Biomarker Field Manual (English, French)

Document text

MEASURE DHS 


Biomarker Field Manual 


[COUNTRY] Demographic and Health Survey 


[IMPLEMENTING AGENCY] 


ICF International / Demographic and Health Surveys 
Calverton, Maryland 
USA 


[9 January 2012] 


MEASURE DHS is a five-year project to assist institutions in collecting 
and analyzing data needed to plan, monitor, and evaluate population, 
health, and nutrition programs. MEASURE DHS is funded by the U.S. 
Agency for International Development (USAID). The project is 
implemented by ICF Macro in Calverton, Maryland, in partnership with 
the Johns Hopkins Bloomberg School of Public Health/Center for 
Communication Programs, the Program for Appropriate Technology in 
Health (PATH), Futures Institute, Camris International, and Blue Raster. 


The main objectives of the MEASURE DHS program are to: 1) provide 
improved information through appropriate data collection, analysis, and 
evaluation; 2) improve coordination and partnerships in data collection at 
the international and country levels; 3) increase host-country 
institutionalization of data collection capacity; 4) improve data collection 
and analysis tools and methodologies; and 5) improve the dissemination 
and utilization of data. 


For information about the Demographic and Health Surveys (DHS) 
program, write to DHS, ICF International, 11785 Beltsville Drive, Suite 
300, Calverton, MD 20705, U.S.A. (Telephone: 301-572-0200; fax: 301- 
572-0999; e-mail: [email protected]; Internet: 
http://www.measuredhs.com). 


Recommended citation: 
ICF International. 2012. MEASURE DHS Biomarker Field Manual. Calverton, 
Maryland, U.S.A.: ICF International. 


PREFACE 


In combination with classroom instruction and practical experience, this manual 
will be used to teach you how to collect biomarkers for the [YEAR] [COUNTRY] 
Demographic and Health Survey (DHS). Before each training session, you should 
carefully study this manual and the biomarker section of the household 
questionnaire. You are encouraged to ask questions during training and to 
discuss problems encountered in order to avoid making mistakes during 
fieldwork. The stages of training are described below: 


e During the first phase, we will review with you the chapters of this manual. 
You will learn how to identify eligible respondents, record information 
relating to biomarker collection in the household questionnaire or on 
special field forms, handle the technical procedures involved in 
height/length and weight measurement and, in blood collection, testing, 
and transportation, and other related instructions. 


e Inthe second phase, you will practice the procedures you’ve been taught 
by role playing with other trainees. This practice will include finger pricks 
for anemia testing [and DBS collection for HIV testing]. 


e Inthe third phase, you will visit a clinic or a health center and, with their 
parent’s consent, practice collecting biomarkers from infants and young 
children. 


e Inthe final phase, known as field practice, you will be assigned to a 
[COUNTRY] DHS trainee team. During field practice, you will collect 
biomarkers from eligible children and adults exactly as you will during the 
survey. Households that you visit will be in clusters that are not part of the 
[COUNTRY] DHS sample. 


Throughout the training, you may be given homework assignments and tests. At 
the end of the training, your overall performance will be assessed and those who 
have performed the best will be selected to work in the survey. 


Your training does not end at the start of fieldwork. Rather, it is a continuous 
process. Your team supervisor and the [COUNTRY] DHS health and survey 
coordinators will play important roles in continuing your training and in ensuring 
the quality of data you collect throughout the survey. They will: 


e Periodically observe your fieldwork activities to ensure that you are 
conducting yourself professionally, obtaining informed consent from 
respondents, and following the biomarker collection protocol correctly; 


e Spot check that you collected biomarkers from the correct households and 
only from eligible respondents; 


+ Collect blood specimens for transport to the laboratory and consolidate 
the field record forms; 


+ Regularly meet with you to discuss your performance and give out future 
work assignments. 


Any field staff member who is not performing at the level necessary to produce 
the high quality data required to make the [COUNTRY] DHS a success may be 
released from service. 


TABLE OF CONTENTS 


CHAPTER 1: GENERAL INFORMATION... nnnnsssssssnnnnnmnnmenemnnnmnmmnmmmnnnnnne 3 
OVERVIEW OF BIOMARKER COLLECTION. ......cccccceecceeecceeeneucceeeuneeeueucaueueueeeauens 3 
[AR LCI LITE ED ÉPPPREPTEEEETEEETEEEETEEEETEEEET EEE EE EE TES EL TETE LLC ELLE EE LISE L LISE EEE ELLE EEE ELLES EE ET ELLE TE EE 4 
INFORMED CONSENT....nnnn nn nsnnmnnnnmnmnmmnnanmnnannnnnnnnnnmenanmnnennnnnnnnnnmnnennnnenennnnnnnnns 7 
CHAPTER 2: ANTHROPOMETRYŸ....nnnnnnnnnnsssnnnmnnmmnnnnmmmmmmmmmnnnnennnnnnnnnnnnnne 10 
MATERIALS AND EQUIPMENT FOR ANTHROPOMETRY......ccccccccceeeeccneeeeeeeunneeens 10 
PROCEDURES AND PRECAUTIONS BEFORE MEASURING.....nnnnnnnssssnnnnnmnnnnmnnnnnns 10 
STEPS FOR MEASURING WEIGHT AND HEIGHT/LENGTH......ccccsccceecceeeneeeeneeeeees 12 
MEASURING WEIGHT... ..cccceccceeccceecceeesneeenneeeeeeaneeeaaeeenaeeeneeeaneeeaneueeauaeeeeenaueae 12 
CHAPTER 3: GENERAL PROCEDURES FOR COLLECTING CAPILLARY BLOOD 
DROP SAM PRES saone near aa nat hare ta Que te tente nant 21 
MATERIALS AND SUPPLIES FOR PERFORMING FINGER OR HEEL PRICK............ 21 
STEPS IN OBTAINING CAPILLARY BLOOD FROM THE FINGER......cccsecsecceeeeenneeee 22 
STEPS IN OBTAINING CAPILLARY BLOOD FROM A CHILD’S HEEL.......... sisi 25 
GOOD BLOOD COLLECTION PRACTICES ......ccccccceeccceecceecseeeeceeeeeeueaeeeeneeeeeeegeuees 27 
CHAPTER 4: ANEMIA TESTING... nn nn nnnneeenennnmnnmmmnnnnnnnnnnnnnnnnnne 28 
MATERIALS AND SUPPLIES FOR ANEMIA TESTING..,.....cccceccceecsceeeeeneeeueeeaeeuens 29 
COLLECTING BLOOD AND TESTING FOR ANEMIA... ..cccccccccceeeecncceeeeeuneeeeeeeeaneee 31 
PRECAUTIONS TO TAKE DURING ANEMIA TESTING... ...cccceeeccccceeeeesncceeeeeeneeeeuns 36 
PROVIDING ANEMIA TEST RESULTS AND REFERRALS FOR SEVERE ANEMIA...... 37 
CHAPTER 5: DBS COLLECTION FOR HIV TESTING.....cccccceeeeeueeeccceeenaueees 38 
MATERIALS AND SUPPLIES FOR DBS COLLECTION FOR HIV TESTING............... 39 
DBS COLLECTION PROCEDURE......ccccccceccceeccceecceeecceuenseueueeeeseeeeagaeeeeeeageueenenaas 42 
PRECAUTIONS TO TAKE DURING DBS COLLECTION FOR HIV TESTING.............. 47 
STORING AND TRANSFERRING THE DRIED BLOOD SPOTS. ......cccceeeccucceeeeeeneneee 48 
CHAPTER 6: BIOHAZARDOUS WASTE DISPOSAL......... ns ssssssnnnnnnnnnnnne 51 
MATERIALS AND SUPPLIES... ..cccccccccceecceeecceeeceeeeseeeceeeaeeueaueeseegueeeeeeuaaaeeeueeuns 51 
PROCEDURES FOR FIELD DISPOSAL OF BIOHAZARDOUS WASTE... ..cssccseseeeenens 51 
APPENDIX A: ANEMIA BROCHURE... nn nnnnnnmmnnnmmmmmnnmmmmnnnnennnnnnnnne 55 
APPENDIX B: COMBINED PROCEDURE FOR ANEMIA TESTING AND 
COLLECTING DBS FOR HIV TESTING... sssnnnnnnnnnnnemeennnnnnnnnnnnnns 56 
APPENDIX C: DRIED BLOOD SPOT (DBS) TRANSMITTAL SHEET............. 63 
APPENDDODEWET VOUCHER so nn ner nest eddwenGesbandeadabaanéreedesyae 65 


CHAPTER 1: GENERAL INFORMATION 


OVERVIEW OF BIOMARKER COLLECTION 


A biomarker may be thought of as a characteristic that can be independently 
measured and evaluated as an indicator of normal biologic processes, 
pathogenic processes, or pharmacologic response to a therapeutic 
intervention’. Biomarker measurements can serve as diagnostic tools to 
identify diseases in their early stages and can be used as surveillance tools to 
track changes in disease patterns or to evaluate intervention programs. In 
population-based surveys, biomarkers help assess the prevalence or 
occurrence of diseases or conditions and can also be used at a macro level to 
measure the long-term effect of policies and programs. In the DHS, 
biomarkers are collected in order to report levels of specific disease and 
conditions on a population level. Specific to the [YEAR] [COUNTRY] DHS, the 
following biomarkers will be collected/tested: [anthropometry], [anemia], 
[HIV], and [OTHER BIOMARKERS]. This training manual will discuss the proper 
collection techniques and the appropriate recording and result reporting of 
these biomarkers. 


Biomarker collection should take place after the completion of the household 
and individual questionnaires. However, prior to collection, certain tasks must 
be completed. This chapter reviews the tasks that need to be completed prior 
to collecting biomarkers: 


+ Determining eligibility 
e Obtaining informed consent. 


Biomarker Definitions Working Group, National Institutes of Health, 2001 


ELIGIBILITY 


Not all household members are eligible for biomarker collection. Members of 
the household who are eligible for biomarker collection are: women age 15- 
49, men age 15-[49], and children under age 6 years old who are usual 
household residents or are visitors that have stayed in the house the night 
before the household interview took place. It is the responsibility of the 
interviewer to identify all of the household members eligible for biomarker 
collection and to enter their names and line numbers into the [biomarker 
pages at the end of the Household Questionnaire (if using paper 
questionnaires) or Biomarker Data Form (if using electronic questionnaires)]. 
Individuals eligible for biomarker collection will be identified by reviewing 
these columns from the Household Schedule: 


e Column (1) Line number 

¢ Column (2) Name 

¢ Column (4) Sex of household member 

e Column (7) Age of household member 

¢ Column (9) Identification of eligible women, (women age 15-49) 

e¢ Column (10) Identification of eligible men, (men age 15-[49]) 

¢ Column (11) Identification of eligible children, (children under age 6) 


HOUSEHOLD SCHEDULE 


IF AGE 15 
OR OLDER 


RESIDENCE MARITAL ELIGIBILITY 
TO HEAD OF STATUS 
HOUSEHOLD 


Please give me the narres | Whatis the i How old | Whatis CIRCLE | CIRCLE | CIRCLE 
of the persons who relationship of | (NAME) ere is (NAME)'s LINE LINE LINE 
usually live in your (NAME) to the | male or | usually (NAME)? | current marital | NUMBER | NUMBER | NUMBER 
household and guests of | head of the female? | live status? OFALL | OFALL | OFALL 
the household w ho household? here? ight? IF 95 WOMEN | MEN CHILDREN 
stayed here last night, OR MORE,| 1=MARRIED AGE AGE AGE 0-5 
starting with the head of | SEECODES RECORD OR LIVING 15-49 15-49 

the household. BELOW. 95". TOGETHER 

AFTER LISTING THE 2 =DNORCED/ 

NAMES AND RECORDING SEPARATED 

THE RELATIONSHIP 3 =WIDOWED 

AND SEX FOR EACH 4 =NEVER- 


PERSON, ASK MARRIED 
QUESTIONS 2A-2C AND 

TO BESURE THAT THE NEVER 
LISTING IS COMPLETE. LIVED 
TOGETHER 


THEN ASK APPROPRIATE 
QUESTIONS IN COLUMNS 
5-20 FOR EACH PERSON. 


INYEARS 
01 01 
oo 


After referencing the Household Schedule, the interviewer will record the 
names and line numbers of people eligible for biomarker collection in the 
[biomarker pages at the end of the Household Questionnaire (if using paper 
questionnaires) or Biomarker Data Form (if using electronic questionnaires)]. 
The interviewer will also record the dates of birth of children in Question 203. 
For a child whose mother was interviewed, the month and year of the child’s 
birth should be taken from the mother’s birth history (recorded in the 
Woman's Questionnaire), while the day of birth must be obtained directly 
from the mother. For a child whose mother has not been interviewed or is 
unavailable, the full date of birth must be obtained from a responsible adult. 


WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5 
201 | CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 Y EARS 
IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). 


LINE NUMBER FROM COLUMN 11 | LINE LINE LINE 
NUMBER NUMBER NUMBER 


NAME FROM COLUMN 2 


IF MOTHER INTERVIEWED, COPY 
MONTH AND Y EAR OF BIRTH 
FROM BIRTH HISTORY AND ASK 
DAY ; IF MOTHER NOT 
INTERVIEWED, ASK: 

What is (NAME)'s birth date? 


CHECK 203: 

CHILD BORN IN J ANUARY 

2005 (9) OR LATER? (GO TO 203 FOR NEXT (GO TO 203 FOR NEXT (GO TO 203 FOR NEXT 
CHILD OR, IF NO I CHILD OR, IF NO | CHILD OR, IF NO sa 
MORE CHILDREN, MORE CHILDREN, MORE CHILDREN, 
GO TO 214) GO TO 214) GOTO 214) 


The [Household Questionnaire/Biomarker Data Form] is then given to the 
health specialist to record all data related to biomarker collection. It is the 
responsibility of the health specialist to verify that the information recorded 
by the interviewer is properly recorded prior to collecting any biomarkers. For 
children under 6 years, verify the child’s name and line number is written in 
Question 202. Verify that an exact date of birth (day/month/year) is written in 
Question 203. Proceed with Question 204. 


For women, verify the line number and name of all women age 15 - 49 in 
Question 215, and for men, verify the line number and name all men age 15 - 
[49] in Question 244. 


WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49 


CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. 
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). 


LINE NUMBER LINE LINE LINE 
FROM COLUMN 9 NUMBER NUMBER NUMBER 


NAME FROM 
COLUMN 2 NAME NAME NAME 


The table below summarizes which household members are eligible for 
measurements and tests. 


Groups [DBS 
dE Ne NE 2 
collection” testing] 
Or |X 

ur DE x x 

15-40 years | À x x x 
Fr SE x x x 


“Must be usual residents or have slept in the household the night before the 
household interview took place. 


The following are important points to keep in mind when completing 
the Biomarker Data Form: 


1) Biomarker data should be collected from eligible consenting adults 
after their individual interview has been completed. 


2) Collect biomarkers from one individual at a time. All biomarker 
information collected for the [COUNTRY] DHS should be collected on one 
individual before moving on to the collection of biomarkers from the next 
eligible, consenting person. For example, if there is more than one eligible 
woman in a household who has consented to biomarker collection, weigh and 
measure her, test her for anemia, and collect blood for HIV testing before 
proceeding to the next woman. Likewise, complete the collection of all 
biomarkers from one child before proceeding to the next. Failure to do so may 
lead to results being recorded in the wrong columns of the questionnaire. 


3) Never alter any responses on the Household Questionnaire without 
consulting the interviewer (if you were not the interviewer for the 
Household Questionnaire). Even in cases where there are concerns about an 
individual’s eligibility for testing, proceed with [anemia testing] and/or [HIV test 
blood sample collection]. Record in the comments section of the Household 
Questionnaire a description of the problem. Provide as many details as possible. 
The field organization/central office will decide later what will be done about the 
test results for the respondent in question. 


