Standard operating manual for malaria and anaemia laboratory ...

National Malaria Indicator Survey March 2010, Zambia

Standard operating manual for malaria and anaemia laboratory

testing and treatment

CONTENTS

Standard Operating Procedures (SOP) for malaria parasite and anaemia testing during field work for the national MIS 2010..............3

Selecting participants..................................................................................3General precautions when taking blood......................................................4HemoCue general instructions....................................................................5

ICT MAL PF general instructions........................................................11Intended Use..............................................................................................11Summary...................................................................................................11Principle....................................................................................................11Precautions................................................................................................12Storage and Stability.................................................................................12Specimen collection and Preparation........................................................12Materials....................................................................................................12Directions for use......................................................................................13Interpretation of results.............................................................................13Quality Control..........................................................................................14Limitation..................................................................................................14How to do the RDT test.............................................................................16DOs...........................................................................................................16DON’Ts.....................................................................................................16

Blood slide general instructions.............................................................18Introduction...............................................................................................18Materials required.....................................................................................18Taking blood samples................................................................................19Making blood films and labeling...............................................................19Common errors in blood film preparations...............................................20Dried blood spots......................................................................................21Staining of blood films..............................................................................22

Summary of steps in collecting blood films and doing anaemia, RDT tests and slides in the field......................................................................23Treatment of positive cases....................................................................24

Anaemia....................................................................................................24Malaria......................................................................................................24

Disposing of hazardous waste................................................................28Avoiding problems arising in the field..................................................29

Problems of haemoglobin testing in the field............................................29Problems of parasitemia testing in the field..............................................30

Blood testing, laboratory and treatment standard operating manualStandard Operating Procedures (SOP) for malaria parasite and anaemia testing during field work for the national MIS 2010

IntroductionThree testing procedures are being used to collect information on the presence of malaria parasites and anaemia during the Zambia National Malaria Indicator Survey 2010. These are:

Anaemia testing with Hemocues© Malaria parasite testing using ICT MAL PF Rapid Diagnostic Tests (RDTs) Malaria parasite testing using both a thick and thin blood smear on

separate frosted end microscope slides

The procedures below are the Standard Operating Procedures (SOP), including the materials and methods that will be used for conducting these three tests in household interviews during field work.

In addition, the treatment procedures for responding to positive test results are presented.

It is important that these SOPs be followed explicitly to promote standardized testing methods and to ensure good quality, consistent results for each test across all field teams.

Selecting participantsWe will test children six years and below in all households for malaria and anaemia.

Children aged 6 years and below are identified from the listing of household members or from eligible female 15-49 household visitors whose children are also present.

Consent must be obtained before the survey questioning and anaemia and malaria parasite testing can begin. Every person whose blood is taken must have a check mark indicating that they have agreed to the blood tests.

Zambia MIS 2010 Page 4 of 34

Blood testing, laboratory and treatment standard operating manualGeneral precautions when taking bloodPersonnel responsible for collecting blood for haemoglobin measurement must take precautions to prevent parenteral, skin, and mucous-membrane exposures to blood-borne infections, such as hepatitis B, or human immunodeficiency virus (HIV). Under general precautions the following rules should be followed to ensure protection from acquiring blood-borne infections.

(1) Wear new gloves for each patient. Gloves help to prevent skin and mucous-membrane exposure to blood. Gloves should be worn during blood collection and haemoglobin measurement until all specimens and materials are disposed of. Gloves must be disposed of as biohazardous wastes (see below under Disposal of Biohazardous Wastes). Gloves must never be reused!

(2) Avoid penetrating injuries. Although gloves can prevent blood contamination of intact and non-intact skin surfaces, they cannot prevent penetrating injuries caused by the instruments used for finger or heel pricks. Generally, self-retractable lancets are recommended to reduce the risk of penetrating injuries. If other devices are employed for testing, care should be taken to develop procedures to prevent such injuries. Whatever the type of lancet, it should not be used for purposes other than a single finger or heel prick to collect blood for the malaria and anaemia testing. The lancets should not be broken or destroyed for curiosity or other purposes.Immediately after pricking the patient, the lancet should be placed in a sharp disposal puncture-resistant container for further disposal without first putting it on the table or the test area surfece. Use a new lancet for each patient. (3) If an accident occurs, any skin surfaces or mucous membranes that become contaminated with blood should be immediately and thoroughly washed and the accident should be reported to the supervisor.PEP procedures should apply when ever there is a self prick with a used a needle or lacent .

