Analysts of Drug Testing Laboratories organized by the Philippine Forensic Drug Testing Society, Inc. is scheduled on February 2 - 4, 2011.

For reservation and details please contact any of the following:

Manila

• Maricar Carasi
  Tel No: (02)928-4990
  Mobile No: 09228227247
  Email: raciram88@yahoo.com, maricar0301@gmail.com
• Angel Dimasaka
  Mobile No: 09228567152

Cebu

• Cleofe Echavez
  Tel No: (PLDT) (032)2624022, (Globe Lines) (032)4125643
  Mobile No: 09324621326
• Cesar Cagalawan
  Mobile No: 09173205518, 09228227245

 Source: Department of Health, National Reference Laboratory for environmental, occupational health, toxicology, and micronutrient assay.


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Upcoming Seminar/Workshop(s) for Drug Testing Laboratories

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Cleaning and Storing of Microscope Slides

Ensure the availability of clean, good quality glass slides for the preparation of blood specimens for microscopic examination;

Ensure that the microscope slides are properly cleaned, stored and readily accessible in all microscopy centers;

Ensure that the following materials and supplies are available for the cleaning and storing of microscopy slides;

i. frosted glass slides 

ii. plastic bowls or basins 

iii. good quality detergent (liquid or powder) 

iv. washing cloths or soft sponges 

v. clean, lint free cotton cloths (the kind used to dry glassware) 

vi. a good supply of clean water 

vii. sheets of clean paper cut to 11 cm. x 15 cm in size 

viii empty slide boxes 

ix. clear adhesive tape 

x. dessicators or activated silica gel

Observe the following procedures in cleaning and storing the slides

a. Cleaning and storing of Slides 

All slides must be thoroughly clean and free from scratches, grease or moisture. This will prevent most of the artifacts which may confuse malaria diagnosis and will avoid the detachment and washing away of thick blood films during the staining process. Poorly cleaned slides will lead to sub-standard blood films, in turn leading to imprecise microscopy. Gloves must be worn when washing microscope slides.

New slides

i. Remove slides from the box and place individually in a basin of warm detergent solution and soak for 2-3 hours preferably overnight; 

ii. After soaking, use the washing cloth or sponge to clean each slide on both sides by rubbing the two surfaces of the slide between the forefinger and thumb; 

iii.Rinse slides individually in clean water to remove all traces of detergent. This may require two bowls; 

iv. Handle slides by the edges to drain the excess water from each slide before drying thoroughly with a clean, lint-free cotton cloth; 

v. Although the slides are new, discard any chipped and scratched slides which are unsuitable for hematology. They may be used for medical entomology activities; 

Using the cut paper pieces, wrap the dried slides in packs of ten. Turn down the ends of the wrapper and secure with clear adhesive tape. Place the slides in the cardboard boxes ready for use. Keep each box secure with a rubber band.

Used slides

i. You may reuse slides after slide validation if still in good condition; 

ii. Place individually the used slides in a basin of warm detergent solution and soak overnight; 

iii. Clean one by one with a washing cloth or soft sponge until all traces of the blood film and oil have been removed; 

iv. Transfer the slides to a fresh solution of good quality detergent and later to running water or several changes of clean water handle the slide by the edges to drain the excess water; 

v. Dry the slides thoroughly with clean, dry and lint free cloth; 

vi. Using the cut paper pieces, wrap the dried slides in packs of ten. Turn down; the ends of the wrapper and secure with clear adhesive tape. Place the slides in the cardboard boxes ready for use. Keep each box secure with a rubber band.

b. Storing and Discarding of Slides

i. Glass slides should not be kept in room temperature of the humid tropics for more than a few weeks. Otherwise they will adhere to each other due to entrapped moisture and there will be a loss of transparency due to ‘frosting’; 

ii. It is recommended that cleaned slides be stored in packages of 10 which have been wrapped in thin paper and secured with cellulose adhesive tape or rubber bands so that they are ready for use; 

iii. Packages of slides can be put in the original cardboard boxes or other suitable boxes with desiccant; 

iv. Slides with the following conditions must be discarded and stored in a puncture – proof container: (i) with scratches, (ii) chipped, or (iii) blue color glass slide. 

v. Used slides can be disposed in any of the following: (i) septic tank, (ii) burial pit, or (iii) cemented vault in accordance to the DOH Healthcare Waste Management Manual (2004);

Source:  Department of Health - Malaria Control Program Manual of Procedures, Guidelines in the Diagnosis and Treatment of Malaria

MALARIA AND DENGUE CONTROL PROGRAM IMPLEMENTATION REVIEW

The Department of Health – Center for Health Development 3 conduct an implementation review on malaria and dengue at the Century Resort Hotel in Angeles City last November 3-5, 2010.