10 


INFORMED CONSENT 


One of the primary tasks before biomarker collection is to explain the purpose 
of the testing to eligible respondents or, in the case of children, to the 
parent/responsible adult, and to obtain their consent before collecting any 
blood samples. In order to ensure that these individuals can make an 
“informed” decision about whether or not to be tested, the [COUNTRY] DHS 
questionnaire includes consent statements which you will read to the 
respondent. These consent statements include the following basic elements: 


e __a description of the objectives of the test 

+ basic information on how the test will be conducted 

+ assurances about the confidentiality of the results 

+ aspecific request for permission to collect the sample 

You must read the informed consent statements to each eligible respondent 
age 18 and over and obtain the respondent’s consent to the testing before 
any blood collection is done. The approach for obtaining consent differs 
Slightly when the eligible individual is a child under age 6 years or an 


adolescent age 15-17 years. 


If the eligible individual is a child, you must obtain the consent of one of the 
child’s parents, or, in the absence of a parent, the consent of a responsible 
adult who is at least 18 years of age. If the parent/responsible adult does not 
consent to the test, the test must not be performed. 


If the eligible individual is an adolescent (age 15-17 years), you must first 
obtain the consent of the adolescent’s parent or responsible adult. If the 
parent of responsible adult gives their consent, you will then seek the consent 
of the adolescent. If either the parent/responsible adult or the adolescent 
does not consent to the test, the test must not be performed. There are two 
exceptions to this rule: 1) if the adolescent is married (or was formerly 
married) or 2) if the adolescent lives alone or in a household in which there 
are no adults. In either instance, the adolescent is considered an 
emancipated minor, and is to be treated like an adult. In this case, consent of 
the adolescent is sufficient. 


Prior to performing the anemia test or collecting blood for HIV testing, you 
must record the outcome of the consent request on the Biomarker Data Form. 
This is discussed in more detail in the upcoming chapters. You must also sign 
your name to indicate that you read the consent statement to the 
respondent, or in the case of children, to the parent/responsible adult and 
have recorded their response accurately. 


Key points to remember include: 


1. Read the applicable consent statements to each eligible 
respondent exactly as they appear in the questionnaire. When you 
arrive at the household and begin talking about the blood tests with the 
respondent, you may informally discuss many of the items included in the 
informed consent statement. However, before beginning the testing 
procedures, you must still read the informed consent statements exactly 


as they are worded in the questionnaire. If you feel that the respondent 
may find the statements repetitive, tell him/her that you are required to 


11 


read the statement to ensure that respondents are given all the 
appropriate information. 


2. Read the informed consent statements clearly. Practice reading the 
consent statements out loud so that you become comfortable delivering 
them in a clear, natural voice and manner. Avoid speaking rapidly or ina 
monotone. 


3. For adults and adolescents, always request consent for the 
anemia and HIV testing separately. Be sure the respondent knows 
that it is possible to consent to one test and not to the other. Since the 
outcome of the consent process may differ for the two tests, it is 
important that you accurately record the results for both the anemia and 
HIV testing. 


4. Never collect blood from an adolescent before obtaining the 
consent of the parent/responsible adult unless the adolescent is 
married, was formerly married, lives alone or lives in a household where 
there are no adult members. 


5. Never attempt to force or coerce consent. Some respondents may be 
suspicious or fearful of having their blood collected for testing. Others may 
have questions or want to discuss the procedures before giving consent. 
Take time to patiently respond to all questions. 


6. Some respondents may be reluctant to allow testing without consulting 
someone not present at the time of your visit (for example, a woman may 
want to consult her husband before giving permission). In such cases, 
make an appointment to return to the household later at an 
agreed upon time. If you believe it will help, ask the team supervisor to 
visit a household where eligible respondents express fear or reluctance to 
be tested. 


Once the individual interviews have been completed, eligible respondents 
have been identified, and consent has been obtained, biomarker collection 
can take place. 


12 


Summary of Steps in Identifying Eligible Respondents 
and Seeking Informed Consent for Blood Collection 


+ Complete the household and individual questionnaires 


e Look at the Household Listing Schedule to confirm individuals who are 
eligible for biomarker collection: 


o Adults, age 15-49, who are usual residents or who stayed in the 
household the night before the interview are eligible for biomarker 
collection 


Children, under age 6, who are usual residents or who stayed in 
the household the night before the interview, are eligible for 
biomarker collection 


« Children 6 months - under 6 years: eligible for 
anthropometry and blood collection 


" Children below 6 months: eligible for anthropometry only 


e For adults, age 18- 49: Obtain consent for blood collection as follows 
o Read consent exactly as written; 


o Record the outcome of the consent request and sign in the space 
provided; 


If consent is granted, proceed with blood collection. 


e For never-married adolescents, age 15-17: 


o Obtain consent for blood collection from parent or responsible 
adult 


" Read consent exactly as written 


" Record whether the parent/responsible adult consented or 
refused and sign in the space provided; 


o If the parent/responsible adult consented, obtain consent for 
blood collection from adolescent 


» Read consent exactly as written; 


" Record the outcome of the consent request and sign in the 
space provided; 


If consent was granted, proceed with blood collection. 


e For children 6 months-6 years: 


o Obtain consent for blood collection from parent or responsible 
adult 


» Read consent exactly as written; 


13 


CHAPTER 2: ANTHROPOMETRY 


Anthropometry refers to the measurement of humans. In the [COUNTRY] DHS, 
anthropometry refers solely to the measurement of a person’s height (length) 
and weight. This information can be used to assess the nutritional status of a 
population. For children, standard indices of physical growth related to 
nutritional status are height-for-age, weight-for-height, and weight-for-age. A 
child who is below minus two standard deviations (-2 SD) from the median of 
a reference population in terms of height-for-age is considered short for 
his/her age or stunted. Stunting reflects the cumulative effect of chronic 
malnutrition. A child who is below minus two standard deviations (-2 SD) 
from the median of a reference population in terms of weight-for-height is 
considered too thin for his/her height, or wasted. Wasting is a condition 
reflecting acute or recent nutritional deficit. Weight-for-age is a composite 
index of stunting and wasting and is a good indicator to monitor nutritional 
status over time. 


Among adults, height and weight measurement are used to calculate a 
person’s body mass index (BMI) and to assess a woman’s risk of having 
difficulty during childbirth due to her short stature (height <145 cm). BMI is 
calculated by dividing the weight in kilograms by the height in meters 
squared (kg/m?). BMI values are used to determine the percentage of the 
adult population that is normal, thin, overweight and obese. 


MATERIALS AND EQUIPMENT FOR ANTHROPOMETRY 


e SECA 874 digital scale?: for weighing children and adults. The scale has 
a 200 kg capacity and weighs in 0.01 kg increments. The scale is powered 
by six AA batteries and has an “ON-OFF” switch located at the side of the 
scale. 


+ Shorr height board: for measuring the height (length) of children and 
adults. 


e¢ Household Questionnaire with Biomarker Data Form 
PROCEDURES AND PRECAUTIONS BEFORE MEASURING 


1. Layout of the Procedures: Each step of the measurement procedure is 
directed at specific participants, who are named in bold letters at the 
beginning of each step: "Measurer" and "Assistant". 


2. Two Trained People Required: Two trained people are required to 
measure a child's height or length. The measurer holds the child and takes 
the measurements. The assistant helps hold the child and records the 
measurements on the questionnaire. If there is an untrained assistant 
such as the mother, then the trained measurer should also record the 
measurements on the questionnaire. One person alone can take the 
weight of a child and record the results if an assistant is not available. 


2The Seca 874 digital floor scale is manufactured by Seca gmbh & co. kg. Hammer Steindamm 9 - 25. 22089 
Hamburg. Germany. The scale can be procured directly from Seca. These instructions were adapted from 
instructions that accompany the scale and revised by Irwin J. Shorr, MPH, MPS. 


14 


. Measuring Board and Scale Placement: Be selective about where you 
place the measuring board and scale. It is best to measure outdoors 
during daylight hours. If it is cold, raining or if too many people 
congregate and interfere with the measurements, it may be more 
comfortable to weigh and measure indoors. Make sure there is adequate 
light. 


. Age Assessment: Before you measure, determine the child's age. If the 
child is less than two years, measure length (the child lying down). If the 
child is two years of age or older, measure height (the child is standing). If 
accurate age is not possible to obtain, measure length if the child is less 
than 85 cm. Measure height if the child is equal to or greater than 85 cm. 


. Weigh and Measure One Child at a Time: If there is more than one 
eligible child in a household, complete the weighing and measuring of one 
child at a time. Then proceed with the next eligible child. DO NOT weigh 
and measure all the children together. If there is more than one eligible 
woman in a household, weigh and measure her and all her eligible 
children before proceeding with the next woman. Otherwise 
measurements may get recorded in the wrong columns of the 
questionnaire. Return measuring equipment to the storage bags after you 
complete the measurements for each household. 


. Control the Child: When you weigh and measure, you must control the 
child. The strength and mobility of even very young children should not be 
underestimated. Be firm yet gentle with children. Your own sense of calm 
and self confidence will be felt by the parent and the child. 


When a child has contact with a measuring board, you must hold and 
control the child so the child will not trip or fall. Never leave a child alone 
with a piece of equipment. 


. Coping with stress: Since weighing and measuring requires touching 
and handling children, normal stress levels for this type of survey work are 
higher than for surveys where only verbal information is collected. 


Explain the weighing and measuring procedures to the mother, father, or 
other responsible adult and to a limited extent, the child, to help minimize 
possible resistance, fears or discomfort they may feel. You must 
determine if the child or the parent is under so much stress that the 
weighing and measuring must stop. Remember, young children are often 
uncooperative; they tend to cry, scream, kick and sometimes bite. If a 
child is under severe stress and is crying excessively, try to calm the child 
or return the child to the parent before proceeding with the measuring. 


Do not weigh or measure a child if: 


e The parent/responsible adult refuses. 

e The child is too sick or distressed. 

e The child is physically deformed which will interfere with or give an 
incorrect measurement. To be kind, you may want to measure such 
a child and make a note of the deformity on the questionnaire. 


15 


8. 


9. 


Recording Measurements and Being Careful: Keep objects out of 
your hands and pens out of your mouth, hair or breast pocket when you 
weigh and measure so that neither the child nor you will get hurt due to 
carelessness. When you are not using a pen, place it in your equipment 
pack or on the questionnaire. Make sure you do not have long fingernails. 
Remove interfering rings and watches before you weigh and measure. 


Strive for Improvement: You can be an expert measurer if you strive for 
improvement and follow every step of every procedure the same way 
every time. The quality and speed of your measurements will improve 
with practice. You will be required to measure women, men, and children. 
Do not take these procedures for granted even though they may seem 
simple and repetitious. It is easy to make errors when you are not careful. 
Do not omit any steps. Concentrate on what you are doing. 


STEPS FOR MEASURING WEIGHT AND HEIGHT/LENGTH 


1. 


Check column 11 of the household schedule to identify all children in the 
household who are eligible for weight and height/length measurement. 
Children born in [YEAR] or later who are usual residents of the household 
or who are visitors who spent the previous night in the household are 
eligible for anthropometry. Each eligible child should be recorded in a 
separate column of the Biomarker Data Form. 


Referring to the household schedule, check the Line Number and Name 
of all eligible children in Question 202. In Question 203, verify the 
month and year of birth of the child from the mother’s birth history 
(Woman’s Questionnaire Section 2), and ask for the day of birth. For 
children not included in a birth history, determine the date of birth from 
the parent/responsible adult and record in Question 203. 


In Question 204 confirm that the child was born in [MONTH YEAR] or 
later. If the child was born before [MONTH YEAR], go to Question 203 for 
the next child. 


Perform the child weight and height/length measurements according to 
instructions below. 


Next, by checking columns 9 and 10 of the household schedule, identify all 
women and men from the household schedule who are eligible for weight 
and height measurement. [Women age 15-49 years] and [men age 15-49 
years] who are usual members of the household or who slept in the 
household the night before are eligible. 


Check that the Line Number and Name of all eligible women and men 
has been recorded in Question 215 and Question 244, respectively, of 
the Biomarker Data Form. 


Perform the adult weight and height measurements according to 
instructions below. 


MEASURING WEIGHT 


Preparing Adult and Child to Take Their Weight 


16 


Show the scale to the adult and explain that you will weigh her/him and 
their children on the scale. Tell her/him that infants and any other children 
who will not stand on the scale alone can be held by the adult to obtain 
the child’s weight. Ask the adult to wear light clothing while being weighed 
and to remove shoes/sandals and any heavy clothing, etc. Ask the adult to 
undress the child just before taking his/her weight. Leave underpants on 
the child. 


Preparing the Scale 


Take the scale out of the storage bag and place the scale on a hard, level 
surface. Uneven surfaces or vibration may cause the scale to malfunction. 
Turn on the power by pushing the switch located at the side to the “ON” 
position. 


The scale will not function correctly if it is bumped, knocked or moved 
during the weighing. It is best to use the scale in the shade or indoors. 
Handle the scale carefully: 
= Do not drop or bump the scale. 
Do not weigh a total weight of more than 200 kg. 
Do not store the scale in direct sunlight or other hot places. 
Protect the scale against excess humidity or moisture. 
Do not use the scale at temperatures below +10°C or above 
+40°C. 
" To clean the scale, wipe surfaces with a damp cloth and dry 
immediately 
« Never put the scale in water. 
« After using the scale, turn off the scale by switching the “ON- 
OFF” switch to the “OFF” position. 


Weighing Adults and Children Who Can Stand on the Scale by Themselves 


i 


3: 


Activate the power supply by pushing the switch in position “ON”. Press 
the “START” key with no load on the scale. The display should show 
“SECA, 8.8.8.8.8 and “0.00” consecutively. The scale automatically sets 
to zero “0.00” and is now ready for use. 


Ask the adult or child to step onto the center of the scale and stand 
quietly. Wait until the numbers on the display no longer change and stay 
fixed in the display. 


The weight will appear in the digital display. Record the weight to 0.01 kg 
on the questionnaire. 


e For children, record the child’s weight measurement in Questions 
205. If the child’s weight was not measured, record the appropriate 
code in Question 205. 


e Record an adult’s weight measurements in Question 216/245. If 


the adult’s weight was not measured, record the appropriate code 
in Question 216/245 


17 


4. If you have just weighed an adult and you are about to weigh an infant or 
child that must be held to take its weight, then ask the adult to remain on 
the scale since the adult will hold the child. 


Weighing Infants or Children Who Must be Held by an Adult While on the Scale 
(NOTE: If it is cold and the adult wants the child to be covered during the 


weighing, give her/him a blanket or cloth for covering the child after you have 
recorded the adult’s weight on the Biomarker Data Form. If you do not give 
the adult a blanket or cloth to cover the child, follow the instructions given under 
“If You Do NOT Give the Adult a Blanket or Cloth to Cover the Child”. If 
you give the adult a blanket or cloth to cover the child, follow the instructions 
given under “If You Give the Adult a Blanket or Cloth to Cover the Child”). 


If You Do NOT Give the Adult a Blanket or Cloth to Cover the Child: 
2 in 1 Function 


The 2 in 1 function enables the weight of babies and small children to be 
determined. The child is held in the arms of an adult. Proceed as follows. 


1. Press the “START” key with no load on the scale and wait until the display 
“0.00” appears. 


2. Ask the adult to step onto the center of the scale without the child and 
stand quietly. Wait until the numbers (weight of the adult) on the display 
no longer change and stay fixed in the display. 


3. Press the 2 in 1 key to activate the function. The scale stores the weight of 
the adult and the display returns to zero. “0.00” and “NET” appear in the 
display. 


4. Give the child to the adult. The scale determines the weight of the child. 
Once the value is stable for about 3 seconds, the display is retained. This 
avoids the display jumping about as a result of the child’s movements. 
“HOLD” and “NET” appear in the display. 


5. Record the weight of the child to 0.01 kg on the questionnaire. 

6. If several children are to be weighed consecutively, it is important that it is 
always the same adult who performs the measurement and that this 
person’s weight does not change (e.g. due to pieces of clothing being 
removed). 

7. The 2 in 1 function remains switched on until: 

- You press the 2 in 1 key again (total weight displayed) 
- The scale switches off automatically. 
If You Give the Adult a Blanket or Cloth to Cover the Child: 


2 in 1 Function 


1. Press the “START” key with no load on the scale. Wait until the display 
“0.00” appears. 


18 


2. Give the adult a blanket or cloth and ask her/him to step onto the 
center of the scale without the child and stand quietly. 


