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The Johns Hopkins UniversityA Training Program on Community-Directed Intervention (CDI) to Improve Access to Essential Health Services

CDI Module 16: RDT Training

Module 16 Objectives

By the end of this module, learners will: Explain why the malaria control program has elected

to use RDTs in the country/district Describe a rapid diagnostic test (RDT) Name appropriate actions for RDT positive, negative

and invalid results Describe the steps in performing a malaria RDT

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In Addition, Learners Will …

Demonstrate the correct and appropriate skills for drawing blood safely and effectively with a finger prick

State the universal precautions Correctly interpret different RDT outcomes Demonstrate the skills for performing RDT safely

and effectively, using the job aid as a guide State appropriate treatment based on RDT results

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Why Use RDTs?

Most of the febrile illnesses share common signs and symptoms: Fever Headache Weakness

Positive RDT results help to confirm malaria and thereby differentiate it from other febrile illness

Giving anti-malarial drugs/artemisinin-based combination therapy (ACT) presumptively is expensive and might lead to drug resistance

Many Different RDT Products

The World Health Organization and its partners have tested over 400 different types and brands of RDT

RDTs are chosen by each country’s National Malaria Control Program (NMCP) based on factors like …

Malaria prevalence Stable endemic, year-

round Unstable, epidemic,

seasonal

Malaria type Plasmodium

falciparum Plasmodium vivax

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Key Similarities among RDTs

Most all RDTs have: A lancet to draw blood A tube, pipette or

straw to transfer blood

A cassette to deposit blood and display results

A buffer solution to add to the blood

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Overall Steps for CHWs/CDDs

When training community health workers (CHWs)/community-directed distributors (CDDs), explain each step and provide an opportunity for them to:1. Determine if signs and symptoms suggest malaria2. Do RDT3. Interpret the test4. Take appropriate action

(If RDT result is positive) treat appropriately, according to national standards

(If RDT result is negative) seek further information, and either:– Treat for other conditions like pneumonia or diarrhea– Refer to the nearest health center, if severe

(If RDT result is invalid) repeat test with a new cassette from a different batch

Prepare for Demonstration and Return Demonstration for CHWs/CDDs

Assemble all needed materials

Ensure that the RDTs used for the demonstration match those approved by your NMCP

Make sure supportive materials like gloves, sharps box, etc. are available

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Gather Materials Needed

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Gather Additional Materials Needed

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Biohazard safety box

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Check Product Expiry Date

Show CDDs where to look for expiry (expiration) date

Explain that expired RDTs will not give correct result

Pass around packets for CHWs to examine and find dates

Discuss importance of planning ahead so RDT stocks do not expire or expired ones are replaced quickly

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Wear Gloves

Why is it important to wear gloves when doing the test?

To protect: CHWs from possible

infection with blood-borne diseases, including HIV/AIDS

Patients from possible infection with blood-borne diseases, including HIV/AIDS

Open the Test Packet and Remove the Contents

As you remove each item, hold it up so that everyone can see it

Explain how it is used

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Review Blood Transfer Devices

Once the packet is opened, the desiccant sachet serves no purpose and should be discarded

It may be harmful if swallowed, so it should be kept away from children

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Examine the Test Cassette

The square hole, labeled “A,” is where you add the blood

The round hole, labeled “B,” is where you add the buffer

The rectangular hole is the results window where you read the test results

The results window is divided into two sections

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How to Determine the Diagnosis

The longer section near the letter “T” is where you determine the diagnosis

If a line appears in this section, it means the patient has malaria

If no line appears here, it means malaria was not detected in the patient

Remember that the lines may be different for different brands/types of RDT—so be sure to explain what is currently approved by the NMCP

Look for Lines to Appear

The smaller section near the letter “C” tells you whether the test is working correctly

A line must appear in this section for the test to be valid

If no line appears here, the test is not working properly and the results are invalid

If no line appears here, you must discard the cassette and test the patient again using a new test packet that has not been previously opened

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Label the Test Cassettefor Proper Identification