Dr. Cruz Presented the Regional Updates

Provincial presentation of malaria and dengue control accomplishment immediately started after the short opening program.

Dr. Paulino Presented the Updates of Bulacan

Malaria Program Updates of Bulacan

Malaria Program Updates of Aurora Province

Dr. Lopez presented the updates of Nueva Ecija Province

Malaria Program Updates of Nueva Ecija Province

San Jose Del Monte Bulacan Dengue Updates Presentation

Zambales Dengue Updates Presentation

The assessment and planning workshop for 2011 was done on the second day.

Nueva Ecija Group

Aurora Group

Pampanga Group

Tarlac Group

Bulacan Group

Bataan Group

Zambales Group

Microscope Use

To meet the high standards required in microscopy, it is essential to know the proper handling and manipulation of a microscope, its limitations, and the ways to keep it in good working condition. It is the responsibility of the immediate supervisor to ensure that the microscopists are conversant with the operations of the instrument and can follow the standard operating procedures as well as the manufacturer’s instructions in operating, maintaining and storing the microscope for day-to-day use.

a. Parts of the Microscope

b. Care and Maintenance of Microscope

Microscopes are to provide precise results. However, they are sensitive to pressure, movement, temperature, dust, etc. Care and maintenance must always be observed to ensure their effective and efficient use.

     b.1 Requirements for Microscope Use and Preventive Maintenance

The following materials, reagents, and equipment are the minimum requirements for using and maintaining the microscope:

i. Lens Paper 

ii. 70% alcohol (ethyl/isopropyl) 

iii. Aspirator Bulb / Rubber Bulb 

iv. Camel Hair Brush / Soft Make-Up Brush 

v. All-purpose wax/weather wax (not floor wax) 

vi. Soft lint- free cloth (muslin cloth or “pranela”) 

vii. Applicator Stick 

viii. Spare Bulb 

ix. other alternative light source (for areas without electricity) 

x. Equipment Maintenance Record (logbook) Polyvinyl Plastic Cover

     b.2 Cleaning the Microscope by Parts

Optical Parts:

Dry Objectives 

• Blow off dust particles using the rubber bulb and wipe the lens with a lens paper, moving the lens paper across and not circularly. 

Oil Immersion Objectives 

•  Remove oil with lens paper moistened with 70% alcohol if needed, moving the lens paper across and not circularly. 

Eyepiece / Ocular 

• Clean upper lens with a lens paper swab slightly moistened with 70% alcohol then followed by dry tissue swab (see Fig. 3) 

• Wipe in circular motion starting at the center going outward.

Figure 3: Preparation of Lens Paper Swab

Illumination Parts:

The condenser and mirror 

• Clean the same way as the objectives using soft cloth or lens paper 

The support and stage 

• Clean using soft cloth

     

     b.3. Handling and Usage

i. Avoid subjecting the microscope to sudden or severe impact as it is a precision instrument; 

ii. Do not use the microscope where it is subjected to direct sunlight, high temperature and humidity, dust or vibrations; 

iii. When moving the microscope, carry it with one hand under the base and the other hand holding the arm; 

iv. Do not hold the microscope by the stage, stage feed knobs, and observation tube to prevent damage; 

v. Do not move the microscope by sliding it on the table. Otherwise, the rubber feet might be damaged or peeled off; 

vi. Install the microscope on a flat sturdy surface. Never block the air vents on the underside of the base (e.g. placing microscope on a flexible surface such as carpet; 

vii. Cover the microscope when not in use with polyvinyl plastic cover; 

viii. Never leave the microscope without the eyepiece; 

ix. Line up the X 10 objective with the ocular when microscope is not in use; 

x. Never try to dismantle or clean any part of the microscope that is difficult to reach unless you have been trained to do so; 

xi. Clean oil immersion objective after use. Never use ordinary paper or cotton wool to clean the lenses of the microscope. Never use xylene in cleaning any part of the microscope; 

xii. Never touch the bulb and the lenses with bare fingers; xiii. Never exchange parts from one microscope to another. Even some models by the same manufacturer have different specifications.

     b.4 Storage

Fungus cannot grow on glass surfaces when the atmosphere is dry. In these circumstances, it is important to store microscope under dry conditions when not in use. Any of the following methods can be used:

Method 1. Keep the microscope in a warm cabinet with a tightly fitting door and two 25 watt bulbs constantly lighted inside. Depending on the size of the cabinet, you can add more 25 watt bulbs as long as the temperature inside the cabinet is kept constant at 30-35° C but with low humidity. 