3. The weight of the adult plus blanket/cloth appears on the display. Wait 
until the numbers on the display no longer change and stay fixed. 


4. Press the 2 in 1 key to activate the function. The scale stores the weight of 
the adult plus blanket/cloth and the display returns to zero. “0.00” and 
“NET” appear in the display. 

5. Give the child to the adult. The scale determines the weight of the child. 
Once the value is stable for about 3 seconds, the display is retained. This 
avoids the display jumping about as a result of the child’s movements. 
“HOLD” and “NET” appear in the display. 

6. Record the weight of the child to 0.01 kg on the questionnaire. 

7. If several children are to be weighed consecutively, it is important that it is 
always the same adult who performs the measurement and that this 
person’s weight does not change (e.g. due to pieces of clothing being 
removed). 

8. The 2 in 1 function remains switched on until: 

- You press the 2 in 1 key again (total weight displayed) 
- The scale switches off automatically. 
Additional Notes on the SECA scale: 

e The SECA scale switches off automatically. If the scale is in “Normal Mode” 
it will switch off 3 minutes after the last weighing. If the scale is in “2 in 1 
mode”, it will switch off after two minutes. 

+ Do not weigh loads with a total weight of more than 200 kg. 


+ Possible reasons for the scale not taring (returning to zero (“0.00”) after 
pressing the “2 in 1 function” key when the adult stands on the scale): 


o There was no weight on the scale to tare (the adult was not on the 
scale). 


o The load weighs more than 200 kg; “STOP” appears in the display. 
Use a lighter load. 


What to do if the Scale Display Shows the Following Errors: 
No weight is displayed when there is a load on the scale? 
+ Check to see if the scale is switched on. Ask the adult to step off the 


scale and step gently on the weighing platform. 


+ Check to see if the switch is in the “ON” position 


19 


e Check the batteries 


The scale keeps switching on, while being transported? The vibration 
switch has been activated. Turn off the scale by switching the “ON-OFF” 


switch to the “OFF” position. 


The scale displays a weight after being transported or after new batteries 
have been put in? Wait until the scale switches off automatically after two 


minutes. The scale will work normally again. 


“0.00” does not appear before weighing? Start the scale again after it 
switches off automatically; there should not be any load on the scale. 


“----" appears instead of “0.00” before weighing? Start the scale again 
after it switches off automatically; there should not be any load on the 


scale. 


One segment of the display is illuminated constantly or not at all? There is 
a problem with that segment of the scale. Inform your service dealer. 


The display shows a battery with split shading? The battery voltage is 
running low. The batteries should be changed in a few days. 


“, batt” appears in the display? The batteries are empty. Replace the 
batteries. 


“Stop” appears in the display? The maximum load capacity of the scale 
has been exceeded. 


The display flashes? Take the load off the scale and start again. Wait until 
0.00 appears and weigh again._ 


‘temp’ appears in the display? The ambient temperature of the scale is too 
high or too low. Place the scale in an ambient temperature between + 
10°C and + 40°C. Wait 15 minutes for the scale to adapt to the 
temperature and weigh again. 


E and a number appear in the display? Start the scale again after it 
switches off automatically. The scale will then work normally again. If this 


does not happen, inform the service dealer. 


MEASURING A CHILD’S HEIGHT (ILLUSTRATION 1): 


1. Measurer or Assistant: Place the Shorr measuring board on a hard, flat 
surface against a wall, table, tree or staircase. Make sure the measuring 
board is stable. Many walls and floors are not at perfect right angles; if 
necessary, place small rocks underneath the height board to stabilize it 
during the measurement. 


2. Measurer or Assistant: Ask the parent to take off the child’s shoes and 


to unbraid or push aside any hair that would interfere with the height 
measurement. Ask the parent to bring the child to the measuring board 


20 


and to kneel in front of the child so that the child will look forward at the 
parent. 


. Assistant: Place the questionnaire and pen on the ground (Arrow 1) and 
kneel on the right side of the child (Arrow 2). 


. Measurer: Kneel on the left of the child (Arrow 3). 


. Assistant: Place the child’s knees and feet in the correct position, with 
knees and feet either together or apart. There are three possible positions 
for the knees and feet: 

+ Knees together and feet together 

e Knees together and feet apar 

e Knees apart and feet togethe 


Whichever touches first! 


. Measurer: Determine if the child’s feet should be against or away from 
the back of the height board by observing the imaginary line drawn from 
the tip of the shoulder to the heel, which is called the “mid-axillary line” 
(Arrow 4). This line should be perpendicular (90°) to the base of the height 
board where the child is standing (you may have to move the child’s feet 
away from the back of the 
height board to put them in 
the proper position). Note 
that with most preschool-age 
children who are not heavy 
or obese, the heels will 
probably touch the back of 
the height board (Arrow 5). 


ilustration 1 
Child Height Measurement 


HEADPIECE FIRMLY ON HEAD. 


bf 


. Assistant: With your 
thumbs against the index 
finger of each hand, place 
your right hand on the child’s 
shins (Arrow 6) and your left 
hand on the child’s knees 
(Arrow 7). Do not wrap your 
hands around the knees or 


LEFT MANO ON KNEES 7) 
\ MEASURER ON KNEE 
N SHINS: HEELS AGAINST] 


RIGHT HANO 0 
BACK AND BASE OF BOAR 


feet (ankles) or squeeze 
them together. Make sure 
the child’s legs are straight. 


. Measurer: Ask the child to 


AE ON KNEES 
LT 
S ses 


QUESTIONNAIRE AND PEN ON CUPS: 
ON FLOOR OR GROUND ica ~ 


BOOY FLAT AGAINST BOARD 


look straight ahead at the 
parent if she is kneeling in 
front of the child. Make sure 
the child’s line of sight is 
parallel to the ground (Arrow 
8). Place the thumb and index finger of your left hand, one finger on each 
side of the child’s chin, and gradually close your hand (Arrow 9). Note that 
with most preschool-age children who are not heavy or obese, the back of 
the head will touch the back of the height board (Arrow 10); however, if 
the child is heavy or obese, there will be a space between the back of the 
child’s head and the back of the measuring board. Make sure the child’s 
shoulders are level (Arrow 11), the hands are at the child’s side (Arrow 


21 


12), and at least the child’s buttocks touch the back of the measuring 
board. Note that with most preschool-age children who are not heavy or 
obese, the back of the head, the shoulder blades, the buttocks, the calves 
and heels will touch the back of the measuring board (Arrows 10, 13, 14, 
15 & 5). 


9. Measurer and Assistant: Check the position of the child (Arrows 1-15). 
Repeat any steps as necessary. 


10.Measurer: When the child’s position is correct, lower the headpiece on 
top of the child’s head (Arrow 16) making sure to push through the child’s 
hair. Read and call out the measurement to the nearest 0.1 cm. Remove 
the headpiece from the child’s head, your left hand from the child’s chin, 
and allow the child to return to the parent. 


11.Assistant: Immediately record the height measurements in Questions 
206 on the questionnaire and show it to the measurer. Record that the 
child was measured standing up in Question 207. 


12.Measurer: Check the recorded measurement on the questionnaire for 
accuracy and legibility. Instruct the assistant to correct any errors. 


MEASURING A CHILD’S LENGTH (ILLUSTRATION 2) 
for children less than two years old; or, when age cannot be obtained, 
length is measured for children less than 85 centimeters: 


1. Measurer or Assistant: 
Place the measuring board sstration 2 


Child Length Measurement 


on a hard, flat surface, such 
as the ground, floor or a 
solid table. Make sure the 
measuring board is stable. 


2. Assistant: Place the 
questionnaire on the 
ground, floor or table 
(Arrow 1) and kneel behind 
the base of the measuring 
board if it is on the ground 
or floor (Arrow 2). 


= pp Lis Où CLIPBOARD 
ON FLOOR 0 


3. Measurer: Kneel at the 
right side of the child (at 
the child’s feet) so that you 
can move the foot piece 
with your right hand (Arrow 
3). 


4. Measurer and Assistant: With the help of the parent, gently lower the 


child onto the measuring board, making sure the measurer supports the 
child at the trunk of the body while the assistant supports the child’s head. 


22 


5. Assistant: Cup your hands over the child’s ears (Arrow 4). With your arms 
straight (Arrow 5), place the child’s head against the base of the board. 
The child should be looking straight up (Arrow 6) so that the line of sight is 
perpendicular to the board. Your head should be directly over the child’s 
head. Watch the child’s head to make sure it is in the correct position 
against the base of the board. 


6. Measurer: Make sure the child is lying flat in the centre of the board 
(Arrow 7). 


Place the child’s knees and feet in the correct position, with knees and 
feet either together or apart. There are three possible positions for the 
knees and feet: 


e Knees together and feet together 

e Knees together and feet apart Whichever touches 
first! 

e Knees apart and feet togethe 


With your thumb against your index finger, place your left hand on the 
child’s knees (Arrow 8) and press them gently, but firmly against the 
board. Do not wrap your hand around the knees or squeeze them 
together. Make sure the child’s legs are straight. 


7. Measurer: Check the position of the child (Arrows 1-8). Repeat any steps 
as necessary. 


8. Measurer: When the child’s position is correct, move the foot piece with 
your right hand until it is firmly against the child’s heels (Arrow 9). Read 
the measurement to the nearest 0.1 cm and call out the measurement to 
the assistant. Return the child to the parent. 


9. Assistant: Record the height measurements in Questions 206 and that 
the child was measured lying down in Question 207. Show it to the 
assistant for confirmation. 


10.Measurer: Check the recorded measurement on the questionnaire for 
accuracy and legibility. Instruct the assistant to correct any errors. 


MEASURING AN ADULT’S HEIGHT (ILLUSTRATION 3): 
NOTE: The height of adults can be taken by one person alone, the Measurer. 


1. Measurer: Place the measuring board on a hard, flat surface against a 
wall, table, tree or staircase. Make sure the measuring board is stable. 
Many walls and floors are not at perfect right angles; if necessary, place 
small rocks underneath the height board to stabilize it during the 
measurement. 


2. Measurer: Ask the person to take off his/ner shoes and ask him/her to 
unbraid or push aside any hair that would interfere with the height 
measurement. Ask the person to stand on the base of the height 
measuring board and to face forward. 


23 


. Measurer: Place the questionnaire and pen on the ground (Arrow 1) and 
stand on the left side of the person (Arrow 2). 


. Measurer: Determine if the person’s feet should be against or away from 
the back of the height board by observing the imaginary line drawn from 
the tip of the shoulder to the heel, which is called the “mid-axillary line” 
(Arrow 3). This line should be perpendicular (90°) to the base of the height 
board where the person is standing. Note that with almost all adults you 
will have to move the person’s feet away from the back of the height 
board to put them in the proper position; Arrow 4. 


. Measurer: Place the knees and feet in the correct position, with knees 
and feet either together or apart. There are three possible positions for 
the knees and feet: 


e Knees together and feet together 
e Knees together and feet apart Whichever touches first! 
e Knees apart and feet togethe 


. Measurer: Ask the person to look straight ahead. Cup the respondent’s 
chin between the thumb and index finger of your left hand and gradually 
close your hand (Arrow 5). Position the person’s head so that the line of 
sight is parallel to the ground (Arrow 6). Note that with most adults, the 
back of the head will not touch the back of the height board—there will be 
a space between the back of the person’s head and the back of the 
measuring board (Arrow 7). After you have placed the person’s head in 
the proper position, release your hand from the person’s chin and ask 
him/her to hold his/her head in the position you have just placed it in. 


Make sure the person’s shoulders are level (Arrow 8), the hands are at the 
person’s side (Arrow 9), and at least the buttocks touches the back of the 
measuring board). Note that with most adults, only the buttocks and 
perhaps the shoulder blades, will touch the back of the measuring board 
(Arrows 10 & 11). 


. Measurer: Check the position of the person (Arrows 1-11). Repeat any 


steps as necessary. 
” d Standing Height of Adults* 


. Measurer: When the 


person’s position is AMuStraHons 
correct, lower the 

headpiece on top of the 
head (Arrow 12) making 
sure to push through the 
person’s hair. Read and 
call out the measurement 
to the nearest 0.1 cm. 
Remove the headpiece 
from the person’s head, 
and escort the person off 
the height board. 


Measurer: Immediately 
record the measurement 


FROM BACK 
OF BOARD 


| ES 


on the questionnaire. Record an adult’s height measurements in 
Question 217/246. If the adult’s height was not measured, record the 
appropriate code in Question 217/246. 


9. Measurer: Check the recorded measurement on the questionnaire for 
accuracy and legibility. Correct any errors. 


Summary of Steps in Measuring Anthropometry 


+ Children less than 2 years old or, in absence of age information, less 
than 85 cm 


o Verify the recorded name and line number in Question 201 
and date of birth in Question 203. 


Confirm child was born in January [YEAR] or later 

Measure weight 

Record weight in Question 205 

Measure length with child laying down on Shorr board 

Record length in Question 206 

Record that child was measured laying down in Question 207 


e Children 2 years or older or, in absence of age information, 85 cm or 
greater 


o Verify the recorded name and line number in Question 201 
and date of birth in Question 203. 


Confirm child was born in January [YEAR] or later 
Measure weight 

Record weight in Question 205 

Measure standing height 

Record height in Q206 

Record that child was measured while standing in Q207 


e Adults 
o Verify the recorded name and line number in Q215/244 
o Measure weight 
o Record weight in Q216/245 
o Measure height 
o Record height in Q217/246 


26 


CHAPTER 3: GENERAL PROCEDURES FOR COLLECTING CAPILLARY 
BLOOD DROP SAMPLES 


Capillary blood will be collected in the [YEAR] [COUNTRY] DHS to test for the 
following biomarkers: [anemia] and [HIV]. Capillary blood can be obtained from 
the palm side of the end of a finger or from a heel. For adults and children six 
months of age and older, a finger should be used. However, if a child is 
undernourished (and skinny), the underlying tissue can be very thin and a lancet 
is likely to pierce the bone. For such children, a heel puncture is recommended. 
This chapter describes the materials needed for and, the steps involved in, 
capillary blood collection. 


MATERIALS AND SUPPLIES FOR PERFORMING FINGER OR HEEL PRICK 


The capillary blood drops collected for biomarker testing will be drawn from a 
finger or the heel. The following supplies and materials will be used in 
performing the finger or heel prick: 


+ Disposable Latex gloves: used to reduce the risk of bloodborne 
diseases. Gloves must be worn by the interviewer/health investigator and 
by anyone else who may assist with the blood collection. 


e Absorbent paper sheets: the surface area where your supplies will be 
placed while you conduct the blood collection. Place the plastic/shiny side 
of the absorbent sheet down (the absorbent side without plastic on it 
should be up). 


e Alcohol preps: used for cleaning the skin prior to pricking the finger or 
heel. 


+ Safety lancets: the lancet is a single- 
use, disposable device used to prick the 
fingertip or heel (Figure 3.1). The needle 
is retractable; when the trigger is 
pressed, a surgical blade quickly 
protrudes from the device, punctures 
the skin, and then automatically 
retracts. Lancets come in different 
sizes; one for use with children (depth : 
of puncture is 2.25 mm) and one for use Figure 3.1 Examples of safety 
with adults (depth of puncture is 2.4 - 
mm). 


e Sterile gauze pads: used to wipe away the first drop(s) of blood in order 
to stimulate a spontaneous capillary blood flow. 


+ Adhesive bandages (plasters or Band-aids): applied to the puncture 
site to minimize the risk of infection. 


+ Plastic Bag for Waste: Large bags that are provided to hold all of the 


biohazardous waste generated during the day. All waste bags are to be 
clearly labeled “biohazard”. 


DT 


STEPS IN OBTAINING CAPILLARY BLOOD FROM THE FINGER 


The following describes the steps that are involved in obtaining a capillary blood 
drop sample from the finger. They apply to both the collection of samples from 
adults and from children six months of age and older. 


