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REPORT ON THE MALARIA DIAGNOSIS USING MICROSCOPY AND RAPID DIAGNOSTIC

TECHNIQUES (RDTS) COURSE

June 2009

FUNDED BY STOP MALARIA - UGANDA

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TABLE OF CONTENTS

1.0 Introduction: ............................................................................................................... 3

2.0 Course Objectives: ...................................................................................................... 3

3.0 Trainee composition .................................................................................................. 4

4.0 Facilitation and content of the course ..................................................................... 4

5.0 Course assessment and evaluation .......................................................................... 4

6.0 Course evaluation .................................................................................................... 5

7.0 Certification .............................................................................................................. 5

8.0 Challenges: .................................................................................................................. 5

9.0 Conclusion .................................................................................................................. 5

10.0 Appendices .................................................................................................................. 5

Appendix 1. List of trainees: ........................................................................................... 6

Appendix 2.Course schedule: .................................................................................... 7

Appendix 3: pre and post test results: ............................................................................. 8

Appendix 4: Picture slide reading results: ............................................................... 9

Appendix 5.Course evaluation .................................................................................. 1

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1.0 Introduction:

The John Hopkins University on behalf of its Bloomberg School of Public Health (JHSPH) signed an agreement with the Infectious Diseases Institute (IDI) under which IDI was to perform work defined in the statement of work to enable JHSPH complete its obligation under its cooperative agreement entitled “Uganda Stop Malaria Program” .The scope of work requires IDI to “conduct Training of trainers (ToT) for district laboratory staff at IDI: Target 20 trainers from 5 districts” among other activities. These trainers would thereafter train other laboratory staff in their districts through cascade training thereby improving skills and performance of laboratory personnel. This would help build capacity for malaria laboratory diagnosis which is essential for implementation of the new Ministry of Health (MoH) policy of giving antimalarials to only those patients with a parasitological diagnosis of malaria. This activity contributes to Intermediate result 2.3 of the Stop Malaria Project (SMP) work plan for the first year which seeks to support the National Malaria Control Program to improve malaria diagnostic capacity in the districts. Further more, it addresses the key challenges identified in the Rapid District Assessments that include lack of support supervision and poor training of some laboratory personnel.

IDI conducted three training of trainers (TOT) courses (each lasting 4 days) on Malaria diagnosis using Microscopy and Rapid diagnostic techniques. The courses were held on the following dates; 16th to 19th June, 2009 for laboratory staff from Kiboga, Mityana and Wakiso districts , 22nd to 25th June 2009 for trainees from Wakiso, Luwero and Nakaseke districts and from 29th June to 2nd July 2009 for participants from the districts of Luwero, Mpigi and Wakiso. A sixth district was added to ensure IDI achieves its grant target; the initial 5 districts could not raise the 20 trainees who had been budgeted for in the grant agreement. This course report therefore presents what transpired during the three courses summarized under the following sections; course objectives, trainees composition, course content, facilitation, course assessment, evaluation and certification.

2.0 Course Objectives:

The courses were intended to ensure that each participant is able to: 1. Observe good clinical and laboratory practices. 2. Correctly diagnose malaria using microscopy. 3. Effectively use microscopy in the process of diagnosing malaria. 4. Efficiently use microscopy in the process of diagnosing malaria. 5. Value the need for quality assurance and quality control in ensuring

reliable laboratory services in a health facility setting.

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6. Correctly diagnose malaria using RDTs. 7. Provide technical support to peers in malaria diagnosis using microscopy

and RDT.

3.0 Trainee composition

The course was attended by a total of 21 trainees (3 females and eighteen 18 males) including Six (6) laboratory technologists and fifteen, (15) laboratory technicians. Of these, eleven (11) trainees were working in District Hospitals, nine (9) were from Health Centre IV facilities and one (1) was from the IDI Clinic laboratory (See appendix 1 for list of trainees).