(4) Eating, drinking, applying cosmetics, and handling contact lenses may distract the procedure and are not permitted during blood collection and haemoglobin measurement.

(5) Properly dispose of all biohazardous materials. All materials coming in contact with blood must be placed in biohazardous waste containers after use and disposed of according to the survey organization’s policy on infectious waste disposal (see below under Disposal of Biohazardous Wastes).

(6) The biohazardous waste containers should be labeled “biohazard.” Take precaution when storing and transporting the waste


Blood testing, laboratory and treatment standard operating manualcontainers during the fieldwork, and follow established procedures to ensure proper disposal of all waste products (see below under Disposal of Biohazardous Wastes).


Blood testing, laboratory and treatment standard operating manualHemoCue general instructionsHemoCue Hb 201+ photometer:

The HemoCue Hb 201+ photometer measures light absorption and presents the results on a display.

The photometer can be safely operated between 18 and 30 degrees centigrade (59 to 86 degrees Fahrenheit). Allow the instrument to come to the ambient temperature and protect it from direct sunlight.

The HemoCue Hb 201+ analyser has an internal electronic “SELFTEST”. Every time the analyser is turned on, it automatically verifies the performance of the optronic unit of the analyser.

To turn it on, open the cuvette holder, press and hold the left button until the display is activated. The display shows the version number of the program, right after which it will show “Hb”. During this time the analyser will automatically verify the performance of the optronic unit. After ten seconds, the display will show three flashing dashes and the HemoCue symbol. This indicates that the HemoCue Hb 201+ is ready to use.


Blood testing, laboratory and treatment standard operating manual

The photometer’s black microcuvette holder has three operating positions:1) pushed in, for measuring;2) pulled out until “clicked,” for placing the microcuvette;3) completely withdrawn for cleaning.

Cleaning the HemoCue 201+

Clean the microcuvette holder daily and check for dirt or dried blood.



Follow these procedures to clean the microcuvette holder:

Check that the analyser is turned off and the display window is blank. Pull the cuvette holder out of its loading position. Carefully press the

small catch positioned in the upper right corner of the cuvette holder. While pressing the catch, carefully rotate the cuvette holder towards

the left as far as possible. Carefully pull the cuvette holder away from the analyser.

Clean the cuvette holder with HemoCue Cleaner or with a cotton tip swab moistened with alcohol and water.

Optronic unit can be cleaned by pushing the swab into the opening of the cuvette holder. Move from side to side 5-10 times. If the swab is stained repeat with a new swab.[Note: It is important that the cuvette holder be completely dry prior to reinserting it in the photometer].

While drying the cuvette holder protect if from dust particles etc.


Blood testing, laboratory and treatment standard operating manualThe HemoCue Hb 201+ microcuvette is a plastic disposable unit that serves as both a reagent vessel and a measuring device. It contains a reagent (sodium azide) in dry form. The reagent is yellow and covers the tip portion of the microcuvette.

The microcuvette is designed to draw up the exact amount of blood needed for the test. It is important to ensure that the entire portion of the microcuvette covered by the reagent (including both circle and the tip) is filled with capillary blood.

Although the HemoCue Hb 201+ system (photometer and microcuvettes) has proven to be durable and reliable under field conditions, there are some technical limitations.

Microcuvettes are sensitive to humidity and the chemical in it is photodegradable. Immediately after taking out a microcuvette, reseal and close the container. Observe the following requirements for the proper handling and storage of haemoglobin microcuvettes:

• Record on the container the date on which it is first opened;• Remove from the container only those microcuvettes required for immediate testing;• Always keep the microcuvette container lid snapped on;• Keep the microcuvette container at room temperature and avoid exposing it to heat or strong sunlight.

Under these conditions, a microcuvette container can be stored for up to 3 months (90 days) after opening. Sealed and unopened containers can be stored up to the expiration date on the container. The microcuvettes are stable for two years from the date of manufacture.


Blood testing, laboratory and treatment standard operating manualUsing the HemoCue 201+

Apply the HemoCue Hb 201+ microcuvette to the middle of the blood drop. The microcuvette will fill itself automatically by capillary action. To fill the microcuvette, the pointed end is placed into the centre of a large drop. The microcuvette should fill completely in one smooth flow.

If the microcuvette does not fill completely on the first attempt, DO NOT try to refill it by placing it back into the drop of blood. Also, never top off the microcuvette after the first filling. Instead discard the first microcuvette and use a second microcuvette to collect the sample.