Method 2. Keep all lenses and prism heads in an airtight box or dessicator where the air is kept dry by an active silica gel. 

A silica gel is a dessicant that has the ability to absorb water vapor from the air. Self-indicating silica gel is blue when active and turns pink as it absorbs water vapor. When silica gel turns bright pink, it can then be reactivated by heating. After cooling (when it becomes bright blue), it can be used again. 

Method 3. Keep the microscope in a continuously air-conditioned room. However, storing microscope in rooms with air-condition only during the working day are not suitable.

     b.5 Transporting the microscope

It is important that the microscope and its parts are properly secured inside its storage box when the microscope is to be transported from one location to another.

i. Loosen the observation tube clamping knob slightly, rotate the tube by 180o, and tighten the knob; 

ii. Put the transport band; 

iii. Secure the stage and other movable parts; Use various protective materials such as packaging carton, styrofoam or pad inside the storage box.

c. Safety Rules in Using the Microscope

It is important that safety precautions be observed while using the microscope to prevent harm to the microscopists and the facility.

(i) Never work with wet hands, wet body or clothes wet; 

(ii) Do not presume that the circuit is turned off; 

(iii) Do not remove equipment grounds; 

(iv) Do not use defective plugs and cords; 

(v) Always use the correct replacement parts; 

(vi) If the bulb burns out during observation, be certain to cool the defective 

bulb completely before replacement; 

(vii) Keep out of children’s reach especially for the BMMCs.

d. Inspection and Performance Check

This part deals with the routine inspections and performance checks before the unit is put to use and/or being kept after using. A regular and thorough inspection of the microscope will certainly help maintain good operational results and increase its technical lifespan. A weekly inspection of a microscope should include the following points:

i. Ensure that the following parts are clean: 

· all outer surfaces of the instrument - must be free of corrosion or other visible damage; 

· electrical plugs, sockets, cables 

· bulb 

ii. Keep the mounting shoulders of the objectives and the corresponding surfaces on the nosepiece absolutely clean. Otherwise, you will lose the proper positioning of the objectives regarding centering and focus. Be careful not to allow any dust or dirt to get into the objective during cleaning; 

iii. Tighten screws securely; 

iv. Check the that the following are functioning well: 

· the field stop diaphragm move through its full range of opening smoothly and easily 

· all blades of the iris must move properly; 

· the condenser height adjustment knob run smoothly through its full range. Some types have an adjustable brake while others are permanently set; 

· condenser centering screws must move the condenser smoothly and in all directions through its full range; 

· mechanical stage must move the specimen smoothly and without any play through its full range of adjustment in both directions. Check by observing at the microscope’s highest magnification; 

· the slightest touch of the control knob must result in a corresponding movement of the specimen. Keep in mind that one micron of stage movement observed at a magnification of 1000x looks like 1 mm viewed without a microscope and at a distance of 250 mm. Therefore, any disassembly, adjustment, re-greasing, etc. of mechanical stages should be performed only by a trained technician; 

· The nosepiece must rotate smoothly through 360˚, reaching all click-stop positions properly from either side and without any play. Any disassembly at this position interferes with the optical alignment and requires special alignment aids for readjustment; 

v. The fine and coarse focusing knobs must run smoothly through their full range of adjustment. Some types have an adjustable brake (see user’s manual), whereas others are permanently adjusted. Ensure specially that the stage does not lower itself automatically. Do not tighten the brake too much; 

vi. Ensure that the upper surface of the stand and the corresponding mounting surface of the observation tube is clean and free of corrosion. The fastening screw for the tube must hold it securely in place; 

vii. Adjustment of the interpupillary distance of the tube must run smoothly and without exerting undue force; 

viii. All optical surfaces must be absolutely clean. Pay special attention to: light bulb, cover glass on field stop, condenser front lens, objective front lens, upper surface of eye lens; 

ix. Consider the following options in the repair of the microscope. 