4.0 Facilitation and content of the course

The course was conducted in the IDI training department and the Molecular Laboratory of Makerere University-University of California San Francisco (MU-UCSF) malaria research collaboration (MOLAB) coordinated by the IDI Laboratory Technologist. The course facilitators were experienced resourceful persons in laboratory practice from Health Care Improvement Initiative (HCI) of Ministry of Health, Faculty of Medicine, Makerere University College of Health Sciences; MU-UCSF malaria Research Collaboration Molecular Laboratory (MOLAB), Mulago National Referral hospital and the IDI. The facilitation methods included lectures, practical sessions, group discussions and presentations among others. The practical sessions were held at the MOLAB and other laboratories within Mulago hospital complex. The following topics were covered; (See course schedule in appendix 2)

Good Laboratory Practice

Microscopy

Preparation of reagents for malaria diagnosis.

Laboratory diagnosis of malaria

Performance and interpretation of rapid diagnostic tests (RDT).

Quality assurance and quality control

Facilitation and mentoring skills for peer trainers.

Facilitation, mentoring and coaching

Demonstration of coaching and mentoring skills

Management of District based training.

5.0 Course assessment and evaluation

To assess the effect of the course on trainees’ knowledge and skills, pre and post tests were conducted at the beginning and end of course respectively. The results for the three courses are indicated graphically in figures 1, 2 and 3.

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Accuracy of performing laboratory diagnosis of malaria was assessed using picture slide reading as well as actual slides reading of pre prepared blood slides. The results indicate a considerable improvement in knowledge and skills after the course (figures 4, 5, 6,7,8,9 respectively). (See course schedule in appendix 3 and 4)

6.0 Course evaluation

The trainees evaluated all session on a daily basis and the entire course at the end. The findings indicate that the course was generally well organized, sessions were delivered well, the course content and materials were appropriate for the kind of work they do (See details of trainees’ comments in appendix 5).

7.0 Certification

At the end of the course, all the participants received certificates of successful completion endorsed by the STOP Malaria Project and the Ministry of health. All of them had scored above 50% in the post test and had attended 90% of all the sessions. The certificate award ceremonies for the three courses were presided over by officials from the MOH, IDI and STOP Malaria project.

8.0 Challenges:

The course duration was very short to allow for adequate practical sessions.

9.0 Conclusion

Over all, the courses were conducted as planned, were well appreciated, trainee knowledge and skills improved. Twenty one (21) laboratory professionals were trained to become district trainers and will work as peer trainers to carry out on site training of lower facility laboratory workers in their respective districts under the technical guidance of SMP. IDI wholeheartedly acknowledges the support given by the following organizations for the various forms of support given: - the STOP Malaria project, training partners, district and health facility leaders who provided trainees.

10.0 Appendices

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Appendix 1. List of trainees:

STOP Malaria TOT course held; 16th -19th June 2009

Name Sex District Qualification Facility type Contact

1 Byakika Grace M Kiboga Technologist Hospital 0772-657002

2 Sebikali Joel M Kiboga Technician HC IV 0776-594781

3 Nakayiza Sarah F Mityana Technician Hospital 0782-593120

4 Kakeeto Alex M Wakiso Technician HC IV 0776-969589

5 Matovu Baker M Wakiso Technician HC IV 0712-840174

6 Roy Xerxes Eyotre M Wakiso Technician Hospital 0772-843338

7 Niwagaba Richard M Wakiso Technician Hospital 0716-380193

STOP Malaria TOT course held: 22nd -25th June 2009

1 Muwanga Enosh M Luwero Technician HC IV 0712-924064

2 Balyesiima Victor M Wakiso Technician Hospital 0782-208684

3 Kalyesubula Edward M Luwero Technologist HC IV 0772-567380

4 Mbaziira Noah M Mityana Technician Hospital 0774-220141

5 Mutumba John M Nakaseke Technician Hospital 0772-546003

STOP Malaria TOT course held: 29th June -2nd July 2009

1 Kiddu Robert M Luwero Technician HC IV 0775-440301

2 Were Moses M Luwero Technologist HC IV 0772-428608

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Nkurikiyimana Stephenson M Nakaseke Technologist Hospital 0782-591013

