Implementation of external quality assessment of microscopy for improved parasite detection and confirmatory diagnosis o
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RESEARCH NOTE
Implementation of external quality assessment of microscopy for improved parasite detection and confirmatory diagnosis of malaria in Tanzanian Military health facilities Akili K. Kalinga1,2* , Saidi Mgata3, Reginald A. Kavishe2, Lucas Mahikwano3, Lucky Temu3, Christopher Mswanya4, Charles Mwanziva4, George Amoo5, Edwin Kamau6, Brian Vesely6 and Deus S. Ishengoma1,7,8
Abstract Objective: Good quality microscopy is critical for accurate detection and confirmation of malaria parasite infections. Microscopy relies on the skills of technicians to prepare and read slides, high quality reagents, and a good program of internal and external quality control (EQA), which are lacking in most malaria endemic settings. This study was undertaken between January 2016 and December 2018 to pilot an EQA of microscopy for improved diagnosis of malaria and patient care in Tanzanian Military health facilities. Results: Of all blood smears crosschecked (n = 4000) at baseline, only 38.5% were incorrectly diagnosed by laboratory staff with false positive and negative rates of 46.7% and 16.4%, respectively. During the implementation of EQA, false positive and negative results decreased due to increased quality index of slide preparation and reading through supportive supervision, and retraining of laboratory personnel. There was a gradual increase of quarterly and annual total quality index for all laboratories, from 60% in 2016 to 78% in 2017 and 90% in 2018. The mean proficiency testing performance scores also increased from 75% in 2016 to 82% in 2017 and to 90% in 2018. Poor blood smear preparation and staining contributed to high false positive and negative rates while EQA helped in improvement of diagnostics. Keywords: Malaria, Microscopy, External quality assessment, Proficiency testing, Total quality index, Military health facility, Tanzania Introduction Prompt parasitological detection and confirmation of parasite infections is recommended as an important pillar of malaria case management for improved care and treatment of febrile patients [1, 2]. Despite recent introduction of rapid diagnostic tests, good quality microscopy is still considered a reference test for malaria *Correspondence: [email protected] 1 National Institute for Medical Research, Dar es Salaam, Tanzania Full list of author information is available at the end of the article
diagnosis [3, 4]. However, the effectiveness of malaria microscopy depends on maintaining a high level of competence and performance of laboratory staff, ensuring good-quality reagents, proper preparation and staining of blood smears and regular internal and external quality assessment, which are currently lacking in most malaria endemic countries [4, 5]. The World Health Organization (WHO) recommends for malaria endemic countries to implement a comprehensive external quality assessment (EQA) to ensure the quality of malaria diagnosis by microscopy [4, 6]. The EQA
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