· Let user of microscope to attend training on preventive maintenance; 

· Send the microscope for repair to the health maintenance department of the provincial/regional hospitals with personnel trained on preventive maintenance; 

· Send microscope for repair to the DOH-national Health Maintenance Service (HMS) 

· Request CHD or HMS trained staff for repair assistance but provide travel allowance of staff as their counterpart) 

Source: Module on Preventive Maintenance, Care and Basic Troubleshooting on Clinical Laboratory Microscope (Hospital Maintenance Service, Davao)

e. Equipment Maintenance Record

It is important that the history of repair and maintenance of the microscope be documented and properly filed. The Equipment Maintenance Record shall have the following information.

(i) Name of equipment 

(ii) Manufacturer’s name, serial number or other unique identification 

(iii) Origin(from what institution) 

(iv) Date received 

(v) Date placed in service 

(vi) Condition when received (new, used) 

(vii) Details of maintenance carried out 

(viii) Current location, where appropriate 

(ix) Copy of manufacturer’s operating instructions, where available 

(x) History of damage, malfunction or repair (date repaired) 

(xi) Name and signature of technician

Source:  Department of Health - Malaria Control Program Manual of Procedures, Guidelines in the Diagnosis and Treatment of Malaria

IMPLEMENTATION OF EXTERNAL QUALITY ASSESSMENT PROGRAM AS A REGULATORY REQUIREMENT FOR LICENSING OF CLINICAL LABORATORIES

Pursuant to Administrative Order No. 2007-0027 entitled "Revised Rules and Regulations Governing the Licensure and Regulation of Clinical Laboratories in the Philippines, " a clinical laboratory is required to have a Quality Assurance Program (QAP).

The QAP shall include an Internal and External Quality Control Program. The Internal QAP covers inputs, processes and outputs as well as practice of continuous Quality Improvement Program covering all aspects of laboratory performance.

On the other hand for External Quality Assessment Program (EQAP) a clinical laboratory is required to participate in the National External Quality Assessment Scheme (NEQAS) administered by the designated
National Reference Laboratories (NRLs) or in other local or international EQAP recognized by the Department of Health.

The NEQAS shall be conducted to ensure that laboratory procedures are done in accordance with standards and laboratory results are accurate and within the standard range for quality health care.

As provided in Department Order No. 393-E s. 2000, five institutions were designated as the National Reference laboratories namely:

• Research Institute for Tropical Medicine - National Reference Laboratory for Dengue, Influenza, Tuberculosis and other Mycobacteria, Malaria and other parasites, Bacterial enteric diseases, Measles and other Viral exanthems, Mycology, Enteroviruses, Antimicrobial resistance and Emerging Diseases; NRL for confirmatory testing of blood units.

• San Lazaro Hospital - National Reference Laboratory for HIV/AIDS, Hepatitis, Syphilis and other Sexually Transmitted Infections (STls).

• East Avenue Medical Center- National Reference Laboratory for Environmental and Occupational Health; Toxicology and Micronutrient Assay

• National Kidney and Transplant Institute - National Reference Laboratory for Hematology including Immunohematology, Immunopathology and Anatomic Pathology (consistent with previously issued D.O. 301-1 s. 1999)
• Lung Center of the Philippines- National Reference Laboratory for Biochemistry.

The following specific guidelines shall be enforced to initially implement the NEQAS:

1. A certificate of participation/registration in NEQAS shall be a licensing
requirement for the renewal of license to operate a clinical laboratory for 2009
in the following areas:

      a. Hematology - Primary, Secondary and Tertiary Clinical Laboratories in the
National Capital Region (NCR).

      b. Clinical Chemistry - Tertiary Clinical Laboratories in the National Capital
Region (NCR) and Center for Health Development IV-A CALABARZON.

      c .. HIV/AIDS , Hepatitis B & C Proficiency Testing - All HIV Accredited Testing
Laboratories and Secondary and Tertiary Clinical Laboratories performing
Hepatitis Band C tests.

      d. Drug and Water Proficiency Testing - All Water and Drug Testing
Laboratories.

2. A Certificate of Participation shall be issued by the NRLs to the participating clinical laboratory every time NEQAS is conducted. For the initial implementation of NEQAS, only one (1) certificate is required for the renewal of license to operate.