4 Muyingo James M Mpigi Technologist Hospital 0772-601316

5 Kakooza Godfrey M Mpigi Technician HC IV 0774-423005

6 Ssonko Paul M Mpigi Technician HC IV 0782-350920

7 Nanyonjo Esther F Wakiso Technologist Hospital 0774-460412

8 Sr Nalweyiso Jacinta F Wakiso Technologist Hospital 0772-834243

9 Opio patrick Romeo M Kampala Technologist Clinic 0773-025825

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Appendix 2.Course schedule:

Time Day 1 Day 2 Day 3 Day 4

8.00 – 8.30 Registration and applications,overview

Review of Day 1

Review of Day 2

Review of Day 3

8.30 – 10.00 Pre-tests Picture reading pre test Slide pre test. Patrick Eyul / Ojaku Alex

Quality Control / Quality Assurance Kilama Maxwell

Picture slide review Ojaku Alex /Moses Kigundu

Introduction to the facilitators guide. Mr. Alex Ojaku

10.00 – 10.30

Midmorning tea/coffee

10.30 – 11.30

Good Laboratory Practice Francis Ocen

Laboratory diagnosis of malaria Nsobya Sam

Slide reading review. Ojaku Alex /Maxwell Kilama

Facilitation. mentoring and coaching Sr. Priscilla O

11.30 – 13.00

Microscopy Moses Kigundu

Performance and interpretation of RDTs. Kilama Maxwell

Skills development in Slide reading Maxwell Kilama

Demonstration of coaching and mentoring skills Sr.Priscilla O

13.00 – 14.00

Lunch break

14.00 – 15.30

Preparation and storage of reagents for malaria microscopy Ayika Ponsiano

Lab diagnosis of malaria-Slide preparation Nakafeero Regina

Post-test: Slide reading Ojaku Alex /Kilama Maxwell

Management of District based training. Umaru Ssekabira

15.30 – 16.45

Skills development in reagents preparation Ayika Ponsiano

Lab diagnosis of malaria-Smear staining Nakafeero Regina

Post-test: Picture reading Ojaku Alex

Post test. Ojaku Alex

16.45 – 17.00

End of day’s evaluation

End of day’s evaluation

End of day’s evaluation

End of course evaluation Closure

17.00 Evening tea /coffee and Retire

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Appendix 3: pre and post test results:

Figure 1: Pre-post assessment results- TOT 1.

Pre and post test -Written

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7

Personal identification number (PIN)

Mark

s (

%)

Pre test

Post test

Figure 3: Pre-Post assessment results TOT 3.

Pre post test results

0

50

100

1 2 3 4 5 6 7 8 9

Participants Identification

Number(PIN)

Marks(%

)

Pre test

Post tset

Figure 2: Pre-post assessment results- TOT 2.

Pre and post test results -Picture

reading

0

20

40

60

80

100

1 2 3 4 5 6 7

Personal identification

number(PIN)

Mark

s (

%)

Pre test

Post test

Figure 4: Malaria skill assessment (Picture slides reading TOT 1 )

Pre and post test-written TOT 2

0

20

40

60

80

100

1 2 3 4 5Personal identification number

(PIN)

Ma

rks

(%

)

Pre test Post test

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Appendix 4: Picture slide reading results:

Figure 5: Malaria skill assessment (Picture Slides reading TOT 2).

Pre post test picture slides TOT 2

0

20

40

60

80

100

1 2 3 4 5

Personal identification number (PIN)

Ma

rk

s (

%)

Pre test Post test

Figure 6: Malaria skill assessment (Picture Slides reading TOT 3).

Test results - Picture slides

0

50

100

1 2 3 4 5 6 7 8 9

Particpants Identification

Number(PIN)

Marks(%

)

Pre test

Post test

Figure 7: Malaria skill assessment (Slides reading TOT 1)

Pre -Post test -Slide reading

0

20

40

60

80

100

1 2 3 4 5 6 7Personal identification

number (PIN)

Mar

ks (%

)

Pre test

Post test

Figure 8: Malaria skill assessment (Slides reading TOT 2)

Pre and post test Slide reading TOT 2

0

20

40

60

80

100

1 2 3 4 5

Personal identificastion number (PIN)

Ma

rks

(%

)

Pre test Post test"

Figure 9: Malaria skill assessment (Slides reading TOT 3).