Wipe any surplus blood off both sides of the microcuvette “like butter from a knife,” using the clean end of a sterile gauze. Ensure that no blood is sucked out of the microcuvette. The microcuvette needs to be filled completely at once.

After filling, the microcuvette needs to be visually inspected for air bubbles. Since air bubbles may influence the results of haemoglobin testing, microcuvettes containing them should be discarded. In such cases, the testing should be repeated using a different finger. Again, you must use new supplies and follow all of the steps described above in obtaining the new sample.



Place the microcuvette in its holder and gently push the holder into the photometer. The microcuvette should be analyzed immediately, no later than ten minutes after being filled.Blood haemoglobin results are displayed after 15 to 45 seconds. Record the haemoglobin level shown on the photometer in the appropriate boxes in the questionnaire.

Remove the microcuvette and discard it straight into the sharp waste bin without touching any surfaces.



After completing the testing, carefully follow the procedures for disposal of all materials.To turn the analyzer off, press and hold the left button until the display reads OFF and then goes blank.Clean the microcuvette holder as instructed and then close it.Pack the HemoCue 201+ and its accessories in their box.


Blood testing, laboratory and treatment standard operating manualICT MAL PF general instructions

Intended UseThe Malaria P.f. Rapid Test Device (Whole Blood) is a rapid chromatographic immunoassay for the qualitative detection of circulating Plasmodium falciparum in whole blood.

SummaryMalaria is caused by a protozoan which invades human red blood cells. Malaria is one the world's most prevalent diseases. According to the WHO, the worldwide prevalence of the disease is estimated to be 300-500 million cases and over 1 million deaths each year. Most of these victims are infants and young children. Over half of the world's population lives in malarious areas. Microscopic analysis of appropriately stained thick and thin blood smears has been the standard diagnostic technique for identifying malaria infections for more than a century. The technique is capable of accurate and reliable diagnosis when performed by skilled microscopists using defined protocols. The skill of the microscopist and use of proven and defined procedures, frequently present the greatest obstacles to fully achieving the potential accuracy of microscopic diagnosis. Although there is a logistical burden associated with performing a time-intensive, labor-intensive, and equipment-intensive procedure such as diagnostic microscopy, it is the training required to establish and sustain competent performance of microscopy that poses the greatest difficulty in employing this diagnostic technology especially at the lower levels of health care provision.

The Malaria P.f. Rapid Test Device (Whole Blood) is a rapid test to qualitatively detect the presence of the P.f. antigen. The test utilizes colloid gold conjugate to selectively detect P.f. antigen in whole blood.

PrincipleThe Malaria P.f. Rapid Test Device (Whole Blood) is a qualitative, membrane based immunoassay for the detection of P.f. antigen in whole blood. The membrane is pre-coated with P.f. antibody. During testing, the whole blood specimen reacts with the dye conjugate, which has been pre-coated in the test strip. The mixture then migrates upwards on the membrane by capillary action and reacts with the P.f. antibody on the membrane on the test line. If the specimen contains P.f. antigen, a red line will appear in the test region. The absence of a red line in the test region indicates that the specimen does not contain any P.f. antigen. A red line will always appear in the control region, indicating that the proper volume of specimen was added and membrane wicking occurred.


Blood testing, laboratory and treatment standard operating manualPrecautions

For professional in vitro diagnostic use only. Do not use after expiration date.

For whole blood specimen use only. Do not use other specimens. Do not eat, drink or smoke in the area where the specimens or kits

are handled. Handle all specimens as if they contain infectious agents. Observe

established precautions against microbiological hazards throughout all procedures and follow the standard procedures for proper disposal of specimens.

Wear protective clothing such as laboratory coats and disposable gloves.

Humidity and temperature can adversely affect results.

Storage and StabilityStore as packaged in the sealed pouch at 2-37°C. The test device is stable through the expiration date printed on the sealed pouch. The test device must remain in the sealed pouch until use. DO NOT FREEZE . Do not use beyond the expiration date.

Specimen collection and Preparation The Malaria P.f. Rapid Test Device (Whole Blood) can be performed

using whole blood. To collect Finger stick Whole Blood specimens:

o Wash the patient’s hand with soap and warm water or clean with an alcohol swab. Allow to dry.

o Massage the hand without touching the puncture site by rubbing down the hand towards the fingertip of the middle or ring finger.

o Puncture the skin with a sterile lancet. Wipe away the first sign of blood.

o Gently rub the hand from wrist to palm to finger to form a rounded drop of blood over the puncture site.

o Add the Finger stick Whole Blood specimen to the test device by using a sucking bulb:

Lightly squeeze the sucking bulb and gently suck the blood until filled to the first mark (approximately 5 microlitres). Avoid air bubbles.