3. NEQAS/Proficiency Testing for Drug and Water Testing Laboratories requires participation and a satisfactory rating on the survey. For Microbiology, TB and Parasitology, participation in the three component is required and a certificate of participation is issued by the Microbiology Department of RITM. A certificate of participation in Antimicrobial Resistance Surveillance Program (ARSP) is recognized as NEQAS for Microbiology component only, and participation in the TB and Parasitology component is still required.

4. The schedule of fees per participation is as follows:
      a. Hematology P 2,000.00
      b. Clinical Chemistry P 2,000.00
      c. HIV/AIDS, Hepa B & C P 2,500.00
      d. Drug Proficiency Testing P 1,000.00
      e. Water Proficiency Testing P 2,500.00
      f. Microbiology P 5,000.00


Republic of the Philippines Department of Health, DEPARTMENT MEMORANDUM No. 2009 - 0086"

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Activities and Guidelines in the Performance of External Quality Assessment Program (EQAP) of the National Reference Laboratory for HIV/AIDS, Hepatitis B & C and STIs

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Preparation of Giemsa Working Solution and Staining of Malaria Blood Films

The use of Giemsa stain is the most reliable procedure to stain malaria blood film, which is composed of eosin and methylene blue. The eosin component stains the parasite nucleus red, while the methylene component stains the cytoplasm blue. Proper preparation of Giemsa staining of high quality standardized malaria blood thick and thin films on the glass slides to be used in microscopy centers must be observed.

a.  Ensure that the following materials, reagents and supplies are available for proper preparation of stain:

• Giemsa Stock solution 

• Buffered water (ph 7.2) 

• Methanol 

• Pasteur pipettes 

• Graduated cylinder 

• Drying Rack 

• Staining trough 

• Clean tap water 

• Timing clock

b. There are two methods of staining with Giemsa stains: (i) the Rapid (10%) method, and (ii) routine or regular (3%) method;

     b.1.1 Preparation of 10% Giemsa working solution( mass staining)

i. Pour 90 mL of buffered water (ph 7.2) into a 100 mL graduated cylinder;

ii. Using a pasteur pipette, draw 10 mL of Giemsa stock solution. Add the stain to the buffered water in the graduated cylinder;

iii. Cover the top of the graduated cylinder with parafilm. Gently invert the cylinder several times until completely mixed;

iv. Giemsa working solution stain must be discarded through the sink after 24 hours and prepare a fresh working solution again.

     b.1.2 Preparation of 10% Giemsa working solution (individual slide staining)

i. For individual slide staining, each slide needs approximately 3 mL of Giemsa working solution to cover it;

ii. Using a Pasteur pipette add 9 drops of Giemsa stock solution to 3ml of buffered water in a 10 mL graduated cylinder.

     b.1.3 Procedure of Rapid staining of Malaria blood films

i. Allow thick film to dry completely. If rapid results are required, drying maybe hastened by using a blow drier or briefly exposing the slide to gentle heat such as from the microscope lamp. Care should be taken to avoid overheating, otherwise the thick film will be heat-fixed;

ii. Fix the thin film by dipping it briefly in a container with methanol for a few seconds. To permit dehemoglobinization, the thick film should not be fixed; thus avoid methanol or its fumes touch the thick film;

iii. Gently pour the stain on the slide using a pipette on the staining assembly. Alternatively, slides can be placed faced down on a concave staining plate and the stain introduced underneath the slide; (not routinely practice);

iv. Staining Time: It depends on the age of the Giemsa stock solution. It may extend up to 15 minutes if Giemsa stock is freshly prepared;

v. Gently flush the stain off the slide with a clean tap water; do not tip off the stain on the slide and wash, as this will leave a deposit of scum over the smear;

vi. Place the slide on the drying rack, film side downwards, to drain and dry making sure that the film does not touch the edge of the rack.

     b.2 Regular Staining Method (3% Giemsa stain working solution)

This regular method is used for staining larger number of slides such as those collected during surveys or research studies.

b.2.1 Preparation of 3% Giemsa working solution

     i. Pour 97 mL of buffered water (ph 7.2) into a 100 mL graduated cylinder;

     ii. Using Pasteur pipette, draw 3 mL of Giemsa stain. Add the stain to the buffered water in the graduated cylinder;

     iii. Cover the top of the graduated cylinder with parafilm or gently invert the cylinder several times until completely mixed;

     iv. Label the cylinder with contents, date and time prepared and technician’s initial;

     v. Buffered Giemsa stain must be prepared fresh and discarded after 6 hours.

