QUALITY CONTROL IN SEROLOGY

Dr.T.V.Rao MD

DR.T.V.RAO MD

WHAT IS QUALITY CONTROL?

Process or system for monitoring the quality of laboratory testing, and the accuracy and precision of results

Routinely collect and analyze data from every test run or procedure
Allows for immediate corrective action
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DEFINITIONS
Quality Control - QC refers to the measures that must be
included during each assay run to verify that the test is working properly.

Quality Assurance

- QA is defined as the overall program that ensures that the final results reported by the laboratory are correct.

The aim of quality control is simply to ensure that the results generated by the test are correct. However, quality assurance is concerned with much more: that the right test is carried out on the right specimen, and that the right result and right interpretation is delivered to the right person at the right time

DR.T.V.RAO MD

DEFINITIONS
Quality Assessment - quality assessment (also
known as proficiency testing) is a means to determine the quality of the results generated by the laboratory. Quality assessment is a challenge to the effectiveness of the QA and QC programs.

Quality Assessment may be external or internal, examples of external programs

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DESIGNING A QC PROGRAM
Establish written policies and procedures Corrective action procedures

Train all staff

Design forms Assure complete documentation and review
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THE QUALITY SYSTEM

Organization
Personnel

Equipment

Purchasing & Inventory

Process Control (QC & EQA) & Specimen Management

Information Management

Documents & Records

Occurrence Management

Assessment

Process Improvement
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Customer Service

Facilities & Safety

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The Quality Assurance Cycle

Patient/Client Prep Sample Collection Reporting Data and Lab Management Safety Customer Service Personnel Competency Test Evaluations

Sample Receipt and Accessioning

Record Keeping

Quality Control
Testing

Sample Transport

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NEED FOR SEROLOGICAL TESTS

SEROLOGICAL TESTS are performed to demonstrate antigens in the serum, or the response of the human body to these infectious agent ( Antibodies ) to establish its contact with the immune system. Their diagnostic importance stems from demonstration of a rising titre of antibodies to the agent which inter alia indicates a progressive infection. In rare instances is the presence of antibody in a single sample indicative of infection and disease. Serological tests are of importance in epidemiological studies and to ascertain the response of the population to vaccines and other immunopotentiators.
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IMPORTANCE OF SEROLOGICAL TESTS

Serological tests are of importance in epidemiological studies and to ascertain the response of the population to vaccines and other
immunopotentiators.
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SEROLOGY PERFORMED MAINLY AS VITRO TESTS

Serological tests are also useful for the in vitro detection of microbial infections, and for the classification and sub classification of infectious agents (e.g. Salmonella, Shigella, Streptococcus, etc.).
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COLLECTION OF SPECIMEN
There must be a system for the orderly and efficient requesting of tests; collection and identification of specimens; and transporting, preparation, and storage of specimens. Nothing is more important than having an adequate amount of an appropriate specimen in good condition for examination. If each specimen is not properly collected, labeled, and handled, or is not representative, the laboratory may do more harm than good by testing it.
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HAEMOLYSED SPECIMENS ARE NOT SUITABLE FOR TESTING

Haemolysed blood specimens are not suitable for serological studies. It is always advisable to avoid factors which cause hemolysis (Table 14.1). Specimens containing precipitates should be centrifuged prior to testing.
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AVOIDABLE CAUSES OF HEMOLYSIS

Blood sampling through too small bore of a needle

Forced suction of blood in the syringe during blood collection

Vigorous shaking of blood from the syringe, especially through a needle Centrifuging blood sample at a high speed before clotting Freezing and thawing of blood Unclean tubes with residual detergents

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SEROLOGY CAN DETECT EITHER ANTIGEN OR ANTIBODY

Serological reactions detect either a specific antigen produced by the microorganism or a specific immune response of the human body. Serological tests may detect: 1 an immunological principle (antigen-antibody reaction: ELISA, Widal) 2 a non-specific reaction (VDRL test) 3 a reaction mediated by complement (complement fixation test)

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ADVANTAGES WITH SEROLOGICAL METHODS.