Then squeeze the bulb to dispense the whole blood to the specimen well (small round well) of the test device.

Whole blood specimens should be used at once after collection for optimum performance.

Materials Individually packaged cassettes (Test devices) Buffer (reagent) Disposable sucking bulb



Package insert Sterile lancet Sterile alcohol swab

Directions for useAllow the test device, specimen, buffer, and/or controls to equilibrate to room temperature (15-37°C) prior to testing.

1. Remove the test device from the foil pouch and use it as soon as possible. Best results will be obtained if the assay is performed within one hour.

2. Place the test device on a clean and level surface. 3. For Finger stick Whole Blood specimen: Fill the sucking bulb to the

first mark and transfer approximately 5 microlitres of fingerstick whole blood specimen to the specimen well of the test device by touch-blotting.

4. Add 5 drops of buffer, and then start the timer. See illustration below.

5. Allow the reaction to proceed for 15 minutes6. The result should be read at 15 minutes. Do not interpret the result

after 20 minutes. 7. NB. clear positive results can read before 15 minutes.

Interpretation of resultsPOSITIVE:* Two distinct Pink lines appear. One line (the control) should be in the control region (near the letter C) and another line (the test) should be in the test region (near the letter T).

*NOTE: The intensity of the pink color in the test line region (near letter T) will vary depending on the concentration of P.f. present in the specimen. Therefore, any shade of pink in the test region (near letter T) should be considered positive.

NEGATIVE: One Pink line appears in the control region (near the letter C). No apparent red or pink line appears in the test region (near the letter T).


Blood testing, laboratory and treatment standard operating manualINVALID: Control line fails to appear. Or only the test line shows without the test line. Insufficient specimen volume or incorrect procedural techniques are the most likely reasons for control line failure. Review the procedure and repeat the test with a new test device.

Quality ControlInternal procedural controls are included in the test. A Pink line appearing in the control region (near letter C) is an internal positive procedural control. It confirms sufficient specimen volume and correct procedural technique.

Control standards are not supplied with this kit; however, it is recommended that positive and negative controls be tested as a good laboratory practice to confirm the test procedure and to verify proper test performance.

Limitation1. The Malaria P.f. Rapid Test Device (Whole Blood) is for in vitro

diagnostic use only. This test should be used for the detection of P.f. antigen in whole blood specimens only. Neither the quantitative value nor the rate of increase in P.f. antigen concentration can be determined by this qualitative test.

2. The Malaria P.f. Rapid Test Device (Whole Blood) will only indicate the presence of P.f. antigen the specimen and should not be used as the sole criteria for the diagnosis of malaria infection.

3. As with all diagnostic tests, all results must be interpreted together with other clinical information available to the physician.

4. If the test result is negative and clinical symptoms persist, additional testing using other clinical methods is recommended. A negative result does not at any time preclude the possibility of malaria infection.




Blood testing, laboratory and treatment standard operating manualHow to do the RDT test- Sit or lie the person down- Check the expire date on the pouch- Open the test pouch: check that the desiccant is not wet and still

shakes; if not discard- Write the name , date and ID number (given by the PDA) onto the

cassette with the fine-tip marker or pencil.- Suck the sample to the first mark of the sucking bulb from the drop of

blood on slide done for the HemoCue analyze by lightly squeezing the sucking bulb

- Take 5 microlitres of blood using the sucking bulb provided, then touch blot on sample well (small round well).

- Hold the buffer bottle vertically upside down over buffer well (large round well) and let out exactly 5 drops

- Write time onto the cassette with the fine-tip marker or pencil.- Wait for 15 minutes before reading the test results- Make sure the control line shows (a pink line near letter C)- Then look at the test window: a positive test shows a pink line in the

test area( pink line near letter T). - A faint pink line also indicates a positive result.- Record the result in the PDA

DOs- Follow instructions carefully in performing the test- Store as packaged in the sealed pouch at 4-37°C DO NOT FREEZE- Label specimens as per MIS 2010 instructions(name, date and ID

number)- Handle all specimens as potentially infectious- Follow standard bio-safety guidelines of MIS 2010 for handling and

disposal of potentially infective material- Read the results at the end of 15 minutes. - However, if the background of the test window has not cleared within

this time, add 1-2 drops of buffer and wait for another 15 minutes before reading the results

- Clear Positive results can be read even before 15 minutes.Note: not negative results.

