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................................................................................... 3
General precautions when taking blood ...................................................... 4
HemoCue general instructions .................................................................... 5
ICT MAL PF general instructions ........................................................ 11
Intended Use .............................................................................................. 11
Summary.................................................................................................... 11
Principle ..................................................................................................... 11
Precautions ................................................................................................ 12
Storage and Stability.................................................................................. 12
Specimen collection and Preparation ........................................................ 12
Materials .................................................................................................... 12
Directions for use ...................................................................................... 13
Interpretation of results.............................................................................. 13
Quality Control .......................................................................................... 14
Limitation .................................................................................................. 14
How to do the RDT test ............................................................................. 16
DOs ............................................................................................................ 16
DON’Ts ..................................................................................................... 16
Blood slide general instructions ............................................................. 18
Introduction ............................................................................................... 18
Materials required ...................................................................................... 18
Taking blood samples ................................................................................ 19
Making blood films and labeling............................................................... 19
Common errors in blood film preparations ............................................... 20
Dried blood spots ....................................................................................... 21
Staining of blood films .............................................................................. 22
Summary of steps in collecting blood films and doing anaemia, RDT
tests and slides in the field ...................................................................... 23
Treatment of positive cases .................................................................... 24
Anaemia ..................................................................................................... 24
Malaria ....................................................................................................... 24
Disposing of hazardous waste ................................................................ 28
Avoiding problems arising in the field .................................................. 29
Problems of haemoglobin testing in the field............................................ 29
Problems of parasitemia testing in the field .............................................. 30
Blood testing, laboratory and treatment standard operating manual
Standard Operating Procedures (SOP) for malaria parasite and
anaemia testing during field work for the national MIS 2010
Introduction
Three 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:
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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 participants
We 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.
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General precautions when taking blood
Personnel responsible for collecting blood for haemoglobin measurement must take
precautions to prevent parenteral, skin, and mucous-membrane exposures to bloodborne 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 mucousmembrane 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 containers during the
fieldwork, and follow established procedures to ensure proper disposal of all waste
products (see below under Disposal of Biohazardous Wastes).
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HemoCue general instructions
HemoCue 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.
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.
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Cleaning the HemoCue 201+
Clean the microcuvette holder daily and check for dirt or dried blood.
Follow these procedures to clean the microcuvette holder:
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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.
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The 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.
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Using 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.
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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.
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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.
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ICT MAL PF general instructions
Intended Use
The Malaria P.f. Rapid Test Device (Whole Blood) is a rapid chromatographic
immunoassay for the qualitative detection of circulating Plasmodium falciparum in
whole blood.
Summary
Malaria 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.
Principle
The 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 precoated 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.
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Precautions
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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 Stability
Store 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
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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
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Individually packaged cassettes (Test devices)
Buffer (reagent)
Disposable sucking bulb
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Package insert
Sterile lancet
Sterile alcohol swab
Directions for use
Allow 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 minutes
6. 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 results
POSITIVE:* 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).
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INVALID: 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 Control
Internal 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.
Limitation
1. 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.
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How 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
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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
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- 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’
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Blood slide general instructions
Introduction
The 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 required
For taking slides in the field
Clean frosted slides
Sterile lancets
70% alcohol swabs
Cotton wool
Clean, lint-free cotton towel
Slide tray for drying slides
Pencil
Slide carrier box
Tape or rubber band
For fixing thin films and staining
Buffer capsules for pH 7.2 or buffer stock
solution
Measuring cylinder (1000, 100, 25ml capacity)
Permanent markers or pencils
Distilled water
Alcohol Jars
Methanol alcohol
Drying rack
Giemsa stain stock solution
Staining Jars or trough
Slide drying rack
Slide carrier boxes
Timer
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Taking blood samples
1.
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 labeling
Making the thin smear
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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.
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Making the thick film
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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 preparations
Edge of spreader slide chipped
Blood film spread on a greasy slide
Too little blood
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Thin film too big
Dried blood spots
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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.
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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 boxes
Stained and dried slides must be packed in slide boxes from each enumeration area
Label boxes including
Region
Zone No
Team No.________Sub team No.___________
Cluster No.
Person No. _____to________
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Summary of steps in collecting blood films and doing anaemia,
RDT tests and slides in the field
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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.
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Treatment 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.
Anaemia
Hemoglobin 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.
Malaria
People 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.
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Blood testing, laboratory and treatment standard operating manual
Artemether-Lumefantrine (Coartem®)
Tablet containing 20 mg Artemether plus 120 mg Lumefantrine in a fixed dose
combination.
Weight Age
(kg)
(Years)
Number of tablets per dose
Twice daily for 3 days
Day 1
5 – 14
15 – 24
25 – 34
35+
3 months
– 2 years
3
–
7
years
8 – 10
years
>10 Years
Day 2
Day 3
First
contact
8 hours Morning
later
Evening
Morning
Evening
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
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.
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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)
200 mg salt
4–6
Age years)
2 – 4 Months
Oral (tablets)
Dosage to be given daily
300 mg salt
1/4
-
6 – 10
10 – 12
12 – 14
14 – 19
20 – 24
25 – 35
36 – 50
50+
4 – 12 months
1 – 2 years
2 – 3 years
3 – 5 years
5 – 7 years
8 – 10 years
11 – 13 years
14+
1/3
1/2
3/4
3/4
1
1 1/2
2
3
Zambia MIS 2010
¼
1/3
½
½
¾
1
1½
2
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Blood testing, laboratory and treatment standard operating manual
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
MALARIA
history or
temperature 37.5c C
or above)
• 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.
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Blood testing, laboratory and treatment standard operating manual
Disposing 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
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Blood testing, laboratory and treatment standard operating manual
Avoiding problems arising in the field
Problems of haemoglobin testing in the field
1. “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
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Blood testing, laboratory and treatment standard operating manual
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 field
"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.
1.
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 in 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.
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Blood testing, laboratory and treatment standard operating manual
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.
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