Part I: Organisation and management
training, supervision and motivation of laboratory staff

If a tuberculosis laboratory is to function effectively, motivated and dedicated staff are crucial. Laboratory personnel must be fully aware of their important role in tuberculosis control and must become full partners in National Tuberculosis Programmes. Training laboratory technicians in the microscopic diagnosis of tuberculosis is, accordingly, an essential activity under the revised tuberculosis control strategy.

One of the biggest problems that arise in laboratories in developing countries concerns the supply, maintenance and repair of equipment, the supply of laboratory consumables and transport. Solutions to these problems require fairly intensive technical training, a knowledge of laboratory administration and management and the development of interpersonal skills. It takes much longer - and is at least as important - to teach peripheral microscopists how the use their microscopes properly, (including maintenance and repair), and how to conduct the day-to-day running of a microscopy laboratory, (including planning of activities and time scheduling) than it is to teach them how to prepare and read slides.

Training
Peripheral laboratory staff
Technicians working in peripheral microscopy laboratories must receive training on the following:

• the relevance of sputum-smear microscopy to tuberculosis diagnosis, follow-up during treatment and treatment evaluation
• the importance of carrying out all requested sputum-smear examinations
• performing Ziehl-Neelsen staining
• reading and reporting the results timely

Laboratory technicians should have elementary knowledge of mathematics and the metric system, use of laboratory equipment and instruments, and measures for ensuring the safety of laboratory personnel and laboratory premises. They should also have an understanding of the concepts of asepsis and sterilisation.

Training in microscopy should specifically cover:

• collection, storage and transport of sputum specimens for microscopy
• smear preparation, including numbering / engraving of slides, selection of useful particles, fixation, staining, decolourisation and counter staining
• use of a microscope with an immersion-oil objective and slide reading
• reporting of results and recording of data in the Tuberculosis Laboratory Register
• procedures for reporting results to the peripheral health structure and / or the patient
• maintenance and minor repairs of microscopes
• storage of positive slides and negative slides for quality assurance
• procedures for sending sputum specimens for culture and drug susceptibility testing
• disinfection and sterilisation of contaminated material
• safety measures for handling sputum specimens and performing microscopy
• identification of problems occurring during sputum-smear microscopy and recording of results
• management of reagents and laboratory supplies

Intermediate laboratories are responsible for organising and conducting the training for the peripheral laboratory staff from each district.

Training should be essentially practical and held over five days. The number of technicians to be trained simultaneously will depend on the available materials and equipment, especially microscopes, to be used for training purposes. On average, one microscope is required for every two technicians to be trained. A separate room for training should be arranged at the intermediate laboratories, for a maximum of 10 trainees per course.

Intermediate laboratory staff
Laboratory staff at intermediate laboratories should be trained in the technical methods required and the managerial functions they must undertake within the National Tuberculosis Programme.

Training should cover:

• the revised control programme, including general information on the revised strategy of the National Tuberculosis Programme and the functions of the tuberculosis laboratory network
• technical methods:
  • Ziehl-Neelsen microscopy (as in the curriculum for peripheral laboratory staff)
  • preparation of reagents for Ziehl-Neelsen microscopy
  • fluorescence microscopy, if equipment is available
  • Löwenstein-Jensen culture procedures, including preparation of sputum specimens for culture, inoculation of media, media incubation, reading, recording and reporting of results
• managerial skills:
  • organization of training on Ziehl-Neelsen microscopy for peripheral laboratory staff
  • supervision of peripheral laboratory staff
  • quality control of microscopy at peripheral laboratories
  • organization of transport of sputum specimens within districts and from districts to the intermediate laboratory
  • estimating supply and equipment requirements for programme budgeting

The national reference laboratory, in collaboration with the other Level III laboratories, is responsible for organising the training of intermediate laboratory personnel. The training should take place over two or three weeks.

Central laboratory staff
Central level staff must in addition be trained in drug susceptibility testing techniques and surveillance methods, identification of mycobacterial species, evaluation of laboratory activities and operational research methodology. They can be trained within the country, or can attend international training courses sponsored by WHO and the International Union Against Tuberculosis and Lung Disease (IUATLD).