- Wear protective clothing such as disposable gloves when specimens are collected & processed

DON’Ts- Do not re-use the test device or lancet- Do not use the test device after the expiration date- Do not open the kit more than 5 minutes before doing the test as the

test is very sensitive to humidity. The test device must remain in the sealed pouch until just before use

- Do not mix reagents from different lots


Blood testing, laboratory and treatment standard operating manual- Do not eat, drink or smoke in the area where the specimens and kits are

handled- Do not use if pouch or devices are damaged or if any lines are visible on

the device before contact with the specimen- Do not use clotted blood for the test- Do not read the test before 15 minutes- Do not miss ‘faint positives’



Blood slide general instructions

IntroductionThe methodology for blood film collection and staining is adopted from Bench Aids for the diagnosis of malaria infections 2nd edition, WHO Geneva 2004. The thick film is the major specimen for examination and parasite count while the thin film is used to confirm parasite species but not for labeling as slides are frosted. Smears are prepared on two separate slides and labeled as per the standard coding identical to their counterpart RDTs and filter papers.Malaria parasites take up Giemsa stain in a special way. The regular method (3% slow staining ) is used to stain the fims in this survey. Slow staining method requires less quantity of stain, but much longer staining time (45 minutes).

Materials requiredFor taking slides in the field

Clean frosted slidesSterile lancets70% alcohol swabsCotton woolClean, lint-free cotton towelSlide tray for drying slidesPencilSlide carrier boxTape or rubber band

For fixing thin films and staining

Buffer capsules for pH 7.2 or buffer stock solutionMeasuring cylinder (1000, 100, 25ml capacity)Permanent markers or pencilsDistilled water Alcohol JarsMethanol alcoholDrying rack Giemsa stain stock solutionStaining Jars or troughSlide drying rackSlide carrier boxes Timer


Blood testing, laboratory and treatment standard operating manualTaking blood samples1. First, clean the slides with gauze before collecting the blood. Greasy

slides will result in bad blood film preparation. (This should be done and made ready at home before departing to the field work)

2. Handling clean slides only by the edges, collect the blood as follows:a. Apply gentle pressure to the finger & collect a single ooze of blood about this size () on to the middle of the slide.b. Apply further gentle pressure to the finger and collect three more oozes of blood about this size on to the other slide.c. Wipe the remaining blood away from the finger with a piece of cotton (Step-1 in the pictorial presentation above).

Making blood films and labelingMaking the thin smear

- Place a small drop of blood on the pre-cleaned, labeled slide (see A below).

- Bring another slide at a 30-45° angle up to the drop, allowing the drop to spread along the contact line of the 2 slides (see B below).

- Quickly push the upper (spreader) slide toward the unfrosted end of the lower slide (see C below).

- Make sure the smears have a good feathered edge (see D below). - Let it air dry on a flat surface- At the end of the day fix it by adding a drop of methanol on the smear.- Let it air dry then pack it in the slide box carrier.

Making the thick film


Blood testing, laboratory and treatment standard operating manual- Using the corner of the spreader quickly join the drops of blood &

spread them to make an even, thick film. The shape of the thick smear should be circular. Remember that the blood shouldn’t be excessively stirred 3-6 movements are enough (Step-3 in the pictorial presentation above).

- Label the slide on the frosted edge with pencil with thename of the patient,date and ID number (given by PDA). Identical to their counterpart RDTs,thin film and filter paper number.

- Allow the thick film to dry in a flat level position protected from flies, dust and extreme heat. DO not fix. Note that sun heat can fix the thick smear.

- The slide used as spreader may now be used for the next person and another clean slide from the pack will be used as a spreader.

Common errors in blood film preparationsEdge of spreader slide chipped

Blood film spread on a greasy slide

Too little blood



Thin film too big

Dried blood spots Label the filter paper with a pencil on the second left square with

the patient name,date and ID provided by the PDA. Draw 10 microlitres of blood from the slide using the sucking bulb Touch blot this blood on the provided well labeled filter paper Put blood on three squares in alternating positions as shown below. Let it air dry, preferably overnight Pack it in the medicine bag with a desiccant. Zip close the medicine bag and store properly.

