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Laboratory
‘Network’ Update
Max Salfinger
New York State Department of Health
Princeton October 24, 2006
‘It is health
which is real wealth
not pieces of silver and gold’
Mahatma Gandhi, 1869-1948
•3 questions
•Survey
•Systems thinking
Adherence/Cure
3
2
sees
a
doctor
1
Time to negativity?
RIF resistance?
Tuberculosis?
Chest x-ray
History / physical exam
1.Tuberculosis
yes
or
no ?
Identification
Growth detection
Microscopy
Nucleic acid amplification
2. RIF res.
yes
or
no ?
Clinical course
Egg based AST
Agar based AST
Radiometric / Non-rad.
rpoB analysis (line probes)
Testing concentrations:
Drug
460TB
MGIT
INH
0.1/0.4 0.1/0.4 0.2/1.0 0.2/1.0
RIF
2.0
EMB
1.0
7H10
7H11
1.0
1.0
2.5/7.5 5.0
5.0/10
7.5
SM
2/6
1/4
2/10
2/10
PZA
100
100
N/A
N/A
What gets captured in
the TB database?
•Result - susceptible; resistant?
•Method - BACTEC 460; MGIT, etc?
•Concentration tested?
•Percent resistant colonies?
•Mutation found, type?
3. Time to negativity
•Follow up specimens until 2 consecutive
specimens are culture negative...
•Initial cavitation & mo-2 culture pos:
extend INH/Rif from 4 to 7 months
•Repeat susceptibility testing after 3 mo
•Pos culture @ mo-4: Treatment failure
Survey [N=11]:
CT, DE, IN, MA,
MI, NJ, NYC,
NYS, PA, VT, WV
NAA:
YES: 6
NO: 5
DST:
Bactec 7
MGIT 2
7H10, ESP ea 1
DST - screening:
SIRE-PZA 5
4 drugs 4
3 drugs 1
DST - 2nd-line:
YES 6
NO 5
Quantiferon:
YES 2
NO 9
Work days:
7 days: 1
6 days: 1
5 days: 8
Biggest concerns:
•Not enough resources
•Federal TB grant reduction
•Gamma Interferon assays: PHL or hospital-based labs
•Ability to keep high level of testing
•Delayed delivery of specimens and isolates
•Loosing 40+ years of experience (retirement)
•Staff shortage
•Time and money
•Maintaining staff competency
•Reduction of Federal $$$
Success stories:
•FAST TRACK program
•Being a member of the LIMS RFQ
•Moving into better lab space
•Implementation of NAA (homeless case)
•NAA turnaround time
•Staff cross-training
•Surpassing CDC turnaround time guidelines
•Improving TAT & client relationship with less staff
•Molecular identification and drug susceptibility
Systems Thinking
‘We tend to focus on snapshots of
isolated parts of the system, and
wonder why our deepest problems
never seem to get solved.’
Peter Senge in The Fifth Discipline, 1990
Did you hear Claudia’s
husband?
If you suspect DR,
MDR, or XDR TB you
have a moral
responsibility to get
the results in the
shortest TAT possible!
$$$
Laboratory
standards
New York: NAA mandatory
for newly diagnosed patients
whose sputum tested AFB
smear positive.
Reference
Laboratory
System
Change
Change
Change
Change
Change
TB
Think Big
Be
Bold !
Picasso: Peace Dove
WE can do it !
Thank YOU
for
Working TOGETHER!
The Journey sets
the Destination
see you ALL in
Tallahassee, FL !