4.4 Examination of sputum specimens

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Microscopy:

Till such time that the phase wise expansion of upfront access to more sensitive tests like molecular diagnostics is completed, testing by sputum microscopy is to be continued. For this, two sputum samples are to be collected and tested as follows:

• "On-the-spot" specimen: the first specimen is collected on the spot when a patient is identified as a pulmonary presumptive TB cases (spot specimen).
• Early morning specimen: the patient is given a sputum container to collect the second specimen at home on the following morning (early morning specimen).

RMDT (GeneXpert, TrueNat etc):

• Early morning sputum is preferable for Xpert MTB/RIF (other similar testing). However, spot sample collection can be done depending on patient’s convenience.

Collection and Transport of sputum specimens: The responsible paramedic/laboratory staff /health worker should provide clear instructions to the patient on how to collect quality sputum: in the open air (preferably under shade) and as far as possible away from other people. A good sputum sample consists of recently discharged material from the bronchial tree with minimum amount of oral or nasopharyngeal material, presence of mucoid or mucopurulent material and should be 2-5 ml in volume. It should be collected in a sterile container after rinsing of the oral cavity with clean water.

If the patient attends a centre where microscopy/Xpert MTB/RIF facilities are available, s/he should either be instructed to bring the specimens to the responsible staff or directly to the laboratory. If the patient attends a centre without microscopy or Xpert MTB/RIF facility, the responsible staff should ensure that the two sputum specimens are collected and transported to the laboratory as soon as possible after collection. If delay is unavoidable, the specimens should be refrigerated (for maximum up to one week) to inhibit the growth of unwanted micro-organisms.

Sputum collected in referring health facilities should be transported to the nearest Microscopy or GeneXpert site within 2 days. Once examined, the test results should be reported on the same day. The containers along with the sample MUST be disinfected with 5% phenol solution and disposed as per guidelines after the sputum smears results are recorded in the laboratory register.

To increase accessibility to diagnostic services, outreach sputum collection camps are organized by NGOs with support of government field staff at Union Health and Family Welfare Centres or other suitable places including community clinics. Patients attending these outreach camps should be provided with one sputum container and counselled beforehand to collect and bring the early morning sputum specimen with them. The spot specimen will then be collected at the outreach camps using a second pot for examination.