Every patient’s test cassette must be clearly labeled for proper identification

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Clean to Prevent Infection

Clean the chosen finger with an alcohol swab

This will help to prevent infection of the finger that could be caused by dirt

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How to Draw Blood

Prick the patient’s finger, preferably toward the side of the pulp (ball) of the finger

Pricking the midline or tip is more painful

Check to be sure the finger prick will produce enough blood

Then discard the lancet in the sharps container

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Follow Universal Precautions toEnsure Blood Safety When Using a Lancet

Remind learners that every time they use a lancet, they must take all of the following steps to ensure blood safety: Discard the lancet in an appropriate sharps

container immediately after using it Never set the lancet down before discarding it Never discard the lancet in a non-sharps

container Never use a lancet on more than one person

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Dispose of Used Materials Safely

Ensure that used sharp objects like lancets and capillary tubes/test tubes are properly discarded immediately after use

Even though it is called “sharps container,” we should dispose of all medical waste in it

How to Collect the Patient’s Blood

On the next two slides, we show four blood collection devices

You may show these devices to the CHWs, but give special attention to the device in the current RDT packet or kit

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Examples of Blood-Collection Devicesfor RDT: Capillary Tube, Straw

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Examples of Two MoreBlood-Collection Devices for RDT: Loop, Pipette

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Loop:

Deposit Blood from Collection Device on Cassette and Then Dispose of Blood-Collection Device Safely

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Dispense the Buffer Reagent Appropriately

Dispense the appropriate number of drops of the buffer reagent to the appropriate hole (round hole) of the cassette

Read out from packet insert the number of drops recommended for the type of RDT being used

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Time the Test Properly

Make sure the test stands for 15 minutes after adding the buffer, before reading the result

Be sure to read the RDT packet insert because some types call for longer times

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Dispose of Used Materials Safely

Take care to remove and discard your gloves safely

Plan a system for safe disposal of all RDT waste materials

Decide whether CHWs will dispose of items in the village or bring these items to the health center for disposal

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How to Interpret the RDT Results

The square hole labeled “A” is where you add the blood

The round hole labeled “B” is where you add the buffer

The rectangular hole is the results window where you read the test results

The smaller section near the letter “C” tells you whether the test is working correctly (it is also known as the control)

Test window

Square hole(for blood)

Round hole(for buffer)

“C” control line

“T1” test line

“T2” test line

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How to Interpret Results of RDTs Designed for More than One Type of Malaria

Lines in “T1” and “T2” and a line in “C” means:

The patient DOES have falciparum malaria monoinfection or a mixed infection

T1 T2

Pf or Mixed +

NO LINE in “T1” or “T2” but a line in ‘C’ means:

C

Negative

T1T2C

The patient DOES NOT have either falciparum malaria or non-falciparum malaria

How to Interpret the RDT Results(continued)

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No line in “T1” or “T2” and NO LINE in “C” means:

Invalid

T1 T2

Line in “T1” or “T2” and NO LINE in “C” means:

T1 T2

Invalid

The test is damaged. Results are INVALID.

The test is damaged. Results are INVALID.

Review Different Possible Results

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A line in “T2” and a line in “C” means:

Non-Pf +

T1T2

The patient DOES have non-falciparum

malaria (P. vivax, P. ovale, P. malariaeor a mixed infection of these).

Review Different Possible Results(continued)

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T1 T2

A line in “T1” and a line in “C”means:

Pf +

Pf +

The test is POSITIVE even if the line in “T1” is very faint.

T1 T2

The patient DOES have falciparum malaria.

RDT Interpretation Chart

Control line Test lines

P. falciparum line Pan-specific line

P. falciparum/pan-specific RDT

e.g., detects P. falciparum-specific and other species (P. vivax, P. malariae, P. ovale)

NEGATIVE /

POSITIVE (P. falciparum only)

/ /

POSITIVE (P. falciparum and other species)

/ / /

POSITIVE non-P. falciparum (i.e., other species)

/ /

INVALID /

INVALID / /

INVALID /

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Can You Interpret These Tests?