Staining of blood films



The regular method (for 20 or more slides) will be used in this survey as follows.For this method, slides must be well dried before staining.

Fix each thin blood film by dipping it in a container of Methanol for a few seconds (5-10 sec).

All the thin and thick films will not be stained in the field but they will be stained centrally at NMCC parasitology laboratory.

Place the slides, back to back or up with the film side in the staining jar, making sure that all thick films are at one end of the trough.

Prepare a 3% Giemsa solution in pH 7.2 buffered distilled de-ionized water.

Use the formula as 3ml Giemsa stock solution for every 97ml distilled and buffered water, pH 7.2 to prepare the working solution.

Gently pour the staining (working solution) in a staining trough. Arrange your slides on a staining rack and immerse them into the staining trough. Adjust final volume of the working solution to ensure slides are totally covered. Avoid pouring the stain solution directly on to the thick films.

Leave the slides in the stain for 30- 45 minutes. (Experience will indicate the correct time for each batch of slides).

In the meantime prepare clean water in a rinsing trough.

Gently immerse the staining rack into the rinsing trough and then rinse gently. Do not leave a deposit of scum over the smear.

Place the slide in the drying rack, thin film side downwards, to drain and dry, making sure that the film does not touch the slide rack.

Packing slides and labeling of slide boxesStained and dried slides must be packed in slide boxes from each enumeration area

Label boxes includingRegionZone NoTeam No.________Sub team No.___________Cluster No.Person No. _____to________



Summary of steps in collecting blood films and doing anaemia, RDT tests and slides in the field

Turn on the Hemocue machine and take out one microcuvette Open one pouch of RDT and label it with the PDA generated ID

number,name of the patient and date Prepare two well labelled slides, lancet and cotton swab Remove one filter paper and label it clearly Clean the 4th finger tip with an alcohol swab Prick the finger using sterile lancet. Dispose of lancet in sharps

biohazard container(Do not re use a lancet) Drop three drops of blood on the slide meant for a thick smear Take and fill in the microcuvette for anaemia. Take sample using sucking bulb for RDT (be fast to avoid blood

clotting on the slide before sampling).- Touch Blot the blood sample into sample well of the test device.- Add 5 drops of buffer into the buffer well and indicate the time as

shown on the test device. Using the same sucking bulb, fill it with blood to the second mark

and then squeeze it on one of the squares on the filter paper and repeat this on the other two squares on alternate positions.

Make 2 films for thick and thin film and put slides in holder to dry. Read the Hb results on the Hemocue for anaemia. Record result in

PDA. Read the RDT result after 15 minutes. Record result in PDA. Transfer the dried slides to carrier boxes and seal with tape or

rubber band. Give the necessary treatment(s) if applicable. Dispose of all materials in the right biohazard container. Pack and carry all the equipment for the next home Fix all the thin smears with methanol for the day The following morning individually pack all the well labelled air

dried filter papers individually in a medicine bag with a desiccant and zip it.


Blood testing, laboratory and treatment standard operating manualTreatment of positive cases Anyone who is seriously ill and/or needs further management will be referred to the nearest health facility. Transport will be provided in case of emergency.

AnaemiaHemoglobin results will be available immediately and will be shared with the parent/guardian.

Children with haemoglobin levels <8g/dl and who are positive with malaria will be given an artemisinin-based combination anti-malarial treatment according to national treatment guidelines (currently Coartem®), albendazole (if >24 months of age per IMCI guidelines). Children with a haemoglobin level of 5 g/dl and less and who are positive to RDTs, will be referred to a health centre for appropriate care.

For Coartem dose guidelines see below under the malaria treatment section.

Albendazole/Mebendazole

Give 500 mg (one tablet) as a single dose if the child is two years of age or older.

Iron tablets

Give one dose daily for 14 days.

MalariaPeople with a positive RDT result will be treated with Coartem®, except for pregnant women, who will be treated with quinine and children weighing less than 5 kgs who will be treated with Fansidar.


Blood testing, laboratory and treatment standard operating manualArtemether-Lumefantrine (Coartem®)

Tablet containing 20 mg Artemether plus 120 mg Lumefantrine in a fixed dose combination.

Weight(kg)

Age(Years)

Number of tablets per dose

Twice daily for 3 days Day 1 Day 2 Day 3First contact

8 hours later

Morning Evening Morning Evening

5 – 14 3 months – 2 years

1 1 1 1 1 1

15 – 24

3 – 7 years

2 2 2 2 2 2

25 – 34

8 – 10 years

3 3 3 3 3 3

35+ >10 Years

4 4 4 4 4 4

Side effects

The following adverse effects have been reported: dizziness and fatigue, anorexia, nausea, vomiting, abdominal pain, palpitations, myalgia, sleep disorders, arthralgia, headache and rash.

