District level external quality assurance (EQA) of malaria microscopy in Pakistan: pilot implementation and feasibility

Abstract

BackgroundPrompt, quality assured laboratory diagnosis is key to effective malaria case management and control, especially since the introduction of the more expensive artemisinin combination therapy (ACT). The malaria programme and its non-government partners, on the basis of WHO recommended Lot Quality Assurance methods, have developed a district level external quality assurance (EQA) system. This study was designed to assess the feasibility, under programme conditions, of an integrated district level external quality assurance and supervision approach for malaria microscopy.Design and MethodsA prospective study conducted over seven months period (May-November 2007). In addition to the standard WHO EQA elements, three operational innovations were introduced, with the a district laboratory supervisor: a) onsite re-checking of slides, b) in ensuring uninterrupted availability of laboratory reagents and supplies at diagnostic centers, and c) supervision of administrative and technical components. The quantitative data for the study came from the service records/documents, whereas the qualitative data came from the key informant interviews.ResultsDuring the seven month period in four districts, a total of 8,118 slides were examined of which 209 (2.6%) were found positive for malaria parasites (slide positivity range between1.6% to 6.0%). The District Laboratory Supervisors in four districts reexamined a total of 1,770 slides (22%). The proportion of slides found discordant ranged from 0.5% to 1%. The quality of smear preparation was found acceptable in 73% slides.ConclusionsA district-based EQA, based on lot quality assurance methods was implemented, using context-specific operational guidelines, tools and training modules, and other inputs from the malaria control programme and partners. This EQA and supervision approach was found to be feasible and acceptable to those involved. Further study is required on the microscopy quality and cost-effectiveness of adding external quality assurance and supervision to district malaria microscopy services.

High Sensitivity and Specificity of Clinical Microscopy in Rural Health Facilities in Western Kenya Under an External Quality Assurance Program

“…Two other programs have reported positive effects of on-site mentorship and slide rechecking. 16,17 In our study, specificity improved over the first few months, probably reflecting the influence of the regular feedback and review of discrepant slides. Some participants were initially reluctant to review slides with the study microscopist and had to be reassured that there was no penalty for discrepant slides, only the opportunity for feedback and improvement.…”

External quality assessment of malaria microscopy diagnosis among public health facilities in West Amhara Region, Ethiopia

“…The blind rechecking method is a process by which slides are randomly selected from diagnostic health centers, transported to the higher level laboratory and reexamined blindly to evaluate the performance of laboratories [6]. Studies done by Pakistan and Congo showed that external quality assessment methods were found to be feasible and acceptable to improve the quality of malaria microscopy service [7, 8]. The major deficiencies may be due to poor competency, poor equipment, poor reagents, or poor infrastructure and work practices that require urgent alteration [7].…”

Evaluación del desempeño mediante paneles de láminas, una herramienta para la clasificación de los microscopistas senior del Programa de Control de Malaria en Colombia

“…En algunos países los supervisores de la red de diagnóstico a nivel del departamento deben ser microscopistas sénior, lo cual garantiza la buena calidad del apoyo técnico que se brinda en los puestos visitados (14). Con base en los hallazgos de estos talleres de evaluación de competencias en Colombia, se recomienda que los participantes sean personas que cuenten con capacitación y experiencia de, por lo menos, un año en el programa, pues las personas que contaban con pocos meses de experiencia y capacitación inadecuada fueron los que presentaron los peores resultados (no se muestran los datos) (13).…”

“…Estos errores pueden presentarse en cualquiera de las etapas, por ejemplo, al extender las muestras o en la coloración y el montaje permanente de la muestra; también, pueden ocurrir accidentes mecánicos y presentarse problemas inherentes a la técnica, como el desprendimiento de la gota gruesa debido a la humedad, la elevada temperatura ambiental, la limpieza inadecuada del portaobjetos o por el fácil desprendimiento de la sangre cuando procede de un paciente anémico (17). La calidad y la estandarización de los paneles de láminas son factores relevantes que permiten controlar variables y obtener paneles más homogéneos (13,14).…”

“…Por último, teniendo en cuenta que las actividades del control de calidad del diagnóstico de malaria son complementarias entre sí, es importante garantizar un programa de capacitación y reentrenamiento continuo para contar con personal técnicamente idóneo (14).…”