1. Complete general preparation 


e If possible, find an indoor site to encourage privacy. If possible, the 
site should have a table or other piece of furniture with a flat surface 
where you can lay out the supplies. A couch, bed or mat should be 
readily available if the respondent feels faint and needs to lie down. 


e If you find you must do the test outdoors, find a site in the full shade 
and away from rain, dust, and other environmental elements that 
might affect the sample. 


e When and where possible, wash and dry your hands. Put on gloves 
before beginning the collection of the blood sample from the first 
respondent. 


e Take out a clean absorbent paper sheet and spread it over a flat 
surface where you will lay out your supplies. 


e Refer to the Biomarker Data Form for children and adults to confirm the 
number of eligible individuals for whom blood samples will be 
collected. After you have established the number of individuals to test, 
take out the appropriate equipment and general supplies. You will want 
to have all general materials in easy reach when you begin collecting 
blood samples from the respondents. 


« Note- please do not remove microcuvettes or filter paper 
until right before pricking. These items should be taken 
out on an individual basis. In other words, if three 
individuals are being tested for anemia, only remove the 
microcuvettes from the canister one at a time, before 
pricking each person. 


e If the respondent is a child, describe to the parent/responsible adult 
exactly what will be done during the collection of the blood sample and 
how they can assist by holding the child on their lap and holding the 
child’s hand during the collection of the sample. 


e The child may be fearful or anxious about what is going to happen. 
Therefore, using a calm and reassuring manner with the child is 
important as you begin to collect the blood sample. Remember that 
nonverbal communication is important, so maintain eye contact with 
the child as you prepare to take the sample. 


2. Select and prepare the prick site 


e Blood collection is usually easier if 
you sit on the side of the 
respondent opposite to the 


a D. 
Figure 3.2 Fingers for blood 


3: 


hand that you will collect blood from. For example, if you want to 
collect the specimen from the left hand, place yourself to the right side 
of the respondent. 


Use the third or fourth finger for collecting the blood (Figure 3.2). 
Do not use a finger with a scar, a wound or cut, an infection, swelling, a 
deformity, or a rash. Also, do not use a finger on which the respondent 
is wearing a ring, because the ring may disrupt the free flow of blood to 
the tip of the finger. You can ask the respondent to remove the ring. 


Warm the skin over the puncture site by rubbing it. This will increase 
blood flow to the finger tip and improve the ease with which a sample 
can be obtained. 


With an alcohol swab, clean the 
skin of the finger thoroughly 
(Figure 3.3). If the skin is very dirty, 
use a second swab. Finish cleaning 
the finger before preparing for the 
finger prick. Allow the alcohol to air 
dry. Do not blow on the area to dry 
the alcohol. Blowing may allow 
bacteria to contaminate the site. 
Fiaure 3.3 Clean the finaer 


Ensure that the correct size 

lancet is easily accessible. For adults, you will use adult lancets 
which have a needle diameter of 0.81 mm (21 G) and pierce the skin to 
a depth of 2.4 mm. For children, you will use children’s lancets which 
pierce the skin to a depth of 2.25 mm. 


Remove the blade slot cover 


o For the child lancet, remove the 
blade slot cover by first twisting 
it 360° and then pulling it out. 


o For the adult lancets, push in the 
blade slot cover and then twist 
360°. Pull it out after twisting. 


0 Do not remove the blade slot Figure Sah Parent assisting with 
cover from the adult or child 
lancets other than as instructed above, as this may cause the 
blade not to pierce the skin. 


Prick the Finger 


Make sure that the finger is below 
the level of the respondent’s 
heart to increase the flow of blood to 
the finger. Using a rolling movement 
of your thumb, lightly press the 
finger from the top knuckle 


Figure 3.5 Placement of adult 


toward the tip. This action will stimulate a flow of blood to the sample 
area. 


For children, it may be helpful if the parent/responsible adult assists 
you by holding the child’s hand (Figure 3.4). 


When your thumb reaches the fingertip, maintain a gentle pressure 
to trap the blood in the finger tip. 


Place the adult lancet firmly against the skin with the trigger facing 
upwards, so that the arrow preceding the trigger is visible 
(Figure 3.5). 


For children, use the child lancet as 
shown in Figure 3.6. Place the lancet so 
that the wide body of the lancet 
faces up. 


Note: for both adults and children avoid 
placing the lancet on the very tip of the 
finger or the sides beyond the palmar 
area or you will risk piercing the 
underlying bone. Proper puncture sites Figure 3.6 Placement of child 
are shown in Figure 3.7. 


Use the lancet to prick the skin by placing the blade-slot surface 
against the area and pressing the 
trigger (Figure 3.5 and 3.6). The tip 
of the blade ejects through the blade 
slot, producing a micro-incision in the 
skin, and immediately retracts into 
the device. After pricking the skin, 
set aside the lancet and turn the 
finger slightly to prevent blood from 
running into the grooves of the 
fingerprints. 


Figure 3.7 Puncture sites on the 


4. Collect the blood drops 


When the blood appears, use a sterile gauze pad to wipe away the first 
one or two drops of blood depending on the tests being performed. 
[Note: anemia testing requires the first two drops be wiped away; 
blood collection for HIV testing requires only the first drop be wiped 
away (See Chapter 5 for more details on collecting blood for HIV). If 
blood is being obtained for both HIV and anemia testing, only the first 
drop is wiped away and blood collection for HIV testing precedes that 
for anemia testing. See Appendix B for more details on combining 
anemia and HIV blood collection. ] 


If the blood stops flowing before you have collected at least three blood 
drops on the filter paper card and/or done the anemia testing, the 
pricking procedure may be repeated with the respondent’s consent. 
For children or minors, you must get consent from the parent or 


30 


responsible adult. Do not reuse any of the supplies used for the 
first finger prick. 


5. Discard all materials used in the blood collection procedure in a labeled 
biohazardous waste container (bag). 


31 


STEPS IN OBTAINING CAPILLARY BLOOD FROM A CHILD’S HEEL 


The heel is the puncture site for infants whose fingers are very thin. A child 
lancet of 2.25 mm will be used to puncture the heel. The following describes the 
steps that are involved in obtaining a capillary blood drop sample from the heel. 


1. The prick should be made outside a line 
drawn from the middle of the big toe to 
the heel or outside a line drawn from the 
area between the fourth and fifth toes to 
the heel (Figure 3.8). Take care to avoid 
the central area of the foot (to avoid 
injury to the nerves and tendons) or the 
center of the heel (to avoid piercing the 
heel bone). 


Figure 3.8 Site for heel puncture 


2. Hold the heel firmly (Figure 3.9). Apply moderate pressure near the 
puncture site. This can be done by wrapping the heel using your thumb 
and second finger. 


3. Clean the site with an alcohol swab. 
Make sure the site is dry before 
puncturing the skin with the lancet. In 
selecting a puncture site, avoid any 
areas of the skin that are broken or 
infected. 


4. Use the lancet for the skin puncture by 
placing the blade-slot surface against 
the area and pressing the trigger. 
Ensure the free flow of blood. Figure 3.9 Holding the infant’s heel 


5. Wipe away the first two drops of blood using a sterile gauze pad and 
collect the third drop for anemia testing (see Chapter 4). 


6. Discard all materials used in the blood collection procedure in a labeled 
biohazardous waste container (bag). 


2 


PRECAUTIONS TO OBSERVE WHEN COLLECTING BLOOD SAMPLES? 


This section describes the universal (general) precautions to be followed 
during blood collection*. You should take precautions when collecting blood to 
prevent exposure to bloodborne infections, such as hepatitis B, or human 
immunodeficiency virus (HIV). Under general precautions the following rules 
should be followed to ensure protection from acquiring bloodborne infections. 


Wear gloves. Gloves help to prevent skin and mucous-membrane exposure to 
blood. Gloves should be worn during blood collection, until the specimen(s) from 
a respondent is collected and all waste materials produced during the collection 
are disposed. At that point, the gloves used should be treated as biohazardous 
waste. A new pair of gloves should be used with each respondent. Gloves must 
never be reused! Avoid penetrating injuries. Although gloves can prevent 
blood contamination of intact and non-intact skin surfaces, they cannot prevent 
penetrating injuries caused by the instruments used for finger or heel pricks. 
Safety lancet devices reduce the risk of penetrating injuries. 


Lancets should not be used for purposes other than a single finger or heel 
prick to collect blood for the biomarker testing. The lancets should not be 
broken or destroyed for curiosity or other purposes. After the device is 
used, it should be placed in a puncture-resistant disposal biohazard bag. 


If an accident occurs, any skin surfaces or mucous membranes that 
become contaminated with blood should be immediately and thoroughly 
washed with running water or copious amounts of standing water. 


Never eat or drink during the testing. Since eating, drinking, and applying 
cosmetics may distract from the procedure, they are not permitted while 
collecting blood samples. 


Properly dispose of all biohazardous materials. All materials coming in 
contact with blood must be placed in a biohazardous waste container after use 
and disposed of according to the survey’s policy on infectious waste disposal 
(see Chapter 6). Take precautions when storing and transporting the waste 
container during the fieldwork. 


° Adapted from National Committee for Clinical Laboratory Standards (NCCLS) 1997 


. For the universal precautions regarding bloodborne pathogens, see the U.S. Centers for Disease Control and 
Prevention guidelines and the U.S. Occupational Safety and Health Administration (OSHA) standards for 
protection from exposure to bloodborne pathogen. 


33 


GOOD BLOOD COLLECTION PRACTICES 


Good position in relation to the respondent. Position yourself well before 
you make a puncture on the respondent’s finger. 


Do not prick the finger if the hand is cold! Warm the hands by asking the 
respondent to rub them together vigorously. In the case of a child, ask the 
mother to rub the child’s hands. 


Never “milk” the finger. Excessive massaging or squeezing of the finger or 
foot will cause tissue juice to mix with and dilute the blood. This will result in 
erroneous test results, particularly yielding low levels of hemoglobin 
concentration in the blood. Instead, the tester should employ only mild pressure 
by using the thumb and the second and third fingers to make a “pad” at the 
puncture site. This will make the connective tissue underlying the skin more 
porous and allow the capillary blood to flow easily after the incision. 


Never mix alcohol with the blood. If the alcohol used to clean the puncture 
site mixes with the blood, it can cause hemolysis of the sample leading to errors 
in the testing results. To avoid this problem, the finger or heel must be air dried 
completely before being punctured. 


Avoid obstructing blood flow. It is important to hold the finger properly to 
allow for the accumulation of blood in the puncture-site area. Holding the finger 
too tightly can obstruct the blood flow to the finger. 


Avoid shallow punctures. A deep puncture should be made for better blood 
flow and to have a representative concentration of red blood cells. 


Dispose of biohazard materials as they are used. Keep the biohazard bag 
open during blood collection and drop each disposable item into the bag as you 
finish using it. 


Summary of Steps for Capillary Blood Collection 


Seek informed consent 


For children between 6 and 12 months, determine if heel or finger prick 
should be performed 


Set up capillary blood collection supplies, making sure to select the 
correct lancet (adult or child) 


Clean surface of finger/heel 

Maintain gentle pressure to trap blood in the fingertip 
Apply moderate pressure near the puncture site of the heel 
Prick finger/heel 

Collect capillary blood 


Dispose of all testing materials in a clearly labeled biohazard bag or 
container. 


CHAPTER 4: ANEMIA TESTING 


Red blood cells contain hemoglobin (Hb), an iron-rich protein that binds oxygen 
in the lungs and carries it to tissues and organs throughout the body. Anemia is 
defined as a reduction in the normal number of red blood cells or a decrease in 
the concentration of Hb in the blood. Symptoms of anemia range from pallor, 
fatigue and weakness, shortness of breath and heart problems. During the 
[COUNTRY] DHS, we will measure the amount of Hb in the respondent’s blood. 
Individuals who have an Hb level below a defined cut-off will be classified as 
anemic. 


Common causes of anemia include: 


e tron deficiency from inadequate intake of foods containing iron, such as 
red meat; 

e Intake of foods that contain non-bioavailable iron; 

e Malaria and other parasitic infections (for example, schistosomiasis; 
hookworm); 

+ Blood disorders (for example, sickle cell anemia; thalassemia). 


Anemia is a common and significant global health problem. Consequences of 
anemia include an increased risk of maternal and child mortality, impaired 
cognitive development in children, increased numbers of pre-term and low 
birthweight babies, and reduced work productivity in adults. 


The measurement of Hb is the primary method of screening for anemia. Hb 
measurement provides an opportunity to: 


e Estimate the prevalence of anemia in a nationally-representative sample; 

e Link the levels of anemia with demographic data so as to examine the 
socioeconomic, residential, and demographic differences in the prevalence 
of anemia among populations; 

e Design programs to prevent iron-deficiency anemia among the 
populations most in need of intervention (for example, iron fortification 
programs for women and young children living in rural districts). 


Anemia testing in the [COUNTRY] DHS will be performed using a HemoCue 
photometer (Hb 201+). This widely used system measures Hb concentration from 
a drop of blood obtained from by finger prick. The test is rapid, allowing results to 
be reported to the respondent immediately following the testing procedure. 
Respondents found to have severe anemia will be referred to a health facility for 
treatment. Anemic status is considered severe with an Hb level below 9 g/dl for 
pregnant women, below 7 g/dl for women who are not pregnant or don’t know if 
they are pregnant, below 9 g/dl for men and below 7 g/dl for children, 

This chapter discusses the materials needed and the procedure for anemia 
testing. In addition, directions are given regarding precautions to take during 
collection and testing, recording results in the Biomarker Data Form, and 
providing test results and anemia information to respondents. 


35 


MATERIALS AND SUPPLIES FOR ANEMIA TESTING 


In addition to the Biomarker Data Form and supplies listed in Chapter 3, the 
following equipment and supplies are required for anemia testing: 


+ Microcuvette: a plastic disposable unit 
that serves as both a reagent vessel and 
a measuring device (Figure 4.1). The tip 
of the microcuvette contains a dry, 
yellow reagent (sodium azide). The 
microcuvette is designed to draw up the 
exact amount of blood needed for the 
test. 


Figure 4.1 HemoCue 


¢ HemoCue Hb 201 + photometer: a device that uses the absorption 
of light to measure hemoglobin concentration from a single drop of 
blood collected in a microcuvette 
(Figure 4.2). Test results are 
presented on the photometer’s 
electronic display. The HemoCue 
system is described in greater detail 
below. 


e Anemia Brochure: a one page 
document designed to educate the 
respondent about anemia, including 
its definition, symptoms, causes, and 
methods of treatment and 
prevention. In addition, the Figure 4.2 HemoCue Hb201+ 
respondents Hb results are recorded photometer 
and classified within this document. 

See Appendix A for an example of an anemia brochure. 


e Anemia Referral Slip for Severely Anemic Respondents: on this 
form is written the name and Hb results of severely anemic 
respondents. It is to be given to individuals with an Hb result indicative 
of severe anemia. They can take the referral to a local clinic or health 
center to receive proper treatment for their anemia. 


The HemoCue Photometer System (Hb 201+) 


Although the HemoCue system has proven to be durable and reliable under field 
conditions, there are some technical limitations related to the fact that 
microcuvettes are sensitive to humidity. Follow these instructions for the proper 
handling and storage of microcuvettes: 
1. Record on the microcuvette container the date the container is first 
opened; 
2. Remove from the container only those microcuvettes required for 
immediate testing; 
3. Remove the microcuvettes by holding the side opposite the tip; 
4. Immediately after taking a microcuvette out of the container, snap the 
container lid back on tightly; 
5. Keep the microcuvette container at room temperature and avoid exposing 
it to heat or strong sunlight. 


36 


Under these conditions, a microcuvette container can be stored for up to 3 
months (90 days) after opening. Under field conditions, it is advisable to store 
the microcuvettes in the opened container for no more than a month. 
Microcuvettes from unopened containers can be used up to the expiration date 
on the container. 


To ensure the HemoCue Hb 201+ system operates properly, allow the 
photometer to come to the ambient temperature and protect it from direct 
sunlight. The device operates optimally between 18 and 30° C. The photometer 
has an internal electronic “SELFTEST”; every time the device is turned on, it 
automatically verifies the performance of its optronic unit. 


The photometer’s black microcuvette holder has three operating positions: 1) 
pushed in, for measuring; 2) pulled out until “clicked,” for placing the 
microcuvette; 3) completely withdrawn for cleaning. 