Supervision
The regional Laboratory Supervisor is responsible for monitoring the day-to-day activities of the peripheral laboratories, and for training and updating staff on all aspects of sputum smear microscopy. The Supervisor must also ensure that laboratory activities are carried out as planned and should perform quality control and proficiency testing. The Supervisor should visit the peripheral laboratories once every four to eight weeks and should work with the District Tuberculosis Co-ordinator to make sure that tuberculosis-related laboratory activities are performed properly.

Supervisory visits should be planned carefully and the laboratory supervisor should keep a checklist of the items to be checked during supervisory visits. Items for checking are usually divided into four categories:

• Competence of the laboratory technician
  The Supervisor should ensure that the laboratory technician knows:
  • how to prepare sputum-smear slides for Ziehl-Neelsen microscopy
  • how to read slides and record results
  • how to complete the Tuberculosis Laboratory Register accurately and how to report the results
  • how information from the Tuberculosis Laboratory Register can be used to cross-check information in the District Tuberculosis Register
  • how to limit administrative errors in the identification of patients
  • how to estimate laboratory supplies and reagents
• Activities of the laboratory technician
  The Supervisor should ensure that the laboratory technician:
  • assesses sputum-smear microscopy through quality control
  • performs examination of sputum specimens for all respiratory symptomatics: three sputum specimen slides if they are negative, and at least two sputum specimen slides if they are positive
  • keeps the Tuberculosis Register up to date and completes it accurately
  • keeps a box of all smear-positive slides and another of selected smear-negative slides for quality control
• Consistency of the Laboratory and District Registers
  The Supervisor should ensure that:
  • the smear-positive patients registered in the Tuberculosis Laboratory Register are also registered in the District Tuberculosis Register
  • the smear results for follow-up patients in the Tuberculosis Laboratory Register are the same as those recorded in the District Tuberculosis Register
• Logistics
  The Supervisor should ensure that:
  • the supply of sputum containers, slides, reagents, forms and other laboratory materials is adequate
  • that the binocular microscope is in good working order

Motivation
Motivation of staff is a neglected issue in tuberculosis bacteriology. It has to be realised that most people dislike manipulating sputum and that microscopy of largely negative smears can become very boring. Moreover, staff in peripheral laboratories often feel isolated and neglected; feelings of frustration are regularly expressed because they often find themselves at the receiving end of blame without being involved in National Tuberculosis Control Programme activities - 'the last to be informed but the first to be blamed'.

Motivation may be fostered in several ways:

• associating laboratory staff with the clinical and epidemiological aspects of tuberculosis control by arranging visits to clinics and hospitals, and talks and demonstrations by health care workers. This will help laboratory staff to appreciate the problems of tuberculosis at the patient level and enable them to identify with a team
• involving laboratory staff in planning and decision making processes through active participation in meetings and discussions with other members of the tuberculosis control team
• giving priority to visiting the laboratory during control programme supervisory visits; by using the laboratory register as the initial tool to evaluate case detection and quality of registration and follow-up of cases, and by discussing the functioning of the control programme jointly with nursing, clinical and laboratory staff
• organising inter-laboratory visits and meetings to discuss mutual problems. This will alleviate the sense of isolation and could lead to innovative solutions to problems that may be perceived as overwhelming
• including laboratory staff in regular feedback sessions on the outcome and performance of tuberculosis control programmes. Working in a successful programme may become a good motivational factor
• providing regular refresher courses on the different aspects of tuberculosis microscopy and awarding staff who complete these courses with certificates

Job satisfaction is a well-known principle in management: a person will perform a job well only if s/he is interested in it and finds it psychologically - if not financially - rewarding. There is no easy answers to the problems of staff motivation - or lack of it - in tuberculosis bacteriology. Nevertheless, aside from training and supervision, support and motivation of laboratory staff should also become an essential activity under the revised tuberculosis control strategy.