Introduction to the course

1. Introduction to the course

2. Agenda Include: TECHNICAL ISSUES PRACTICAL ISSUES

3. TB situation • TB is the typical disease of poverty. Of the 22 countries that have 80% of the world's TB burden, 17 are classified as low-income countries. • The lack of human resources available for TB control at all levels is a global problem. New donors and opportunities for international collaboration have become available as recently highlighted by the launch of the Global Laboratory Initiative

4. General objectives • Train laboratory personnel: • in performing M. tuberculosis culture and DST; • in working safely in a laboratory performing cultures and DST; • in complying with quality assurance requirements. • Raise awareness of the importance of laboratory performance in TB control.

5. Target audience • Laboratory personnel who will perform specimen processing, cultures of tubercle bacilli and drug susceptibility testing of isolated strains in the laboratory component of the national TB control programme (or other sector involved in TB diagnosis). • The course is intended for laboratory personnel in low- and middle-income countries working in laboratories at the central and intermediate levels.

6. Requirements for trainees • Proficient in TB smear microscopy and handling of specimens (recognize good-quality samples, use registers, aware of consequences of laboratory errors for patient management). • Trained in good laboratory practice (familiarity with laboratory environment and differentiation between clean/dirty working areas; use and maintenance of standard laboratory equipment such as balance, incubator, freezer, refrigerator) and used to following written protocols. • Familiar with quality control (QC) and external quality assurance (EQA) for smear microscopy. • Aware of the national TB control programme structure and laboratory network.

7. Course methodology • Lessons • Interactive • Exercise/experience/problem-solving • Practical work in the laboratory

8. Materials provided • Participant’s manual, in modules (folder) • Agenda (folder) • PowerPoint presentations and exercise slides (handouts and CD) • Technical materials (CD)

9. Learning objectives ‒ Module 1Overview: Tuberculosis, the global emergency At the end of this module, participants will be able to: • comment on the worldwide and local TB epidemic; • explain TB/HIV and MDR- XDR-TB; • describe the forms and transmission of TB; • describe the new Stop TB Strategy; • explain the roles of the NTP and the laboratory network; • explain the importance of AFB microscopy, culture and DST in TB control.

10. Learning objectives ‒ Module 2Safety precautions for tuberculosis culture and DST At the end of this module, participants will be able to: • explain airborne transmission of TB; • adhere to safe practice; • explain the biosafety levels of TB laboratories; • work safely in biological safety cabinets; • use adequate protective personal equipment; • use appropriate disinfectants; • cope with accidents in the TB laboratory; • handle chemicals safely in the laboratory .

11. Learning objectives ‒ Module 3Use, calibration and maintenance of laboratory equipment • At the end of this module participants will be able to: • describe briefly the operating characteristics of biological safety cabinets, centrifuges, autoclaves, inspissators, pH meters, incubators; • correctly use biological safety cabinets, centrifuges, autoclaves, inspissators, pH meters, incubators; • describe the main maintenance operations for biological safety cabinets, centrifuges, autoclaves, inspissators, pH meters, incubators.

12. Learning objectives ‒ Module 4 Preparation of solid media for culture and DST At the end of this module participants will be able to: • recognize different media for mycobacteria culture and explain their advantages/disadvantages; • prepare all the reagents, including drug solutions, for preparation of media for culture and DST; • prepare and dispense the culture medium; • check the quality of tubes at the end of the process and store properly; • perform the sterility check.

13. Learning objectives ‒ Module 5Collection, transportation and receipt of specimens At the end of this module participants will be able to: • explain the proper collection of specimens; • explain how to select suitable containers for the collection of different specimens; • explain the proper labelling of specimens to be submitted to the TB laboratory; • explain the proper transportation of specimens; • list the features of a good specimen; • fill in the laboratory register.

14. Learning objectives ‒ Module 6Processing the specimens and inoculation of solid and liquid media At the end of this module participants will be able to: • work properly within a BSC; • Process specimens from sterile and non sterile sites, according to protocols, for TB culture; • homogenize and decontaminate respiratory specimens by: • Petroff modified method, • NALC-NaOH method; • Kudoh method; • inoculate cultures (solid and/or liquid media); • incubate inoculated media under proper conditions.

15. Learning objectives ‒ Module 7 Reading cultures At the end of this module participants will be able to: • examine cultures at appropriate times; • identify presumptive M. tuberculosis colonies; • recognize contaminations; • report the suspect positive cultures.

16. Learning objectives ‒ Module 8Identification of M. tuberculosis At the end of this module participants will be able to: • evaluate growth characteristics for species identification; • perform and interpret the PNB growth inhibition test; • perform and interpret the niacin test • perform and interpret the nitrate reduction test • perform and interpret the catalase test: • heat-labile; • Understand the principle of immunochromatographic tests.

17. Learning objectives ‒ Module 9Recording and reporting culture results At the end of this module participants will be able to: • record culture results in the laboratory register; • record and report accordingly (semiquantitative) on WHO forms.

18. Learning objectives ‒ Module 10Performing drug susceptibility testing At the end of this module participants will be able to: • understand the objectives and rationale of combined anti-TB therapy; • understand the basic definitions of drug resistance in TB; • understand how drug resistance develops; • understand the rationale for using a critical concentration of drug in laboratory assays; • understand the rationale for determining the proportion of resistant bacteria that is clinically significant; • explain the different methods for performing DST; • perform and interpret the proportion method; • record and report DST results; • store strains.

19. Learning objectives ‒ Module 11Compliance with established quality assurance requirements At the end of this module participants will be able to: • explain the three main components of the QA system and their importance; • adhere to the QC and EQA procedures.

20. Learning objectives ‒ Module 12Managing supplies for a tuberculosis laboratory performing culture At the end of this module, participants will be able to: • list supplies required for culture; • explain ordering of supplies; • maintain proper records; • explain use of the stock book; • calculate supplies required; • inspect and verify supplies required; • explain storage of supplies.

21. Course evaluation • Self-evaluation by suggested key questions at the end of each module • Evaluation by participants (questionnaire)