Contra-indications

- Malaria prophylaxis either alone or in combination.- Persons with a previous history of reaction after using the drug- Pregnant women, mothers with infants less than three months of age and infants less than five kg- Persons with severe malaria.

Note: Appropriate storage and use of Artemether-Lumefantrine

Artemether-Lumefantrine has a short shelf life of two years only. It is a highly hygroscopic chemical compound; moisture and temperatures of 30°C and above severely affect its efficacy. To prevent this, therefore, the drugs should be stored at temperatures below 30°C and should not be removed from the blister if they are not going to be used immediately.


Blood testing, laboratory and treatment standard operating manual Artemether-Lumefantrine is packaged as shown below.

Quinine

Quinine 8 mg base/kg 3 times daily for 7 days

Weight(kg)

Age years) Oral (tablets)Dosage to be given daily

200 mg salt 300 mg salt 4 – 6 2 – 4 Months 1/4 -

6 – 10 4 – 12 months 1/3 ¼ 10 – 12 1 – 2 years 1/2 1/3 12 – 14 2 – 3 years 3/4 ½ 14 – 19 3 – 5 years 3/4 ½ 20 – 24 5 – 7 years 1 ¾ 25 – 35 8 – 10 years 1 1/2 1 36 – 50 11 – 13 years 2 1 ½ 50+ 14+ 3 2

Fever Management in children aged five years and below

Classification and Treatment of the Child’s Fever



(Child Aged 2 Months to 5 Years)

Signs Classification Treatment

▪ Fever (by history or temperature 37.5c C or above)

MALARIA • Treat with sulfadoxine-pyrimethamine (SP).• If the child has already been appropriately treated with SP during this episode of fever, treat with oral quinine.• Do tepid sponging• Give one dose of paracetamol for fever of 38.5o C or above (see Table 4.14)• Advise the caretaker when to return immediately• Ask the caretaker to return in 2 days if fever persists • If fever is present every day for 7 days, refer for further assessment

▪ •

* Fever of 37.5c C does not require treatment with paracetamol; in this age group you should give paracetamol only when the child’s temperature reaches 38.5o C.


Blood testing, laboratory and treatment standard operating manualDisposing of hazardous waste Any material coming in contact with blood or serum (lancets, alcohol swabs, gauzes, and gloves) is considered to be biohazardous, i.e., hazardous to other human subjects. Safe disposal of such materials is very important to prevent the transmission and spread of various blood-borne diseases, such as Hepatitis B and HIV, among survey personnel and within the study community. Biohazardous wastes have to be collected in a special container during the parasitemia and anaemia testing, securely stored and transported, and safely disposed of at the end of each day of fieldwork at the near by health facility.

Materials and Supplies

The following items are required in the field for disposal of biohazardous materials after parasitemia testing:

Four percent sodium hypochlorite solution1

Matches or lighter Ziplock-type polyethylene bags Sharps container labelled "Biohazard" (for example, a wide-mouth

plastic jar).

Procedures for Field Disposal of Biohazardous Wastes

At the end of each blood collection , parasitemia and anaemia measurement, all materials used during the testing like gloves, alcohol swabs, sharps, microcuvettes, pipettes, wrappers, desiccants and gauze pads have to be placed in waste bins container (a wide-mouth plastic jar) and kept there until the end of the working day. NB. It is advisable to have two waste bins. One for sharps, microcuvettes and pipettes. The second one for all the other survey waste. The waste bins should be taken to the nearest health facility where they will be incinerated.

1 Four percent hypochlorite solution could be purchased as a commercially available product. It could also be prepared in the field by substituting a hypochlorite powder using water. The liquid solutions (sodium hypochlorite solution and kerosene) should be stored in leakproof and airtight containers


Blood testing, laboratory and treatment standard operating manualAvoiding problems arising in the field

Problems of haemoglobin testing in the field1. “Milking” the finger. Excessive massaging or squeezing of the finger will cause tissue juice to mix with and dilute the blood. This will result in erroneous test results, particularly in yielding low levels of haemoglobin concentration in the blood. Instead, the tester should employ only mild pressure by using the thumb and the second and third fingers to make a “pad” at the puncture site. This will make the connective tissue underlying the skin more porous and allow the capillary blood to flow easily after the incision.

