Early Infant Diagnosis Sample Management in Mashonaland West Province, Zimbabwe, 2017

Abstract

Background In 2016, Mashonaland West Province had 7.4% (520) dried blood spot (DBS) samples for early infant diagnosis (EID) rejected by the Zimbabwe National Microbiology Reference Laboratory (NMRL). The samples were suboptimal, delaying treatment initiation for HIV-infected children. EID is the entry point to HIV treatment services in exposed infants. We determined reasons for DBS sample rejections and suggested solutions. Methods A cause-effect analysis, modelled on Ishikawa, was used to identify factors impacting DBS sample quality. Interviewer-administered questionnaires and evaluation of sample collection process, using Standard Operating Procedure (SOP) was conducted. Rejected samples were reviewed. Epi Info™ was used to analyze findings. Results Eleven (73.3%) facilities did not adhere to SOP and (86.7%) did not evaluate DBS sample quality before sending for testing. Delayed feedback (up to 4 weeks) from NMRL extended EID delay for 14 (93.3%) of the facilities. Of the 53 participants, 62% knew valid sample identification. Insufficient samples resulted in most rejections (77.9%). Lack of training (94.3%) and ineffective supervision (69.8%) were also cited. Conclusion Sample rejections could have been averted through SOP adherence. Ineffective supervision, exacerbated by delayed communication of rejections, extended EID delay, disadvantaging potential ART beneficiaries. Following this study, enhanced quality control through perstage evaluations was recommended to enhance DBS sample quality.

Inadequate dried blood spot samples for Early Infant Diagnosis, how common and what are the reasons for rejection in Zimbabwe?

“…These findings were similar to the findings of another study conducted in Kwazulu Natal province in South Africa where the rejection rate was 4% [6]. Even higher aggregated EID program DBS rejection rate of 7.4% was reported in similar study conducted in Zimbabwe in 2017 in Mashonaland West province [10]. However, the latter was a smaller study looking at only one province compared to the current study that looked at five provinces.…”

“…The implications of the rejections may result in missed diagnostic opportunities of HIV-infected infants, loss to follow up on the infants and challenges in early initiation of HIV-positive infants on ART. DBS rejection rates contribute towards delays in accessing of laboratory results for EID testing, have serious implications on the PMTCT program and lives of infants that may be in need of life long ART [8,10].…”

“…Similarly, in a study conducted in Nigeria, the main reasons for rejection were: poor collection technique (26.3%), improper labeling (16.4%) and insufficient blood collection (14.8%) [9]. The same stuy also showed that DBS collected at primary and secondary health care facilities were two to three times more likely to be rejected than those collected at tertiary healthcare facilities [10].…”

“…In Zimbabwe, it takes up to fourteen days from sample collection before NMRL communicates rejection to the submitting healthcare facility [11]. It takes further few weeks before the healthcare facility informs the mother-baby pair that the sample has been rejected and that therefore there is a need to provide a new DBS sample [10]. This inevitably results in delay in diagnosing and initiating treatment for the infants confirmed to be HIV-infected and result in MDO and loss to follow up.…”

Common causes of EID sample rejection in Zimbabwe and how to mitigate them

“…Similarly, in a study conducted in Nigeria, the main reasons for rejection were poor collection technique (26.3%), improper labelling (16.4%) and insufficient blood collection (14.8%) [9]. The same study also showed that DBS collected at primary and secondary health care level were two to three times more likely to be rejected than those collected in tertiary healthcare facilities [10].…”