Clean the microcuvette holder (the drawer) at the end of each day’s fieldwork. 
For cleaning the holder, use an alcohol swab or cotton wool/cotton-tipped swabs 
moistened with 70% alcohol. Follow these procedures to clean the microcuvette 
holder: 


1. Check that the analyzer is turned off and 
the display window is blank. 


2. Pull the microcuvette holder out of its 
loading position. Carefully press the small 
catch positioned in the upper right corner 
of the microcuvette holder. 


3. While pressing the catch, carefully rotate 
the microcuvette holder towards the left 
as far as possible. Carefully pull the 
microcuvette holder away from the 
analyzer. Figure 4.3 Cleaning microcuvette 


4. Clean the microcuvette holder with an alcohol swab or cotton wool 
moistened with 70% alcohol (ethanol or isopropyl alcohol). 


5. The HemoCue cleaner swabs are used to clean the optronic unit inside the 
machine. Clean the optronic unit by pushing the swab into the opening of 
the microcuvette holder (Figure 4.3). Move the cleaner from side to side 5- 
10 times. If the swab is stained (blood or dirt), repeat the cleaning 
procedure with a new swab. It is important that the microcuvette holder is 
completely dry prior to reinserting it in the photometer. 


Blood may get on the optronic system if you do not wipe the outside of the 
microcuvette before placing the microcuvette in the holder. If this happens, you 
will get an error message (E01-E05; E09-E30). Clean the HemoCue machine as 
described above when you get an error message. 


a7 


COLLECTING BLOOD AND TESTING FOR ANEMIA 
Children: Follow the procedure below to test children for anemia: 


1. Determine if the child is 6 or more months old and eligible for anemia 
testing: For Question 208, refer to Question 203 to determine if the 
child is less than 6 months old If the child was born in the month of 
interview or in the 5 months before the month of interview, the child is not 
eligible for anemia testing. For example, if you are visiting the household 
in July, a child born in February, March, April, May, June, or July will not be 
eligible for testing. In other words, if the child is less than 6 months old, 
the child is not eligible for anemia testing, so you will record ‘1’ and 
continue to the next child. If the child is older than 6 months, record ‘2’ 
and proceed to Question 209. 


2. Refer to the household schedule and record the Line Number of the 
parent/responsible adult of the child in Question 209. 


3. Read the statement in Question 210 to seek consent for anemia testing 
of the child from the parent/responsible adult. Record the outcome of the 
consent process in Question 211. Confirm that you read the statement to 
the parent/responsible adult and recorded their response accurately by 
signing in the space provided. 


4. If consent was granted, collect a finger or heel stick blood sample from the 
child, following the procedure described in Chapter 3. Use a sterile gauze 
pad to wipe away the first two blood drops from the finger (heel) prick. 


5. Conduct the anemia test as follows: 
o Step 1: Collect the capillary blood in the microcuvette: 


« Apply the tip of the HemoCue 
microcuvette to the middle of 
the blood drop. The 
microcuvette chamber will fill 
itself automatically by capillary ——, ‘ 
action. The chamber needs to be ME RS Aen 
filled completely (Figure 4.4). oo 
Never “top off” the 
microcuvette. Instead, if the 
microcuvette is not completely 
filled, use a fresh microcuvette 
and fill it with the next blood 
drop that forms. 


« Wipe any surplus blood off both 
sides of the microcuvette “like 
butter from a knife,” using the 
clean end of a sterile gauze pad. 
Ensure that no blood is sucked <a 
out of the microcuvette when Heel prick 


Figure 4.4 Filling the microcuvette 


38 


wiping it - do not let the tip of the filled microcuvette touch the 
gauze. 


« After filling the chamber, the microcuvette needs to be visually 
inspected for air bubbles. Since air bubbles may influence the 
hemoglobin measurement, any microcuvette containing air 
bubbles must be discarded. In such cases, with the permission of 
the parent/ responsible adult, repeat the blood drop collection 
using a different finger (heel). Again, you must use new 
disposable supplies and follow all of the steps described 
previously in obtaining the new 
sample. 


" Place the microcuvette in its holder 
and gently push the holder into the 
photometer (Figure 4.5). 


o Step 2: Stop bleeding at the site of the 
prick: 


« After the blood drop collection, wipe 
any remaining blood from the prick 
site with a sterile gauze pad. Press _ Figure 4.5 Placing the 
the gauze pad against the prick site ica al da 
until the blood flow has stopped 
completely. 


" Take an adhesive bandage from its wrapper and apply it to 
the prick site (Figure 4.6). Advise the mother, especially when 
the child is a toddler, to watch 
carefully that child does not take 
off the bandage and put it in 
his/her mouth where the child 
may choke on it. 


o Step 3: Obtain the hemoglobin level: 


" Reading the results: The 
microcuvette should be analyzed — 


immediately, and no later than Figure 4.6 Applying adhesive 
ten minutes after being filled. 
The blood hemoglobin level in grams per deciliter (g/dl) is 
displayed 15 to 45 seconds after the drawer is closed (Figure 
4.6). 


o Step 4: Record the hemoglobin level 
and test result: 


" Record the hemoglobin level 
shown on the photometer 
(Figure 4.7) in the appropriate 
box in Question 212 of the 
Biomarker Data Form. If there is 


Figure 4.7 Hemoglobin level displayed 
on the HemoCue photometer and as it 
should be recorded on the Household 


no value to record because the child was not present, the 
parent/responsible adult refused to consent to the test, or there 
was some other problem, record the appropriate code in 
Question 212. If more than one child in the household is 
eligible and is listed, check carefully that you are recording the 
hemoglobin level in the correct column of the schedule. 


o Step 5: Collect biohazardous waste: 


« Place all biohazardous waste (lancets, microcuvettes, alcohol 
swabs, gauze, and gloves) into a plastic bag provided for field 
disposal of these items. At the end of the day, follow the 
procedures described in Chapter 6 for the proper disposal of 
waste materials. 


6. Record the child’s hemoglobin level in the anemia brochure. Inform the 
parent/responsible adult of the results and provide the parent with the 
brochure (see Appendix A). 


7. Provide a written referral to a health facility for medical treatment for any 


child with severe anemia (hemoglobin level less than 7 g/dl; referral 
described at the end of chapter). 


40 


[WHEN PREPARING THIS MANUAL FOR A SPECIFIC SURVEY AND THE 
SURVEY CALLS FOR BOTH ANEMIA TESTING AND COLLECTING BLOOD 
FOR HIV TESTING: 


Remove the 9 steps below for adult anemia testing (it will be covered in 
the “Combined procedure for anemia testing and collecting DBS for HIV 
testing”.] 


Adults: Follow the procedure below to test adults for anemia: 


1. Check the respondent’s age and marital status in Question 218/247 and 
Question 219/248 by referring to Column 7 and Column 8, 
respectively, of the household schedule. Record whether a female 
respondent is age 15-17 or age 18-49; record whether the male 
respondent is age 15-17 or age 18-49. You must do this step because if 
the respondent is age 15-17 and never in a union, he/she is considered an 
adolescent and consent for testing must be obtained from the parent or 
responsible adult as well as the respondent. If the respondent has been in 
a union or is age 18-49, skip to Question 223/252. 


2. For a respondent age 18-49 or a respondent age 15-17 who has 
been in a union: 


a. Seek consent for anemia testing from adult respondent in 
Question 223/252 by reading the consent statement. If the adult 
does not consent to the anemia test, in Question 224/253 record 
REFUSED, sign your name on the blank line. If the adult does 
consent, in Question 224/253 record GRANTED, sign your name. 


b. For a female respondent who has consented to anemia testing, 
record pregnancy status in Question 225. 


3. For a respondent age 15-17 who has never been in a union (an 
adolescent): 


a. Record the line number of his/her parent/responsible adult in 
Question 220/249. 


b. Seek consent for anemia testing from the parent/responsible adult 
in Question 221/250. If the parent/responsible adult does not 
consent to the adolescent’s anemia test, in Question 222/251 
record REFUSED, sign your name on the blank line. If the 
parent/responsible adult does consent, in Question 222/251 
record GRANTED, sign your name, and go to Question 223/252. 


c. Seek consent for anemia testing from adolescent in Question 
223/252 by reading the consent statement. If the adolescent does 
not consent to the anemia test, in Question 224/253 record 
REFUSED, sign your name on the blank line. If the adolescent does 
consent, in Question 224/253 record GRANTED, sign your name. 


d. For a female respondent who has consented to anemia testing, 
record pregnancy status in Question 225. 


41 


. Prepare the equipment and supplies for the tests for which consent has 
been granted as described in Question 239/267. 


. If consent was granted, collect blood from a finger prick following the 
procedure described in Chapter 3. Use a sterile gauze pad to wipe away 
the first two blood drops from the finger prick. 


Conduct the anemia test as described above for children: 


OO OO 


O 


Step 1: Collect the capillary blood in the microcuvette 

Step 2: Stop bleeding at the site of the prick 

Step 3: Obtain the hemoglobin level 

Step 4: Record the hemoglobin level and test result in Question 
240/268. 

Step 5: Collect biohazardous waste 


. Record the respondent’s hemoglobin level in the anemia brochure. 


. Inform the respondent of her/his hemoglobin level and provide the anemia 
brochure. 


. Provide a written referral to a health facility for treatment for any 
respondent with severe anemia (below 9 g/dl for pregnant women, below 
7 g/dl for women who are not pregnant (or don’t know if they are 
pregnant), and below 9 g/dl for men. 


42 


PRECAUTIONS TO TAKE DURING ANEMIA TESTING 


Please take the following precautions while doing anemia testing: 


Never remove a microcuvette from the container with fingers wet 
with alcohol. This can result in alcohol coming into contact with the 
reagents inside the microcuvette and destroying them. Using fingers wet 
with alcohol to handle other microcuvettes in the container can also affect 
them. 


Never use the first two drops of blood for hemoglobin testing. If 
the respondent consents to the anemia test, wipe away the first two 
drops of blood and then collect the third drop in the microcuvette. This 
ensures the free flow of blood and allows for the collection of blood with a 
representative concentration of red blood cells. [When testing for HIV in 
addition to anemia, follow the instructions provided in Appendix B, and 
use the fifth drop of blood for hemoglobin testing. ] 


Avoid inadequate filling or re-filling of the microcuvette. The 
chamber of the microcuvette that contains dry reagents (yellow portion) 
has to be completely filled. The microcuvette should be filled with a drop 
of blood in one continuous motion. A microcuvette that contains air 
bubbles should be discarded. 


Wiping off blood on the microcuvette. Blood on the exterior of the 
microcuvette should be removed; failure to clean the exterior of the 
microcuvette can lead to an erroneously high hemoglobin reading. 


Avoid keeping the microcuvette out for too long. Keeping the 
microcuvette out of the container for too long before using it can lead to 
errors. Remove the microcuvettes from its container immediately before 
starting the testing procedure. 


Avoid misalignment of the microcuvette in the photometer. The 
microcuvette only fits into the photometer’s microcuvette holder in one 
position. Therefore place it carefully in the holder and slowly push the 
holder inside the photometer to obtain a reading. Slamming the 
microcuvette holder can cause blood to spray onto the optronic system, 
an action that can damage the photometer. 


Old or improperly stored microcuvettes should not be used for 
testing. While in the field, microcuvettes should not be used if more than 
1 month has elapsed since the seal on the container was broken. The 
containers must be kept closed when not in use to avoid exposure to 
moisture, which can destroy the reagents. 


43 


PROVIDING ANEMIA TEST RESULTS AND REFERRALS FOR SEVERE ANEMIA 


Before leaving the household, you will verbally report the results of the 
hemoglobin measurement for each person for whom an anemia test was 
completed. In addition to verbally reporting Hb results, Hb results will also be 
written in an informational brochure that will be left at the household. When 
reporting the results, briefly explain to the respondent what his/her 
hemoglobin reading means, using the anemia brochure as a guide. Please see 
Appendix A for an example of the anemia brochure. 


Respondents with severe anemia should be informed about the effects of severe 
anemia and recommended to visit a health facility for follow-up medical 
attention. For each respondent with severe anemia, you will fill out an Anemia 
Referral Slip (Figure 4.8), on which you have recorded the hemoglobin level. 


FIGURE 4.8 EXAMPLE OF AN ANEMIA REFERRAL SLIP* 


[COUNTRY] DEMOGRAPHIC AND HEALTH SURVEY 


During the [COUNTRY] DHS, [YEAR], Ms./Mr./child 
age___ years, was tested for anemia on . His/her level of 


hemoglobin was. | g/dl, which indicates he/she is severely anemic. 
This person needs medical attention to treat the anemia 


* You will use a referral slip designed by [IMPLEMENTING AGENCY]. 


Summary of the steps involved in testing for anemia: 


Seek informed consent 
Clean the finger or heel with an alcohol swab; 
Prick the finger or heel with the appropriate-sized lancet; 

o Children 2.25 mm depth 

o Adults 2.4 mm depth 
Wipe away the first two drops of blood; 
Collect the third blood drop in a microcuvette; 
Stop the bleeding and apply an adhesive bandage to the puncture site; 
Measure hemoglobin level in the blood sample using the HemoCue 
photometer; 
Record the hemoglobin level in the appropriate column of the Biomarker 
Data Form; 
Collect biohazardous waste; 
Inform the respondent of his/her hemoglobin level and provide an 
informational brochure on anemia; 
Provide a written referral for follow-up medical attention for a respondent 
found to be severely anemic. 


44 


CHAPTER 5: DBS COLLECTION FOR HIV TESTING 


Acquired Immune Deficiency syndrome (AIDS) is a disorder of the immune 
system caused by the human immunodeficiency virus (HIV). People with AIDS 
are vulnerable to contracting life-threatening infections that people with a 
properly functioning immune system would not typically develop. 


Most of the current information on HIV prevalence in [COUNTRY] comes from 
surveillance of women attending antenatal clinics or of other special 
populations such as sex workers or individuals treated at health facilities for 
sexually transmitted infections. However, surveillance data do not yield an 
estimate of the prevalence of HIV among the general population. For 
example, the antenatal surveillance system excludes men and non-pregnant 
women. Since HIV is transmitted principally through sexual contact, obtaining 
an estimate of HIV prevalence for both men and women will provide a better 
estimate of the current level of HIV in [COUNTRY] than is available from other 
sources. Therefore, to estimate the national prevalence of HIV, for the 
[COUNTRY] DHS, a nationally-representative sample of women 15-49 and 
men 15-[49] will be tested. 


HIV testing itself does not take place in the field. Instead, blood samples are 
collected from a finger prick on a filter paper card, dried, transported to the 
[IMPLEMENTING AGENCY] for logging in and checking, and brought to [NAME 
OF LAB] in [LOCATION]. The dried blood spots (DBS) will be stored at the 
laboratory until field work is completed and then processed for testing in 
batches. 


HIV testing in the [COUNTRY] DHS is anonymous. Personal identifiers are 
delinked from the DBS-containing filter paper card, and respondents who 
agree to be tested are not told their results. Instead, respondents are given a 
voucher for voluntary counseling and HIV testing (VCT) at a nearby facility. 
For individuals living in communities in which there is no facility with the 
capacity to provide VCT within [15] km distance, arrangements will be made 
to bring mobile VCT to the community. 