Rapid identification of agent High specificity of detection of antigen Simplicity of performance Safe procedures Diagnostic aids

Epidemiological tools

Retrospective confirmation of diagnosis DR.T.V.RAO MD

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LIST OF TESTS ADDED EVERY DAY

A wide variety of serological tests

are now available and every day new ones are added to an already impressive list. Every laboratory must define a policy for conducting these tests because some may be expensive, all require certain reagents (sera or antigens etc.) which have limited shelf life, and all require standardised techniques which must be documented in SOPM.

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STANDARD OPERATING PROCEDURES ARE FOUNDATIONS IN ALL PROTOCOLS

An important element in maintaining day-to-day uniformity in laboratory results is an established procedure manual (SOPM) which details all phases of the laboratorys operation (including safety precautions) and is used by all laboratory personnel. It should include instructions for collecting, transporting, and storing specimens, for preparing and storing reagents, and for performing tests. In addition, the controls and calibrators to be used should be listed along with directions for their use, expected results, and instructions for corrective measures if the expected results are not obtained.
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CONTROL SERA
Source
Some control sera are available commercially. Small volumes are generally available as components in kits but are intended to be used only with a single kit. A few may be available in larger quantities.

Preparation
Sera to be used as controls should be kept sterile to avoid deterioration. In general each procedure should have a normal control serum (negative), a strong positive control serum, and another positive control serum which is reactive at the critical concentration (borderline positive). With some tests, controls with a low concentration of analyze should be included. Controls recommended by the manufacturer of a particular test should always be used and additional control sera can be included if a test involves special problems.

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STORAGE
Sera to be used as controls should be standardized against international reference materials when they are available. "Standards" included in commercial kits are not calibrated with each other and often are not interchangeable. These should be stored in aliquotes in frozen forms. Repeated
freezing and thawing should be DR.T.V.RAO MD avoided.
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QUALITY REAGENTS GIVE OPTIMAL RESULTS

Quality reagents are necessary for quality performance. A record should be kept of any changes in reagents in case the performance of a test changes. Before new reagents are introduced into a system they should be tested in parallel with the old reagents against a panel of appropriate reference sera to be sure that consistent reactions are obtained. The results obtained with the panel should reflect the sensitivity and specificity of the reagents being compared. 20

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LABEL ALL THE REAGENTS

Reagents should be clearly labeled to indicate their identity, hazards involved in their use, recommended storage conditions, and preparation and expiration dates.
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EQUIPMENT AND INSTRUMENTS

All glassware used in immunologic tests must be clean and free of detergent. Chipped or etched glassware should be discarded. Calibrated glassware should be checked for accuracy. The users accuracy and precision requirements should be met or exceeded when equipment is tested under working conditions. The manufacturers specifications for performance should be checked and met. Instruments and equipment should be monitored routinely. The temperature of water baths, incubators, refrigerators, and freezers should be checked periodically and records maintained. Maintenance should be performed and records kept on a regular basis by individuals who are trained and are familiar with the equipment.
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QUALITY CONTROL OF INSTRUMENTS

Instruments used for measurements including spectrophotometers, spectrometers, dilutors, and automatic pipettes should be calibrated on a regular basis.
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SELECTING A PROCEDURE OR A PROTOCOL

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CHOOSE THE APPROPRIATE TEST TO YOUR LABORATORY

As new tests and methods are developed for various analytes (antibodies or antigens), the most appropriate must be chosen for each laboratorys needs. A number of factors must be considered, including bias, specificity, sensitivity, precision, cost and ease of performance. Bias, specificity and sensitivity may be related. Frequently the more sensitive a test, the less specific it is. Bias may result from low specificity or sensitivity .
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HOW TO REDUCE THE PRESENCE OF BIAS

To determine the presence of bias, the proposed method should be compared with other reliable methods, preferably with a standard method or clinical data. The same specimens should be run with both methods in the same laboratory and the results compared, although interlaboratory comparisons are also useful. If the results from the different methods do not agree, one must determine the reason for the difference and then decide which result is more useful.