Pre post tests Slide reading

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9

Personal identification number (PIN)

Mar

ks (%

)

Pre test Post test

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Appendix 5.Course evaluation

End of course evaluation

STOP 19th June 2009 Areas of improvement

Need to increase time for the course, four days are so few

Time for some sessions was not kept, delays in some session presentations.

Cold tea was served

The sodas were never enough

Matooke should always be included on the menu

Lacked a permanent place for training

Sessions were never started on time. Likes

Good training, placement and labs

Meals on time, good facilitators and coordination

Conducive environment and friendly facilitators

Good facilitators, meals were okay

Active participation by trainees

Good learning environment and accommodative staff Benefits

Gained knowledge and skills

Ability to identify stages of malaria

Learnt the recommended ways of performing in blood slide

Learnt how to be a good facilitator

Reagent preparation

Counting parasite density

Smear preparation and examination Interacted with fellow technicians

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End of course evaluation STOP Malaria 25th June 2009

Areas of improvement

Need to increase time for the course for at least 5 days.

All people who attend ToT should have had trainings in basic lab

Instrumentation needs more time to cover all the four instruments

IDI needs its own training lab that is not congested Benefits

Refreshed on malaria diagnosis and acquired knowledge to train our fellow comrades in the district

Learnt new methods of diagnosis, reagent preparation and good laboratory practice

Boosted my skills and can now mentor

Gained knowledge / skills in malaria diagnosis and good lab practice

Improved on lab diagnosis and interacted with IDI staff Likes

Facilitators are friendly, admired teaching methodologies and session set up and meals were always on time.

Excellent teaching methods and skills presentation

The environment and people, teaching aids and internet

Course content

Facilitation and allowance

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End of Course Evaluation Stop Malaria Course 2nd July 2009

Benefits The trainees agreed that their expectations where met during the course and that the course will enable them improve service delivery in their duty stations. They pinpointed the following benefits from attending the course.

New methods of malaria diagnosis in the laboratory i.e diagnosing malaria using Rapid Diagnostic Tests (RDTs).

Skills of preparation of standard smears, staining, reading, reporting and differentiation of malaria species. Preparation of Romano sky stains was well appreciated by the trainees.

Facilitation and mentoring skills

Other reporting methods of smears for malaria e.g. in per micro liters.

Practical demonstration

Knowledge and skills in laboratory management of Malaria

Quality assurance and quality control

Facilitation guide and other handouts.

Made friends

Financial benefit i.e. some money Likes The trainees appreciated the fact that the training was well administered/managed. To them the course was perfectly run by the training team. Help was there when needed and the environment provided a good teaching-learning experience.

The training was interactive

Time management by facilitators was excellent.

Course organization was excellent.

Facilitation methods and learning aids were appropriate.

The learning environment was conducive i.e. both classroom and laboratory settings.

Participants were accorded care and respect.

The meals were good.

All the facilitators were knowledgeable and skilled in addition to being friendly and willing to help trainees understand.

Sessions were well conducted. Dislikes The course participants noted the following shortfalls that they felt needed to be improved to complete/add on the IDI experience.

The course was short given the volume of things to be covered. The trainees suggested that the course duration should be extended to two weeks.

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Catering service providers did not keep time. Much as they provided good meals, there was always a delay of meals. In addition to time managed, the trainees said that the bottled water provided by caterers was ‘bichupuli’ i.e. had signs that the bottle had been tampered with. Likewise, prevention control was not enhanced by the caterers since water for washing hands was not provided. They were particularly concerned that serviettes alone could not help clean their hands adequately.

Moving up and down for practicals. The trainees mentioned the distance between IDI and Mo-Lab as a hindrance. They noted that transport was provided for dropping them to Mo-Lab on the first day only.

Perdiem rates below the standard rates provided for by the Ministry of Health. Other things that notably came up are: -

The trainees needed more information on how to access more trainings provided at IDI. A general overview was given.

They also requested that being ambassadors of the trainers (IDI) and sponsors (Stop Malaria), they would be happy to go back to their work stations with corporate items of these organizations. An example given by the trainees was T-shirts proclaiming a message to the public.