This chapter will describe the procedure for DBS collection for HIV testing. It 
includes: 


Required Materials and Supplies 
DBS Collection Procedure 
Collection Precautions 

Providing VCT Information 

DBS Storage and Transfer 


45 


MATERIALS AND SUPPLIES FOR DBS COLLECTION FOR HIV TESTING 


In addition to the Biomarker Data Form and supplies listed in Chapter 3, the 
following materials are required for DBS collection for HIV testing: 

e Filter paper card: You will use special 
filter paper cards (Figure 5.1) to collect 
the blood samples. Each card has five 
preprinted circles that hold about 100 ul 
of blood when filled. 


o The pre-printed circles of the 
filter paper cards must be kept 
clean and dry at all times. 
Water, dust, sweat from your Figure 5.1 Filter paper card 
hands, or other environmental 
contaminants can affect HIV testing. Use gloves at all times 
when handling the filter paper cards. 


o The filter paper cards come in 100 card packets. Before opening a 
new packet, put on gloves. Open the packet and place the cards in 
3-4 smaller zip-loc bags; place these smaller bags in a large zip-loc 
bag. The bags must be stored stacked so as to avoid compressing 
the filter paper. Place a few desiccant packets and a humidity 
indicator card in each small bag before sealing it. You must 
also place desiccants and a humidity indicator card in the 
larger zip-loc bag. If the humidity indicator card and/or desiccants 
change color before the cards have all been used, replace the 
humidity indicator card and desiccants following the instructions 
described in the Desiccant packets and Humidity indicator 
card sections below. 


o Note: Keeping the unused filter paper cards with desiccants in a zip- 
loc bag will prevent moisture from being absorbed on the filter 
paper card which will prevent 


over-saturation or merging of CTATE UC mn 1) OCTO 

circles when blood is collected. et To slum 

il NL CD BALL Le LL QUE LD 

e Bar code labels: because the HIV MLD LIT Litiaa uit LC TEL 
testing in the [COUNTRY] DHS is ET at 1 ata QUE LOL] 
anonymous, respondent names are QUE IL TLC ALT UU QU LIL TT) 


never written on the filter paper cards. — rene us 
Instead, bar code labels are used to eee a = 
identify the DBS samples and link them HAE Re — 
to the interview data. You will be 

provided with sheets of “peel-off” UU AN 
adhesive bar code labels (Figure 5.2). Y8B3L 

The barcodes are arranged in rows; the 


Figure 5.2 Bar code labels (sheet 
codes on each label are the same across and individual). 


one row. A different row of bar code 
labels is to be used for each respondent for whom a DBS sample 
is collected. 


e Drying box: a plastic box with a cardboard rack positioned inside. 


46 


o For proper use, stand the box vertically (the filter paper cards will 
be positioned horizontally). The drying boxes are to be used for 
overnight drying of DBS samples. They are not to be used for long- 
term sample storage. 


Desiccant packets: drying agents that 
absorb moisture from the air that are 
used to keep the filter paper cards as dry 
as possible (Figure 5.3). The granules 
inside the packets change color from 
blue to pink as they absorb moisture. 

o Change the desiccants when the 
granules change to a pink color or 
as indicated by the humidity 
indicator cards. 

o Treat used desiccants as 
biohazardous waste and throw them away in a biohazardous waste 
bag. 


Figure 5.3 Desiccants 


Humidity indicator cards: cards that 
allow closer monitoring of the level of 
moisture than monitoring the color of the bape inan 
desiccant packets alone. 

o There are three circles on the 


humidity indicator card (Figure DESCLANT 

5.4). If the circle at the bottom of ES 

the card (labeled 30%) turns pink, WARNING 

it indicates a relatively high level of bitte 

humidity and is a warning to AVG MTL NT 
carefully monitor the humidity 


level. If the middle circle (labeled Figure 5.4 Humidity indicator 
40%) turns pink, replace the 

desiccant packets and humidity card. If the top circle (50%) turns 
pink, you must examine the DBS cards as their quality might have 
been compromised due to the high humidity in the bag. You should 
replace the desiccant packets and humidity card with fresh ones. 


Glassine paper: thin, glossy, semi-opaque paper squares used to protect 
the dried blood spots on the filter paper cards during storage. 


Low gas-permeable bags (small zip-loc bags): special small zip-loc 
bags used for storing the DBS samples in the field. These bags are 
specially manufactured to reduce the exposure of their contents to air and 
moisture. These bags are expensive and should never be used for other 
purposes, such as carrying food or adhesive bandages. The bags have a 
Sliding “zipper” that is used to close and seal the bag. 


Large zip-loc bags: A large zip-loc bag will be provided for each of the 
[COUNTRY] DHS sample clusters in which you will work. These bags will 
be used to hold the small zip-loc bags with DBS samples from the cluster 
during storage and transport to the [IMPLEMENTING AGENCY] and 
[LABORATORY]. 


47 


DBS Transmittal Sheet: accompanies the DBS samples to the 
laboratory. The purpose of this form is to ensure that the number of DBS 
samples sent to the laboratory matches the number of samples collected 
in the field, and to track the samples throughout the transport process. A 
bar code with the same unique identifier as the bar code label attached to 
the DBS sample is also attached to the DBS Transmittal Sheet and to the 
Biomarker Data Form (Question 241 for women or Question 269 for men). 
See Appendix C for an example of the DBS Transmittal Sheet. 


Voucher/Coupon for free VCT (Voluntary Counseling and HIV 
Testing) Services: contains information regarding HIV, VCT services, and 
a list of local VCT centers where respondents can receive HIV testing. See 
Appendix D for an example of a Voucher/Coupon for free VCT Services. 


48 


[WHEN PREPARING THIS MANUAL FOR A SPECIFIC SURVEY AND THE 
SURVEY CALLS FOR BOTH ANEMIA TESTING AND COLLECTING BLOOD 
FOR HIV TESTING, FOLLOW THESE STEPS: 


1) Replace section titled “DBS COLLECTION PROCEDURE” with 
APPENDIX B “Combined procedure for anemia testing and collecting 
DBS for HIV testing”. 

2) Keep the sections in this chapter titled “Precautions to take during 
DBS collection for HIV testing” and “Storing and transferring the 
DBS”. 

3) Replace the “Summary Steps” at the end of this chapter with the 
“Summary Steps” from Appendix B. 

4) Change this chapter title to “ANEMIA TESTING AND DBS COLLECTION 
FOR HIV TESTING” and change the figure numbers in the remainder 
of this chapter. 

5) Remove instructions for adult anemia testing found in chapter 4. 


If combined testing is not part of the survey, remove Appendix B.] 
DBS COLLECTION PROCEDURE 


1. Identify all women and men from the household schedule who are eligible 
for DBS collection. Women age 15-49 and men 15-[49] years who are 
usual members of the household or who slept in the household the night 
before are eligible. 


2. Record the Line Number and Name of all eligible women and men in 
Question 215 and Question 244, respectively, of the Biomarker Data 
Form. 


3. Check the respondent’s age and marital status in Question 218/247 and 
Question 219/248 by referring to Column 7 and Column 8, 
respectively, of the household schedule. Record the age group. You must 
do this step because if the respondent is age 15-17 and never in a union, 
he/she is considered to be an adolescent and consent for testing must be 
obtained from the parent or responsible adult as well as the respondent. If 
the respondent is or has been in a union or is age 18-49, skip to Question 
230/258. 


4. For a respondent age 18-49 or a respondent age 15-17 who has 
been in a union: 


o Read the informed consent statement for HIV testing to the 
respondent in Question 230/258. Record the outcome of the 
consent request in Question 231/259; confirm that you read the 
statement to the respondent and recorded their response 
accurately by signing in the space provided and entering your 
interviewer number. 


o Read the informed consent statement for additional testing to the 
respondent in Question 236/264. Record the outcome of the 
consent request in Question 237/265; confirm that you read the 
statement to the respondent and recorded their response 
accurately by signing in the space provided. 


49 


O 


If the respondent did not grant consent for additional testing, write 
“No additional tests” on the filter paper card. Go to Question 
239/267. 


5. For a respondent age 15-17 who has never been in a union (an 
adolescent): 


(e) 


Seek consent for HIV testing from the parent/responsible adult by 
reading Question 228/256. If the parent/responsible adult does 
not consent to the HIV test, record REFUSED in Question 229/257, 
sign your name on the blank line. If the parent/responsible adult 
does consent, in Question 229/257, record GRANTED and sign 
your name. 


Read the informed consent statement for HIV testing to the 
respondent in Question 230/258. Record the outcome of the 
consent request in Question 231/259; confirm that you read the 
statement to the adolescent respondent and recorded their 
response accurately by signing in the space provided and entering 
your interviewer number. 


Seek consent to store blood for additional testing from the 
parent/responsible adult by reading Question 234/262. If the 
parent or responsible adult does not consent to additional testing, 
record REFUSED in Question 235/263, sign your name on the 
blank line, and go to Question 238/266. If the parent/responsible 
adult consents, record GRANTED in Question 235/263 and sign 
your name. 


Read the informed consent statement for additional testing to the 
adolescent respondent in Question 236/264. Record the outcome 
of the consent request in Question 237/265; confirm that you read 
the statement to the adolescent respondent and recorded their 
response accurately by signing in the space provided. 


If either the parent/responsible adult or the adolescent respondent 
does not grant consent for additional testing, write “No additional 
tests” on filter paper card. 


6. If consent for HIV testing was granted, identify the next available complete 
set (row) of bar code labels. Wearing a pair of latex gloves, carefully 
remove a new filter paper card from the plastic zip-loc bag in which you 
have stored the cards. Make sure to handle the card in such a way that 
you do not touch the areas within the preprinted circle. Never handle a 
card with your bare hands as you may transfer sweat, dirt or other 
contaminants on to the card. 


Place the card with the pre-printed circles face-up on the clean 
absorbent sheet that you have spread out on a flat surface. Discard 
the card if it drops on the floor or ground or if it becomes dirty in 
any other manner. 


50 


o Take the first bar code label from the first complete row on the 
sheet of bar code labels and paste it in the column of the 
Biomarker Data Form containing the line number of this 
respondent (Question 241 for women or Question 269 for men). 


o Take the second bar code label from the same row on the sheet 
of bar code labels and paste it at the bottom of the filter paper card 
where it says ‘NAME’. Do not cover up or touch any part of the 
preprinted circles. 


o Take the third bar code label from the same row on the sheet of 
bar code labels and paste it on the Blood Sample Transmittal Sheet 
for the cluster in which you are working. 


o If additional bar code labels will not be needed for a 
particular respondent, remove all extra bar code labels 
remaining in the row and discard them. 


o DO THE ABOVE STEPS CAREFULLY. The bar code label is the 
only means of identifying the blood sample and for linking the HIV 
test results to the interview data. Mistakes will result in 
mismatches later on. CHECK THAT THE THREE MATCHING BAR 
CODE LABELS HAVE BEEN PLACED ON THE FILTER PAPER 
CARD, THE BIOMARKER DATA COLLECTION FORM, AND THE 
TRANSMITTAL SHEET BEFORE YOU PROCEED TO COLLECT 
BLOOD DROPS FROM THE RESPONDENT. 


7. Perform the DBS collection as follows: 


» Step 1: Obtaining Blood from the 
Finger 


«Follow the steps for 
producing a finger stick 
blood sample as described 
in Chapter 3. Use a sterile 
gauze pad to wipe away 
the first blood drop. While 
maintaining a firm grip on 
the finger, press gently on 
the side of the finger from 
which you are taking the blood sample to get a large second 
drop. Be careful to avoid ‘milking’ or ‘squeezing’ the 
finger as this could affect the test results. Wait until the drop 
is large enough to fill one of the preprinted circles on the card 
(Figure 5.5). 


Figure 5.5 Large drop of blood 


" Step 2: Position of Filter Paper Card 


" Move the card underneath the finger, with the pre-printed 
side of the card facing the pricked finger. 


= The card must not be pressed against the prick site on the 
finger. Make sure that the respondent’s finger does not 


51 


touch the card at any point when you are collecting the blood 
spots. 


" Step 3: Blood Collection on the card: 


" Let the blood drop fall 
freely in the center of the 
preprinted circle. In case 
the blood drop does not 
fall readily, you may touch 
the filter paper gently 
against a LARGE blood 
drop (but not the skin). In 
one step, a sufficient 


quantity of blood should willl 
be allowed to soak aa 
through and completely Figure 5.6 Filling up the pre-printed 


circle on the filter paper card 


fill the circle (Figure 5.6). 


« To enhance blood flow, gently apply intermittent pressure to 
the area surrounding the prick site to get a third drop. Allow 
sufficient time for a large blood drop to form before filling the 
next circle on the filter paper card. Again, avoid milking or 
squeezing the finger. 


" You must continue to 
collect drops of blood until 
you have fully saturated @ cS) S&S 
at least three circles on 
the filter paper card EEL! 
aes HNL 


« If possible, continue to fill 
the remaining circles with 
blood. 

Figure 5.7 Fully-filled circles 

« If the blood flow stops or without layering or caking 
decreases before you fully 
saturate the three circles, you will need to do another finger 
prick. Whenever this is necessary, you should explain to the 
respondent that you were unable to obtain an adequate 
sample and ask permission to obtain blood from another 
finger. Use fresh supplies and a different finger for the 
second finger prick. 


« Place the filter paper card with the blood spots on the 
absorbent paper sheet away from other items. Be careful not 
to drop the completed filter paper card. 

" Step 4: Stopping bleeding at puncture site 


« After the blood drop collection, wipe any remaining blood 
from the puncture site with a sterile gauze pad. Press the 


92 


gauze pad against the prick site until the blood flow has 
completely stopped. 


" Take an adhesive bandage from its wrapper and apply it to 
the prick site. 


» Step 5: Placing the completed filter paper card in the drying box 


" The drying box should be placed vertically on a flat surface at 
the time you set up your equipment. The position of the 
drying box is especially important anytime it contains filter 
paper cards that have not completely dried. Keep the box 
vertical whenever it contains blood spots that are not fully 
dried to prevent blood that has not yet completely dried from 
spreading. 


" Keep the drying box closed during blood collection to prevent 
dust and dirt from entering the box or from contaminating 
DBS cards that were collected earlier and are already in the 
box. After the blood collection process is finished, open the 
drying box (keeping it vertical). Carefully pick up the 
completed filter paper card and place it in a horizontal 
position in one of the slots in the drying rack in the box. The 
blood spots should face towards the back of the drying box. 
Close the box. 


« Avoid touching or smearing the blood spots on other 
cards already in the box when you are storing a new 
card. Never put more than one completed filter paper 
card ina single slot in the drying rack. 


« Allow blood spots to dry overnight at ambient temperature. 
The box should be handled carefully so that the cards do not 
fall out of their slots. 


» Step 6: Collecting biohazardous waste 


« Place all biohazardous waste (lancets, alcohol swabs, gauze 
pads, and gloves) into a clearly labeled “biohazard” plastic 
bag, which has been provided for field disposal of these 
items. At the end of the day, follow the procedures described 
in Chapter 6 for the proper disposal of waste materials. 


8. Record the result for blood collection for HIV testing in Question 
241/269. 


9. Provide an informational brochure on HIV/AIDS. The brochure will include a 


voucher for free HIV VCT services, and a list of the nearest participating 
VCT centers in [COUNTRY]. 


53 


PRECAUTIONS TO TAKE DURING DBS COLLECTION FOR HIV TESTING 


With respect to DBS collection for HIV testing, there are a number of precautions 
that should be carefully observed including: 


e Always use the pre-printed side of the card to collect the blood 
spots. 


¢ Do not ‘layer’ the sample in an attempt to fill in the circle. 


o There may be times when a drop of blood will not completely fill the 
circle. If a circle is not completely saturated, the next drop or just a 
portion of the next drop of blood may be used to saturate the circle 
if the drop is obtained immediately. If the first drop starts to dry 
due to any interruption in getting the subsequent drop, you must 
begin filling another circle. Layering or application of successive 
drops of blood to a dried or partially dried blood spot causes caking. 


¢ Do not overfill the circles. 
Overfilling the circles can cause 
super saturation (top panel of 
Figure 5.8), which is 
unacceptable. 


¢ Do not place box horizontally 
until blood dries. Placing the 
box horizontally before the blood 
dries can cause serum rings 
(bottom panel of Figure 5.8), Figure 5.8 Supersaturated (top) and 
which is also unacceptable. The serum rings (bottom) DBS samples are 
blood should not extend beyond 
the pre-printed area, as shown in Figure 5.7. 


e Try to have the first drop fall exactly in the center of the pre-printed circle. 
However, if by accident the drop falls outside of the circle and is not large 
enough, then let the next drop of blood fall again exactly in the center of 
the original drop and not in the center of the pre-printed circle. Note: all 
circles should have uniform blood volume. 


e Protect the filter card from contamination. Do not allow water or 
other contaminants to come into contact with the specimen card before or 
after use. 


¢ Do not place the specimens in the small zip-loc bags until the 
blood has dried thoroughly (chocolate brown). Insufficient drying 
adversely affects the quality of the samples and consequently, the test 
results. 