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WHAT IS CLINICAL SPECIFICITY The clinical specificity of a method is evaluated by testing negative samples and samples containing substances which might cause interference. Closely related or cross-reacting substances frequently found in clinical specimens should be included .
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MAKING SUITABLE DILUTIONS

100 ul serum in tube 1 Mix and Transfer

Discard

100ul diluent in each tube

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Each tube is a 1:2 dilution

of the previous tube

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SELECTING A SUITABLE SAMPLE DILUTION

Serial Dilutions on Abbott AxSYM HIV-1/HIV-2 MEIA
20 18 16 14

S/Co Ratio
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12 10 8 6

4
2 0 1024 2048 4096 8192 16384 32768 65536 2 4 8 16 32 64 128 256 512 131072 262144 524288

Pos Cont 3.3 Cut Off 1.0 Neg Cont 0.38

Doubling Dilutions

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WHAT IS CLINICAL SENSITIVITY

The clinical sensitivity of a method being evaluated should be compared to that of other methods, but the purpose of the test must also be considered. In general, a definitive test need not be as sensitive as a screening test. The test should distinguish between normal and abnormal levels of analyze.
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EVALUATION ON PRECISION
The precision of a quantitative or Semiquantitative test must be evaluated in light of the precision required for the clinical application of the test results. Many factors affect precision, but one that is frequently overlooked in serologic tests is the size of the dilution increments. If all other variables are held constant, serologic tests tend to become less precise as the size of the dilution increment increases. For example, it should be expected that a test based on a four fold dilution would be less precise than the same test with a twofold dilution.

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ERRORS IN MEASUREMENT
True value - this is an ideal concept which cannot be achieved. Accepted true value - the value approximating the true value, the difference between the two values is negligible. Error - the discrepancy between the result of a measurement and the true (or accepted true value).
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WHEN YOU NEED A HIGHLY SENSITIVE TEST

A test with maximum possible sensitivity is desirable when a disease is serious and its diagnosis should not be missed when the disease is treatable, and when false-positive results do not lead to serious problems. Similarly a test with maximum specificity is desirable when a disease is serious but is not treatable, the knowledge that the disease is absent has psychological or public health value, and false-positive results can lead to serious problems. A high predictive value of a positive test result is desirable when treatment of a false positive might have serious consequences.
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QUALITY CONTROL OF TESTS DETECTING ANTIBODIES

The performance of tests is monitored with controls. Antigenic serum panels as well as sera with known quantities of antibodies are available and should be routinely used. Correct performance of reagents is reflected by the expected reaction in tubes which lack one or more of the components necessary for the reaction. For example, the presence of anti-streptolysin O reagent is demonstrated by haemolysis in the tube containing the reagent buffer and cells but no antibody to inhibit haemolysis.
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ANTIBODY TEST
Flocculation test (RPR) control procedures required Nonreactive serum control Weakly reactive serum control Reactive serum control

Expected results
No clumping Clumping of graded activity Clumping of graded activity
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ANTIBODY TEST
Antibody test

Latex agglutination test (ASO)

Control procedures required Negative control serum Positive control serum Expected results

No clumping Clumping
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ANTIBODY TEST
Antibody test
Direct agglutination (Widal test, STA for Brucellosis)
Control procedures required Antigen control Negative control serum Positive control serum Expected results No clumping No clumping Clumping
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ANTIBODY TEST
Antibody test Passive haemagglutination (ASO) Control procedures required Streptolysin control Red cell control Expected results Hemolysis No hemolysis

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ANTIGEN TEST
Antigen test Coagglutination test (Haemolytic streptococci meningitis antigens) Control material

Group A,B,C streptococci

N.meningitidis Expected result Agglutination with corresponding serum,
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QUALITY CONTROL PROCEDURES FOR TESTS DETECTING ANTIGENS

Antigen test
capsular Quelling reaction (Omni serum, H.influenzae type b)

Control material
Pneumococci Haemolytic streptococci H.influenzae type b Acinetobacter anitratum Expected result Capsular swelling No reaction Capsular swelling No reaction

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REPORTING AND RECORD KEEPING

Complete and accurate records must be maintained in a good quality assurance programme. These records should include personnel information; details of equipment, preventive maintenance, service, and repair; copies of reports to physicians or other clients; accession records; records of reagents and materials used; records of observations made concurrently with the performance of each step in the examination of specimens; proficiency testing results; and internal quality control results.

