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.