¢ Taking the filter paper card out of the storage bag. The filter paper 


card should be the last item taken out of the package before starting the 
blood collection procedure. 


94 


STORING AND TRANSFERRING THE DRIED BLOOD SPOTS 


The dried blood spot (DBS) samples must be carefully maintained until they are 
picked up and taken to the laboratory. They should never be exposed to sunlight 
during storage, and it is important to regularly monitor the level of humidity in 
the stored samples. The following describes the steps that should be followed in 
storing and transferring the DBS samples. 


Storage: Each morning, before you go to the field, you must remove the filter 
paper cards with the DBS samples that you collected on the previous day 
from the drying box and prepare them for storage as follows: 


1. 


Put on a pair of latex gloves and carefully open the drying box. Check that 
the blood spots on each filter paper are completely dried (chocolate 
brown). 


. Separately remove each filter paper card on which the spots have dried 


from the drying box. Be careful not to touch the blood spots. 


Gently fold a piece of glassine paper over the blood spots and put one 
filter paper card into a small (low gas-permeable) zip-loc bag. Put one 
desiccant packet and a humidity indicator card behind the filter paper 
card, with the circles on the humidity card and the ‘window’ in the 
desiccant sachet facing out so that the humidity indicator level and 
granules, respectively, are visible. It is important that the desiccant 
packet and the humidity indicator card do not touch the blood spots. Close 
the zipper, gently pushing out any excess air in the bag as you are zipping 
it, being careful not to press on the blood spots. DBS samples should 
not be allowed to come into contact with other DBS samples 
during handling, shipment or storage. 


. Continue to package each of the filter paper cards from the previous day 


which have dried overnight, putting one filter paper card into one small 
zip-loc bag with one desiccant 
packet and one humidity indicator 
card. 


e When you have packaged 
all of the filter paper cards, 
put them into the large zip- 
loc bag that has been 
labeled for the cluster in 
which the samples were a 
collected (Figure 5.9). Note Figure 5.9 Packaged DBS Samples 
that the Cluster Sample 
(zip-loc) Bag itself should also contain a few desiccant packets. 


Check the humidity indicator cards for the individually packaged DBS 
samples that you have previously placed in the Cluster bag before adding 
newly packaged DBS samples to an existing Cluster Sample Bag. The 
buildup of humidity can damage the quality of the sample. 


e A bottom circle that is pink (30% humidity) indicates a warning of 
increasing humidity. If the middle circle (40%) or top circle (50%) is 


99 


pink, gently open the small zip-loc bag, remove the desiccant 
packet and replace it with a fresh desiccant packet. If any of the 
circles on the humidity indicator card have merged together so that 
they are not completely separated, remove the indicator card and 
replace it with a fresh indicator card. Close the zipper, gently 
pushing out any excess air in the bag as you are zipping it. Please 
review the storage instructions, using the humidity cards as 
a guide. 


6. Check the condition of the desiccant packets and humidity indicator card 
before closing the zipper on the Cluster Sample Bag. Replace as needed. 


e If you have additional Cluster Sample Bags for completed clusters 
that have not yet been collected by a Field Supervisor, examine all 
of the samples in those bags in the same manner, every couple of 
days, as long as they are with your team in the field. 


Transfer: The purpose of the DBSTransmittal Form (see Appendix C) is to account 
for the samples at each step of the way. 


1. Fold the DBS Transmittal Form along the dotted lines (so that the bar-code 
labels are not folded), and keep it in the Sample Cluster Bag along with 
the DBS samples for that cluster. 


2. When you have completed the cluster, remove the packaged DBS samples 
from the Cluster Sample Bag (do not open the small zip-loc bags). 


3. One by one, check the bar codes on the labels on the filter paper cards 
against the bar codes affixed to the back side of the DBS Transmittal 
Sheet. For each DBS sample, put a check mark in the column labeled 
TECHNICIAN for each corresponding bar code found on the transmittal 
sheet. Count the number of DBS samples and record in the boxes provided 
in Column (3) on the front side of the transmittal sheet in the column 
labeled TOTAL COUNT OF BLOOD SAMPLES. If there are any 
discrepancies, you must attempt to account for them. Use Column (7) to 
explain. Sign your name in Column (4) and the date in Column (6). 


The team’s field supervisor will follow behind you, re-verify the samples, and 
sign his/her name in the FIELD TEAM SUPERVISOR row. 


Periodically, a sample pick up person/vehicle will visit the teams to collect the 
DBS samples for the completed clusters. When he/she collects the DBS 
samples, he/she will recount the DBS samples for each of the completed 
clusters and sign the DBS Transmittal Sheet. The samples and transmittal 
sheet will be transported to [IMPLEMENTING AGENCY] for logging before 
being transferred to the laboratory for processing. 


56 


[WHEN PREPARING THIS MANUAL FOR A SPECIFIC SURVEY AND THE 
SURVEY CALLS FOR COMBINED ANEMIA/HIV TESTING: 


Replace the “Summary of the steps involved in collecting blood for 
HIV testing” below with the “Summary of the steps involved in 
collecting blood for HIV testing and for anemia testing” from 
APPENDIX B.] 


Summary of the steps involved in collecting blood for 
HIV testing: 


Prepare Biomarker Data Form for individuals eligible for testing; 

o Seek voluntary consent for blood collection for HIV testing from 
the respondent (if the respondent is age 15 to 17 and unmarried 
seek voluntary consent from the parent/responsible adult and the 
respondent). 

Place a bar code label on a filter paper card, the Biomarker Data Form, 
and the DBS Transmittal Sheet; 

Clean and prick the respondent’s finger with an adult lancet; 

Wipe away the first drop of blood; 

Fill the pre-printed circles on the filter paper card with the second, third, 
and fourth drops of blood; 

If possible, continue to collect the fifth and sixth blood drops on the filter 
paper; 

Collect the sixth and seventh blood drops on the filter paper, if possible; 
Stop the bleeding at the prick site; 

Place the filter paper card in the drying box; 

Collect biohazardous waste. 

Provide all respondents with an informational brochure on HIV/AIDS, 
vouchers for free VCT services, and a list of nearby VCT centers. 


97 


CHAPTER 6: BIOHAZARDOUS WASTE DISPOSAL 


Any material coming in contact with blood or serum (lancets, microcuvettes, 
alcohol swabs, gauze, and gloves) is considered to be biohazardous (hazardous 
to other humans). Safe disposal of such material is very important to prevent the 
transmission and spread of various bloodborne diseases, such as hepatitis B and 
HIV, among survey personnel and within the study community. Biohazardous 
waste has to be collected in a special container during the blood collection and 
testing, securely stored and transported, and safely disposed at the end of each 
day of fieldwork. 


If possible, commercially available biohazardous waste disposal containers 
should be used for waste disposal. These types of containers are red and have a 
special logo warning about biohazardous content. They can be securely closed 
for safe storage and transportation during the fieldwork. 


There are two options for disposal: 
1) Take the biohazardous waste to the nearest health facility for disposal in 
an incinerator (preferred option). The health facilities should employ 
standard procedures for biohazardous waste disposal. 
2) Follow the procedures outlined below for burning the waste in the field. 


MATERIALS AND SUPPLIES 


The following items are required in the field for disposal of biohazardous 
materials: 


e Kerosene 

* Four percent sodium hypochlorite solution” 

e Matches 

+ Spade or other tool for digging a small pit 

e Ziploc-type polyethylene bags 

e Forceps 

e Puncture-resistant container labeled "Biohazard" (for example, a wide- 
mouth plastic jar). 

e Scissors 


PROCEDURES FOR FIELD DISPOSAL OF BIOHAZARDOUS WASTE 


At the end of each blood collection and hemoglobin measurement within the 
household, all materials used during the testing (gloves, microcuvettes, lancets, 
alcohol swabs, and gauze pads) are to be placed in a biohazard bag (plastic). 
Upon return to the field house/site, the waste is transferred to the sharps 
container (a wide-mouth plastic jar), which will be disposed of following the 
procedure below. 


Before beginning the biohazardous waste disposal procedure, determine a place 
where the waste can be safely destroyed. An open field area with loose soil is 
preferable, since the materials need to be burnt and buried. To reduce the risk 


> Four percent sodium hypochlorite solution could be purchased as a commercially available product. It could 
also be prepared in the field by substituting a hypochlorite powder using water. The liquid solutions (sodium 
hypochlorite solution and kerosene) should be stored in leak proof and airtight containers. 


58 


of spreading a fire, avoid starting a fire in drought areas, and keep away from 
other flammable materials. 
Follow the procedure below to safely dispose of biohazardous waste in the field: 


Step 1: At the end of each day, bring the 
sharps container (plastic jar) with 
biohazardous materials to the area 
selected for the waste disposal. Wearing 
gloves, add a half liter of 4 percent sodium 
hypochlorite solution into the sharps 
container (plastic jar) with the 
biohazardous materials (see figure 6.1). 
After adding the hypochlorite solution, 
close the container (jar) so it is airtight. 
Keep the jar in an upright position for five 
minutes. After that, invert the plastic jar 
and keep in that position for an additional 
five minutes. This step is necessary to 
ensure that all of the materials in the 
sharps container (plastic jar) are 
disinfected by complete immersion in the 4 
percent sodium hypochlorite solution. 


L 
sodium hypochlorite 


Figure 6.1 Adding 


Step 2: Transfer the contents of the 
plastic jar, including the sodium 
hypochlorite solution to a thick 
polyethylene bag (Figure 6.2). 


FE 4 à 
Figure 6.2 Transferring contaminated materials 


Step 3: A forceps can be used to transfer 
any material that sticks to the walls of the 
plastic jar to the polyethylene bag (Figure 
6.3). 


Figure 6.3 Removing remaining materials 


Step 4: Dig a small hole with a spade, and 
put the polyethylene bag containing the 
biohazardous materials in the pit (Figure 
6.4). 


4 


| Figure 6.4 Digging a pit for bag 


59 


Step 5: Use scissors to make a hole atthe 
bottom of the polyethylene bag (Figure 
6.5). 


t 


Figure 6.5 Making a hole in the bag 


Step 6: Drain off the hypochlorite solution 
from the polyethylene bag (Figure 6.6). 


Figure 6.6 Draining off hypochlorite solution 


Step 7: Put waste paper on top of the 
polyethylene bag containing biohazardous 
materials (Figure 6.7). 


Figure 6.7 Putting waste paper on top of bag 


Step 8: Pour kerosene on the bag (Figure 
6.8). 


| Figure 6.8 ‘Pouring kerosene on bag 


Step 9: Burn the polyethylene bag 
containing the biohazardous materials in 
the pit (Figure 6.9). 


Figure 6.9 Burning contaminated materials 


60 


Step 10: Wait until all of the contents are 
burned (Figure 6.10). 


Figure 6.10 Ascertaining that contaminated 
materials are completely burned 


Step 11: Cover the pit with soil (Figure 
6.11). 


Figure 6.11 Covering the pit with soil 


It is your responsibility to ensure proper disposal of biohazardous waste. It is 
unacceptable that the materials used during the testing in one fieldwork cluster 
are carried by the team to the next cluster. Biohazardous materials must be 
destroyed at the end of the day. 


61 


APPENDIX A: Anemia Brochure 


What is anemia? 

Anemia is a serious health condition in which there 
are not enough red blood cells or hemoglobin in 
the blood. 


Hemoglobin is a substance in the blood that 
carries oxygen to the brain, muscles, disease- 
fighting organs and other parts of the body. Iron is 
important for making hemoglobin. 


What are the symptoms of anemia? 
Some of the symptoms of anemia are: 

© tiredness 

headaches 

dizziness 

poor appetite 

heart palpitations 

shortness of breath 


SOS S S 


Why is anemia dangerous? 

Anemia is dangerous because: 

©  itreduces one’s resistance to infections 

© severe anemia can lead to heart failure 

© during childbirth, anemic women are more 
likely to die from excessive bleeding 

© anemic children have low birth weight, poor 
learning capacity, and less resistance to 
infections than other children 


What causes anemia? 
Anemia is caused by: 
© loss of blood due to 
+ malaria; 
+ parasites, especially hookworms; 
+ excessive menstrual losses; 
“+ chronic diseases such as ulcers or 
tuberculosis. 
© lackofironin the diet 
©  inability of the body to absorb iron from food 


TEST RESULTS 


WEIGHT, HEIGHT, and HEMOGLOBIN 
MEASURES 


Name Name Name Name 


WEIGHT (kg) 


HEIGHT (cm) 


HEMOGLOBIN (g/dl) 


Hemoglobin level (grams per decilitre) 
< : Severe | Moderate Mild 
Diagnosis Anemia Anemia Anemia Norrrel 
Children 10.0- 
<6 years <7.0 7.0-9.9 10.9 11.0 + 
Women 
not <70 | 7099 | YS | 120+ 
pregnant pf 
Pregnant | <990 | 9099 | 100 | 110+ 
women 10.9 
12.0- 
Men <9.0 9.0-11.9 129 13.0 + 


How can anemia be prevented? 


© Pregnant mothers and infants should take iron 
tablets or syrup. 

© Eata diet adequate in iron-rich foods such as 

dark green vegetables, liver, meat or fish, and 

fruits rich in vitamin C. 

Avoid giving tea to infants and young children. 

Avoid taking coffee or tea with meals. 

Prevent and treat worms. 

Prevent malaria by using mosquito nets. 

Limit the number of births through child 

spacing and delaying first pregnancies. 


SSSSS 


What do the test results mean? 


Severe anemia: You have a seriously low level of 
hemoglobin in your blood. You need to see your 
doctor or health center immediately for treatment. 
Eat more foods rich in iron and treat malaria and 
worms immediately. 


Moderate anemia: Y ou have a reduced level of 
hemoglobin. Iron deficiency, worms, excessive 
bleeding, or malaria may cause you to be anemic. 
You should visit your doctor or health center as 
soon as possible. Eat more foods rich in iron. 


Mild anemia: Your hemoglobin level is slightly 
lower than normal. You need more daily iron. Treat 
malaria and worms immediately. Eat more foods 
rich in iron, such as dark green vegetables, meat, 
liver or fish. 


To increase the body's use of iron, eat more fruits 
rich in vitamin C, such as oranges, lemons, 
mangoes. 


62 


APPENDIX B: COMBINED PROCEDURE FOR ANEMIA TESTING AND 
COLLECTING DBS FOR HIV TESTING 


This section focuses on the steps involved in collecting the blood samples for 
both HIV and anemia testing. When blood is collected for both HIV and anemia 
testing, the order of collection is very important and must be followed strictly. 
Blood is to be collected for HIV first, while collection of blood for anemia testing 
follows. 


Consent for each test must be separately obtained, following the order of the 
Biomarker Data Form. If a test has not been consented to, follow the skip 
instructions. You should complete the testing process with each 
respondent before proceeding to the next eligible individual. 


Follow the procedure below to collect blood for both filter paper cards for HIV 
testing and anemia testing: 


2. Identify all women and men from the household schedule who are eligible 
for anemia and DBS collection. Women age 15-49 and men 15-[49] years 
who are usual members of the household or who slept in the household 
the night before are eligible. 


3. Record the Line Number and Name of all eligible women and men in 
Question 215 and Question 244, respectively, on the Biomarker Data 
Form. 


4. Check the respondent’s age and marital status in Question 218/247 and 
Question 219/248 by referring to Column 7 and Column 8, 
respectively, of the household schedule. Record the age group. You must 
do this step because if the respondent is age 15-17 and never in a union, 
he/she is considered to be an adolescent and consent for testing must be 
obtained from the parent or responsible adult as well as the respondent. If 
the respondent is in a union or has been in a union or is age 18-49, skip to 
Question 223/252. 


5. For a respondent age 18-49 or a respondent age 15-17 who has 
been in a union: 


o Read the informed consent statement in Question 223/252 to the 
respondent and record the outcome of the consent request in 
Question 224/253. If the respondent does not consent to anemia 
testing, follow skips to Question 230/258. 


o For a female respondent who has consented to anemia testing, 
record pregnancy status in Question 225. 


o Read the informed consent statement for HIV testing to the 
respondent in Question 230/258. Record the outcome of the 
consent request in Question 231/259; confirm that you read the 
statement to the respondent and recorded their response 
accurately by signing in the space provided and entering your 
interviewer number. Follow the skips to Question 236/264. 