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ACCURACY AND PRECISION

The degree of fluctuation in the measurements is indicative of the precision of the assay. The closeness of measurements to the true value is indicative of the accuracy of the assay. Quality Control is used to monitor both the precision and the accuracy of the assay in order to provide reliable results.
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PRECISION AND ACCURACY

Precise and inaccurate Precise and accurate

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DESIGNING A QC PROGRAM
Establish written policies and procedures Corrective action procedures Train all staff Design forms Assure complete documentation and review
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QUALITATIVE QC
Quality control is performed for both, system is somewhat different Controls available Blood Bank/Serology/Micro RPR/TPHA Dipstick technology Pregnancy
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ESTABLISHING CONTROL RANGES

Select appropriate controls

Assay them repeatedly over time

at least 20 data points Make sure any procedural variation is represented:

different operators
different times of day Determine the degree of variability in the data to establish acceptable range
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MEASUREMENT OF VARIABILITY
A certain

amount of variability will naturally occur when a control is tested repeatedly.

Variability is affected by operator technique, environmental conditions, and the performance characteristics of the assay method. The goal is to differentiate between variability due to chance from that due to error.
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SOURCES OF ERROR
Input data required - such as standards used, calibration values, and values of physical constants.
Inherent characteristics of the quantity being measured - e.g. CFT and HAI titer.

Instruments used - accuracy, repeatability.

Observer fallibility - reading errors, blunders, equipment selection, analysis and computation errors. Environment - any external influences affecting the measurement. Theory assumed - validity of mathematical methods and approximations.
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AVOIDING THE ERRORS

The accessioning and reporting system should minimize the possibility of clerical errors. Precautions should be taken to prevent reporting results on the wrong specimen and transposing digits in reporting quantitative data. The system should be so designed that the history associated with a sample can be reconstructed in detail if necessary. Who performed which tests, what reagents and lot numbers they used, what the control results were for that run, and how and when the results were reported should also be documented DR.T.V.RAO MD

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RANDOM ERROR

An error which varies in an unpredictable manner, in magnitude and sign, when a large number of measurements of the same quantity are made under effectively identical conditions. Random errors create a characteristic spread of results for any test method and cannot be accounted for by applying corrections. Random errors are difficult to eliminate but repetition reduces the influences of random errors. Examples of random errors include errors in pipetting and changes in incubation period. Random errors can be minimized by training, supervision and adherence to standard operating procedures.

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SOURCES OF ERROR
Input data required - such as standards used, calibration values, and values of physical constants. Inherent characteristics of the quantity being measured - e.g. CFT and HAI titer. Instruments used - accuracy, repeatability. Observer fallibility - reading errors, blunders, equipment selection, analysis and computation errors. Environment - any external influences affecting the measurement. Theory assumed - validity of mathematical methods and approximations. DR.T.V.RAO MD 51

HOW TO IMPLEMENT A QC PROGRAM?

Establish written policies and procedures Assign responsibility for monitoring and reviewing Train staff Obtain control materials Collect data Set target values (mean, SD) Establish Levey-Jennings charts Routinely plot control data Establish and implement troubleshooting and corrective action protocols Establish and maintain system for documentation
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MONITORING QC DATA
Use Levey-Jennings chart

Plot control values each run, make decision regarding acceptability of run
Monitor over time to evaluate the precision and accuracy of repeated measurements Review charts at defined intervals, take necessary action, and document
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INTERNAL QUALITY CONTROL PROGRAM FOR SEROLOGICAL TESTING

An internal quality control program depend on the use of internal quality control (IQC) specimens, Shewhart Control Charts, and the use of statistical methods for interpretation. Internal Quality Control Specimens
IQC specimens comprises either (1) in-house patient sera (single or pooled clinical samples), or (2) international serum standards with values within each clinically significant ranges.
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 Created by Dr.T.V.Rao MD for e learning resources for Microbiologists in Developing World

Email

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