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Interpretations for Test Results 1‒10

1. P. falciparum

2. Negative

3. Invalid (no control)

4. Non-falciparum (P. vivax, P. ovale, P. malariae, or a mixed infection of these)

5. P. falciparum

6. Non-falciparum (P. vivax, P. ovale, P. malariae, or a mixed infection of these)

7. Negative

8. P. falciparum

9. P. falciparum

10.P. falciparum or a mixed infection

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Positive ( + ) Negative (-) Invalid

Pf Pf or Mixed

Non-Pf

1 ↔

2 ↔3 ↔4 ↔5 ↔

6 ↔7 ↔8 ↔9 ↔10 ↔

How to Record Results 1‒10 on a Chart

Demonstrate the RDT for Learners

The facilitator will demonstrate the steps in performing an RDT for all to see

He/she will ask questions of the learners as he/she performs the demonstration

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Review and Questions

Which RDT is currently used in your country? What are the main components of the test? How do we distinguish between a positive and

negative test? How do we know if a result is invalid or

unclear? What should we do with such results?

How do we know what treatment is appropriate after conducting the RDT?

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Learners Practice Performing an RDT

Learners will form small groups

Each learner will have a chance to practice the RDT

Group members will give feedback after each person attempts the test

Make copies of the checklist that follows for learners to observe each other

RDT Performance Checklist—Procedure 1

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Procedure Task

1. RDT preparation (four tasks)

• Assemble all materials required for the RDT test

• Read expiration date

• Use test with earliest expiration date

• Allow RDT to come to room temperature (if kept in cool storage)

RDT Performance Checklist—Procedure 2

Procedure Task

2. Patient preparation (four tasks)

• Wash hands

• Identify patient’s details and record patient’s name on the RDT cassette

• Explain procedure to patient. Provide reassurance, as needed

• Wear gloves

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RDT Performance Checklist—Procedure 3

Procedure Task

3. Blood collection + dispensing (five tasks)

• Select site for blood collection. Clean site with alcohol swab and allow it to dry

• Prick site firmly with sterile lancet

• DO NOT squeeze finger excessively

• Collect an adequate volume of blood

• Dispense blood in correct well

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RDT Performance Checklist—Procedure 4

Procedure Task

4. RDT procedure + reading results (four tasks)

• Dispense correct volume of buffer

• Wait for correct time (according to manufacturer’s instructions)

• Verify internal test control

• Read results correctly

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RDT Checklist—Procedures 5, 6, 7

Procedure Task

5. Recording results (two tasks)

• Record results correctly (including mixed infections if a combo test is used)

• Record date and time of reporting results

6. Disposal of infectious material (two tasks)

• Dispose of used tests, and transfer devices and other contaminated material to plastic-lined bin

• Dispose of used lancet in a sharps container

7. Deliver the results (one task)

• Explain to the patient the results and what they mean

RDT Performance Checklist

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After the small group practice sessions, bring the whole group back together

Ask learners to talk about their experience

Using the checklist findings, ask learners what steps were easy or difficult—and why

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Summary: RDT Results

If RDT result is positive, treat according to national guidelines

If RDT result is negative, seek further information and either: Treat for other conditions like pneumonia or diarrhea

as seen in our modules, or Refer to the nearest health center, if severe (i.e.,

lethargic or unconscious)

If RDT result is invalid, repeat test with a new cassette from a different batch

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Summary: Safety and Precautions

Employ universal precautions to ensure safety when handling blood: Always put on gloves before handling blood Avoid contacting any wound with blood (Wounds must be

appropriately covered before conducting the RDT test) Wash hands appropriately with soap before and after conducting

the RDT test Clean the finger to be pricked with an alcohol swab to prevent

infection Never use a lancet or any blood collection device (loop, capillary

tube, straw or pipette) on more than one person Dispose of all sharp objects appropriately (use a sharps box) Take care to remove and discard your gloves safely

Storing and Using RDTs in the Village

In closing the session, ask CHWs/CDDs to discuss and plan the following:

1. How can we store RDTs in a safe and cool place in the village?

2. How can we safely dispose of sharps and medical waste from the RDTs in the village?

3. How can we explain to patients who believe they have malaria, but their RDT is negative?

4. What other concerns do you have?

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