b.2.2 Procedure of Regular Staining of Malaria Blood Film

     i. Fix thin film by briefly dipping it in a container with methanol for a few seconds. Prolong fixation make it   difficult to demonstrate Schuffner’s dots and Maurer’s spots. To permit dehaemoglobinization, the thick film should not be fixed, therefore avoid methanol or its vapor touching the film.

     ii. Place malaria blood film in a staining rack and stain singly, or in batches in staining jar to avoid cross-contamination. Batch staining is advisable only when several malaria blood films are from a single patient.

     iii. Stain films for 30-45 minutes out of the sunlight.

     iv. Pour clean tap water gently into the trough to float off the iridescent scum on the surface of the stain. Alternatively, gently immerse the whole trough in a vessel filled with clean tap water.

     v. Rinse slides briefly and gently under running tap water or by a gentle flow of clean water from a beaker.

     vi. Place the stained slides in a drying rack to drain and dry, film side downwards, making sure the film does not touch the slide rack.

     vii. At all times during preparation and storage, slides should be protected from exposure to dust and insects.

c. Evaluation of Stained Blood Film
  
     c.1 Evaluation of a well-stained blood thin film:

i. The background should be clean and free from debris; the color of erythrocyte is a pale grayish pink;

ii. Leukocytes have deep purple nuclei and well defined granules;

iii. The chromatin of malaria parasite is a deep purplish red and clear purplish blue cytoplasm;

iv. Stippling should show up as schuffner’s dots in erythrocytes containing P. vivax or P. ovale, and Maurer’s spots in erythrocytes containing the larger ring forms of P. falciparum.

     c.2 Evaluation of a well-stained thick film:

i. The background should be clean and free from debris, with a pale mottled-grey color derived from the lysed erythrocytes;

ii. Leukocytes nuclei are a deep-rich purple;

iii. Malaria parasites are well defined with deep-red chromatin pale purplish blue cytoplasm. In P. vivax and P. ovale infections, the presence of schuffner’s stippling in the “ghost” of host erythrocytes can be seen especially at the edge of the film.

     c.3 Staining quality:

i. A malaria blood film that is too pinkish suggests low ph or overstraining;

ii. A malaria blood film that is too bluish or purplish suggests high ph, film is too thick or under-stained.

Source:  Department of Health - Malaria Control Program Manual of Procedures, Guidelines in the Diagnosis and Treatment of Malaria

BLOGGING MADE FUN WITH MINUTE MAID

By Jeffrey V. de Guzman

People nowadays are more conscious about their health with the emergence of fast foods including bottled drinks to cope with the fast pace of life. Anything made instantly might be bad for our health because of the chemical preservatives added. As health conscious individuals, we want to make sure that everything we eat and drink is safe and good for our body. The good news though, is that food companies are now creating mouth-watering and refreshing goods that do not damage our health. Take Minute Maid, for instance, with it's  pulpy orange juice drink which now has no preservatives added!

In line with this, Minute Maid is promoting this new line of product through the power of internet. Bloggers are asked to share their pulpy story through a blog post. Quite interesting because prizes await those chosen with the best post. One more thing, best commenter of blog will also get the chance to take home a month’s supply of Minute Maid.  To join you must like Minute Maid Pulpy by clicking the 'Like' button on the Facebook Fan Page.

But before jumping on the bandwagon, I want to know your opinion about this drink after having tried one. Below are some reviews I found on the net:

“I drank the whole bottle and seriously it has no taste at all, not even the taste of a powdered orange juice.” “Perhaps coca cola should release a new batch of this juice, improved taste, or flavor and that is the time I would risk drinking a bottle.”

“I discovered a new product on my favorite grocery store shelf that deserves to be patronized. It is Minute Maid Pulpy Orange by Coca Cola Philippines, Inc. I love it and more importantly, my four year old loves it. It also fits right into my budget at less than PHP 20 for a 330 ml bottle.”

You might have a different view of this drink after the company released new batches of this juice with its improved taste. For the information and welfare of the consumers, please do leave a comment below.

Your participation is very much appreciated.