2. Mixing alcohol with the blood. Alcohol, which is used to clean the puncture site, can mix with the blood and cause errors in the haemoglobin reading. Any residual alcohol will cause haemolysis and specimen dilution, as well as excessive platelet clumping, red blood cell aggregation, and sedimentation at the skin-puncture site. To avoid this problem, the finger or heel must be wiped dry completely before being punctured.

3. Removing a microcuvette from the container with fingers wet with alcohol. This can result in alcohol coming into contact with the reagents inside the microcuvette and destroying them. Using fingers wet with alcohol to handle other microcuvettes in the container can also affect them.

4. Shallow puncture. A deep puncture should be made for better blood flow and to have a representative concentration of red blood cells.

5. Using the first or second drop of blood. Only the third or fourth drop of blood should be used for haemoglobin testing. This ensures the free flow of blood and allows for the collection of blood with a representative concentration of red blood cells.

6. Obstructing blood flow. It is important to hold the finger properly to allow for the accumulation of blood in the puncture-site area. Holding the finger too tightly can obstruct the blood flow to the finger.

7. Inadequate filling of the microcuvette. The compartment of the HemoCue Hb 201+ microcuvette that contains dry reagents (yellow portion) has to be completely filled. The microcuvette should be filled with a drop of blood in one continuous motion. An inadequately filled microcuvette that contains air bubbles should be discarded.

8. Not Wiping blood off the microcuvette. Excess blood on the outside of the microcuvette should be cleaned. Blood on the outside of the microcuvette can lead to high haemoglobin reading and contamination of the HemoCue Hb 201 .



9. Inadequate placement of the microcuvette. The microcuvette has to be carefully placed on HemoCue Hb 201+’s microcuvette holder and pushed slowly inside the photometer into position for reading. Avoid “slamming” the microcuvette holder and spraying the blood into the HemoCue Hb 201+’s optic system. This action can damage the photometer.

10. Improperly stored microcuvettes should not be used for testing. Microcuvettes should not be kept in unsealed containers for longer than 3 months. The containers must be kept closed when not in use to avoid exposure to moisture, heat and sunlight, which can destroy the reagents.

Problems of parasitemia testing in the field1. "Milking" the finger. Excessive massaging or squeezing of the finger or foot will cause tissue juice to mix with and dilute the blood. This will result in erroneous test results, particularly in yielding low levels of parasitemia concentration in the blood. Instead, the tester should employ only mild pressure by using the thumb and the second and third fingers to make a "pad" at the puncture site. This will make the connective tissue underlying the skin more porous and allow the capillary blood to flow easily after the incision.

2. Mixing alcohol with the blood. Alcohol, which is used to clean the puncture site, can mix with the blood and cause errors in the parasitemia reading. Any residual alcohol will cause haemolysis and specimen dilution, as well as excessive platelet clumping, red blood cell aggregation, and sedimentation at the skin-puncture site.It will also fix the thick blood smears, which will make it difficult to reading the smears. To avoid this problem, the finger or heel must be allowed to air dry completely before being punctured.

3. Shallow puncture. A deep puncture should be made for better blood flow and to have a representative concentration of red blood cells.

4. Using the first or second drop of blood. Only the third or fourth drop of blood should be used for parasitemia testing. This ensures the free flow of blood and allows for the collection of blood with a representative concentration of red blood cells.

5. Obstructing blood flow. It is important to hold the finger properly to allow for the accumulation of blood in the puncture-site area. Holding the finger too tightly can obstruct the blood flow to the finger.

6. Not labeling the slide or the RDT. As the blood smear will be taken to another location to do the microscopy examination, it is critical that the glass slide is properly labeled so that the result can match with the child (or mother) when recorded. Similarly, the RDT result which may be read 10-15 minutes later must be properly labeled so that there is no mistake


Blood testing, laboratory and treatment standard operating manualin linking the result to the child tested. Also both the used RDTs and slides will be required for quality control hence proper labeling is essential.

7. Improperly stored RDTs should not be used for testing. RDTs may have specific storage requirements and should not be used if these storage requirements were not followed. The cassettes must remain un opened until just before use to avoid exposure to moisture, which may destroy the reagents or alter the properties of the test.8.Application of too much blood, when more than enough blood is applied the test area does clear fast and the reading of the results especially the faint positive results can easily be missed.


Date post:	25-Jan-2017
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