63 


O 


Read the informed consent statement for additional testing to the 
respondent in Question 236/264. Record the outcome of the 
consent request in Question 237/265; confirm that you read the 
statement to the respondent and recorded their response 
accurately by signing in the space provided. 


If the respondent did not grant consent for additional testing, write 
“No additional tests” on the filter paper card. Go to Question 
239/267. 


6. For a respondent age 15-17 who has never been in a union (an 
adolescent): 


O 


Record the line number of his/her parent/responsible adult in 
Question 220/249. 


Seek consent for anemia testing from the parent/responsible adult 
in Question 221/250. If the parent/responsible adult does not 
consent to the adolescent’s anemia test, in Question 222/251 
record REFUSED, sign your name on the blank line, and go to 
Question 228/256. If the parent/responsible adult does consent, in 
Question 222/251 record GRANTED, sign your name, and go to 
Question 223/252. 


Read the informed consent statement in Question 223/252 to the 
adolescent respondent and record the outcome of the consent 
request in Question 224/253. If the adolescent respondent does 
not consent to anemia testing, skip to Question 228/256. 


For a female adolescent respondent who has consented to anemia 
testing, record pregnancy status in Question 225. 


Seek consent for HIV testing from the parent/responsible adult by 
reading Question 228/256. If the parent/responsible adult does 
not consent to the HIV test, record REFUSED in Question 229/257, 
sign your name on the blank line, and go to Question 239/267. If 
the parent/responsible adult does consent, in Question 229/257, 
record GRANTED and sign your name. 


Read the informed consent statement for HIV testing to the 
adolescent respondent in Question 230/258. Record the outcome 
of the consent request in Question 231/259; confirm that you read 
the statement to the respondent and recorded their response 
accurately by signing in the space provided and entering your 
interviewer number. 


Seek consent to store blood for additional testing from the 
parent/responsible adult by reading Question 234/262. If the 
parent or responsible adult does not consent to additional testing, 
record REFUSED in Question 235/263, sign your name on the 
blank line, and go to Question 238/266. If the parent/responsible 
adult consents, record GRANTED in Question 235/263 and sign 
your name. 


64 


O 


Read the informed consent statement for additional testing to the 
adolescent respondent in Question 236/264. Record the outcome 
of the consent request in Question 237/265; confirm that you read 
the statement to the adolescent respondent and recorded their 
response accurately by signing in the space provided. 


If either the parent/responsible adult or the adolescent respondent 
does not grant consent for additional testing, write “No additional 
tests” on filter paper card. 


7. Prepare the equipment and supplies for the tests for which consent has 
been granted as described in Question 239/267. 


8. If consent for HIV testing was granted, identify the next available complete 
set (row) of bar code labels. Wearing a pair of latex gloves, carefully 
remove a new filter paper card from the plastic zip-loc bag in which you 
have stored the cards. Make sure to handle the card in such a way that 
you do not touch the areas within the preprinted circle. Never handle a 
card with your bare hands as you may transfer sweat, dirt or other 
contaminants on to the card. 


fo) 


Place the card with the preprinted circles face-up on the clean 
absorbent sheet that you have spread out, on a flat surface. 
Discard the card if it drops on the floor or ground or if it becomes 
dirty in any other manner. 


Take the first bar code label from the first complete row on the 
sheet of bar code labels and paste it in the column of the Biomarker 
Data Form containing the line number of this respondent 
(Question 241 for women or Question 269 for men). 


Take the second bar code label from the same row on the sheet 
of bar code labels and paste it at the bottom of the filter paper card 
where it says ‘NAME’. Do not cover up or touch any part of the pre- 
printed circles. 


Take the third bar code label from the same row on the sheet of 
bar code labels and paste it on the Blood Sample Transmittal Sheet 
for the cluster in which you are working. 


Remove all extra bar code labels remaining in the row and 
discard them if applicable. 


DO THE ABOVE STEPS CAREFULLY. The bar code label is the 
only means of identifying the blood sample and for linking the HIV 
test results to the interview data. Mistakes will result in 
mismatches later on. CHECK THAT THE THREE MATCHING BAR 
CODE LABELS HAVE BEEN PLACED ON THE FILTER PAPER 
CARD, THE BIOMARKER DATA COLLECTION FORM, AND THE 
TRANSMITTAL SHEET BEFORE YOU PROCEED TO COLLECT 
BLOOD DROPS FROM THE RESPONDENT. 


9. Perform the DBS collection as follows: 


65 


" Step 1: Obtaining Blood from the 
Finger 


Follow the steps for 
producing a finger stick 
blood sample as described 
in Chapter 3. Use a sterile 
gauze pad to wipe away 
the first blood drop. While 
maintaining a firm grip on 
the finger, press gently on 
the side of the finger from which you are taking the blood 
sample to get a large second drop. Be careful to avoid 
‘milking’ or ‘squeezing’ the finger as this could affect the 
test results. Wait until the drop is large enough to fill one of 
the pre-printed circles on the card (Figure 5.5). 


Figure 5.5 Large drop of blood 


" Step 2: Position of Filter Paper Card 


Move the card underneath the finger, with the pre-printed 
side of the card facing the pricked finger. 


The card must not be pressed against the prick site on the 
finger. Make sure that the respondent’s finger does not 
touch the card at any point when you are collecting the blood 
spots. 


" Step 3: Blood Collection on the card: 


Let the blood drop fall freely in the center of the pre-printed 
circle. In case the blood drop does not fall readily, you may 
touch the filter paper gently against a LARGE blood drop (but 
not the skin). In one step, a sufficient quantity of blood should 
be allowed to soak through and completely fill the circle. 


You must continue to collect drops of blood until you have 
fully saturated three circles on the filter paper card (Figure 
5.6). 


To enhance blood flow, gently apply intermittent pressure to 
the area surrounding the prick site to get a third drop. Allow 
sufficient time for a large 
blood drop to form before 
filling the next circle on the 

filter paper card. Again, © © © 
avoid milking or squeezing 
the finger. HT 


If the blood flow stops or 
decreases before you fully 
saturate three circles, you 
will need to do another 


: | : Figure 5.6 Fully-filled circles 
finger prick. Whenever this | without layering or caking 


66 


is necessary, you should explain to the respondent that you 
were unable to obtain an adequate sample and ask 
permission to obtain blood from another finger. Use fresh 
supplies and a different finger for the second finger prick. 


« After collecting three spots on the filter paper card, place the 
filter paper card with the blood spots on the absorbent paper 
sheet away from other items. The next blood drop will be 
collected for anemia testing. Be careful not to drop the 
completed filter paper card. 


Before conducting the anemia testing, first wipe away any excess blood on the 
skin of the finger. Next, apply gentle pressure to 


the puncture site to promote blood flow and 
then fill the microcuvette with blood to measure 
the Hb level. 


10.Collect the capillary blood in the NE à 


microcuvette: 


Apply the tip of the HemoCue 
microcuvette to the middle of the 
blood drop. The microcuvette Figure 5.7 Filling the 
chamber will fill itself automatically 
by capillary action. The chamber needs to be filled completely 
(Figure 5.7). Never “top off” the microcuvette. Instead, if the 
microcuvette is not completely filled, use a fresh microcuvette and 
fill it with the next blood drop that forms. 


Wipe any surplus blood off both sides of the microcuvette “like 
butter from a knife,” using the clean end of a sterile gauze pad. 
Ensure that no blood is sucked out of the microcuvette when wiping 
it - do not let the tip of the filled microcuvette touch the gauze. 


After filling the chamber, the 
microcuvette needs to be visually 
inspected for air bubbles. Since air 
bubbles may influence the 
hemoglobin measurement, any 
microcuvette containing air bubbles 
must be discarded. In such cases, 
with the permission of the parent/ 
responsible adult, repeat the blood 
drop collection using a different finger 
(heel). Again, you must use new 
supplies and follow all of the steps 


described previously in obtaining the _ Figure 5.8 Placing the 
new sample microcuvette in photometer 


Place the microcuvette in its holder and gently push the holder into 
the photometer (Figure 5.8). 


67 


11.If possible, continue to fill the 
remaining two circles on the filter paper 
card with blood (Figure 5.9). If not 
possible, stop bleeding at the site of 
the prick 


12.Reading the results: The microcuvette 
should be analyzed immediately, and 
no later than ten minutes after being 
filled. The blood hemoglobin level in 
grams per deciliter (g/dl) is displayed 
15 to 45 seconds after the drawer is 
closed (Figure 5.10). 


13.Record the hemoglobin level in 


After the blood drop collection, 
wipe any remaining blood from 
the prick site with a sterile gauze 


pad. Press the gauze pad 4 
against the prick site until the _ 
blood flow has stopped Figure 5.9 Filling up the pre-printed 
completely. circle on the filter paper card 


Take an adhesive bandage from its wrapper and apply it to the prick 
site. 


Question 240/268. If a hemoglobin Figure 5.10 Hemoglobin level 
measurement was not obtained displayed on the HemoCue 

because the respondent was not Éd ed and a= th Snould Be 
present, did not consent to the test, or there was a technical problem with 
the testing, circle the appropriate code. 


14.Placing the completed filter paper card in the drying box: 


The drying box should be placed vertically on a flat surface at the 
time you set up your equipment. The position of the drying box is 
especially important anytime it contains filter paper cards that have 
not completely dried. Keep the box vertical whenever it contains 
blood spots that are not fully dried to prevent blood that has not yet 
completely dried from spreading. 


Keep the drying box closed during blood collection to prevent dust 
and dirt from entering the box or from contaminating DBS cards 
that were collected earlier and are already in the box. After the 
blood collection process is finished, open the drying box (keeping it 
vertical). Carefully pick up the completed filter paper card and place 
it in a horizontal position in one of the slots in the drying rack in the 
box. The blood spots should face towards the back of the drying 
box. Close the box. 


Avoid touching or smearing the blood spots on other cards 
already in the box when you are storing a new card. Never 


68 


put more than one completed filter paper card in a single 
slot in the drying rack. 


« Allow blood spots to dry overnight at ambient temperature. The box 
should be handled carefully so that the cards do not fall out of their 
slots. 


15.Collect biohazardous waste 


“" Place all biohazardous waste (lancets, alcohol swabs, gauzes, and 
gloves) into a clearly labeled “biohazard” plastic bag, which has 
been provided for field disposal of these items. At the end ofthe 
day, follow the procedures described in Chapter 6 for the proper 
disposal of waste materials. 


16.Record the respondent’s hemoglobin level in the anemia brochure. 


17.Inform the respondent of her/his hemoglobin level and provide the anemia 
brochure. 


18.Provide a written referral to a health facility for treatment for any 
respondents with severe anemia (below 9 g/dl for men and pregnant 
women and below 7 g/dl for women who are not pregnant or don’t know if 
they are pregnant). 


19.Record the result for blood collection for HIV testing in Question 
241/269. 


20.Provide an informational brochure on HIV/AIDS. The brochure will include a 


voucher for free HIV VCT services, and a list of the nearest participating 
VCT centers in [COUNTRY]. 


69 


Summary of the steps involved in collecting blood for 


HIV testing and for anemia testing for adults: 


Prepare Biomarker Data Form for individuals eligible for testing; 

o Seek voluntary consent for anemia testing and blood collection for 
HIV testing from the respondent (if the respondent is age 15 to 17 
and unmarried seek voluntary consent from the 
parent/responsible adult and the respondent). 

Place the bar code labels on a filter paper card, the Biomarker Data 
Form, and the DBS Transmittal Sheet; 

Clean and prick the respondent’s finger with an adult lancet; 

Wipe away the first drop of blood; 

Fill the pre-printed circles on the filter paper card with the second, third, 
and fourth drops of blood - you will fill 3 circles on the filter paper card; 
Wipe away any excess blood on the skin; 

Collect the fifth blood drop in a microcuvette; 

Collect the sixth and seventh blood drops on the filter paper, if possible; 
Stop the bleeding at the prick site; 

Test the blood sample with the HemoCue photometer; 

Record the hemoglobin level on the Biomarker Data Form 

Place the filter paper card in the drying box; 

Collect biohazardous waste. 

Inform the respondent of his/her hemoglobin level and provide an 
informational brochure on anemia; 

Provide a written referral for follow-up medical attention for respondents 
found to be severely anemic; 

Provide all respondents with an informational brochure on HIV/AIDS, 
vouchers for free VCT services, and a list of nearby VCT centers. 


70 


APPENDIX C: DRIED BLOOD SPOT (DBS) TRANSMITTAL SHEET 


Dried Blood Spot (DBS) TRANSMITTAL SHEET (FRONT) 


KEEP IN LARGE ZIPLOC BAG WITH SAMPLES UNTIL FINAL SIGNATURE OBTAINED 


TECHNICIAN NUMBER 


PERSON 
SENDING/ 
RECEIVING 


TIME TO FILL IN 


SIGNATURE 
CONFIRMING THAT 
EACH BLOOD 
SAMPLE IS PRESENT 
—SEE BACK OF 


SIGNATURE 
CONFIRMING THAT 
THE NUMBER OF 
BLOOD SAMPLES 
MATCHES 


LUSTER NUMBER 


NOTES 
(NOTE ANY DISCREPANCY 


SAMPLES FORM 
(1) 


IN NUMBERS OF SAMPLES) 


WHEN CLUSTER IS 


TECHNICIAN COMPLETED 


AFTER 
TECHNICIAN HAS 
DONE HIS/HER 
COUNT 


FIELD TEAM 
SUPERVISOR 


WHEN SAMPLES 
ARE PICKED UP IN 
FIELD 


SAMPLE PICK 
UP PERSON 


RECEIVER AT | UPON ARRIVAL AT 
[IMPLEMENTIN [IMPLEMENTING 
G AGENCY] AGENCY] 


RECEIVER AT 
LABORATORY 


UPON ARRIVAL AT 
LABORATORY 


TECHNICIAN: Upon completion of a cluster, verify that the bar code number on each blood sample (filter paper card) collected 
and stored in the large zip-loc bag labeled with the cluster number corresponds to a bar code number pasted to the back of this 
transmittal sheet (and vice-versa). Note any discrepancies in Column (7). Count and record the total number of blood samples 
in Column (3). Sign your name in Column (4) and the date in Column (6). Fold and store this transmittal sheet in the large zip- 
loc bag. 


FIELD TEAM SUPERVISOR: After the technician has verified the blood samples, you will conduct a second verification. Count the 
number of blood samples, record the total in Column (3). Verify that the bar code number on each blood sample (filter paper 
card) collected and stored in the large zip-loc bag labeled with the cluster number corresponds to a bar code number pasted to 
the back of this transmittal sheet (and vice-versa) and sign Column (4). Verify that your count of blood samples is the same as 
the number reported by the technician and sign Column (5). Note any discrepancies in Column (7). Record the date in Column 
(6). Fold and store this transmittal sheet in the large zip-loc bag. 


SAMPLE PICK UP PERSON: Before leaving a cluster to return to [Implementing Organization], you will verify the number of blood 
samples collected in the completed cluster. For the completed cluster, count and record in Column (3) the total number of 
blood samples stored in the large zip-loc bag labeled with that cluster number. Note any discrepancies in Column (7). Sign your 
name in Column (5) and the date in Column (6). Fold and store this transmittal sheet in the large zip-loc bag. 


AT THE IMPLEMENTING AGENCY OFFICE: For each large zip-loc bag arriving from the field, you will verify the number of blood 
samples received. Count and record in Column (3) the total number of blood samples stored in the large zip-loc bag labeled 
with the cluster number. Note any discrepancies in Column (7). Sign your name in Column (5) and the date in Column (6). Fold 
and store this transmittal sheet in the large zip-loc bag. 


RECIEVER AT THE LABORATORY: Upon receiving blood samples from [IMPLEMENTING AGENCY], verify that the bar code number 
on each blood sample (filter paper card) collected and stored in the large zip-loc bag labeled with the cluster number 
corresponds to a bar code number pasted to the back of this transmittal sheet (and vice-versa). Note any discrepancies in 
Column (7). Count and record the total number of blood samples in Column (3). Sign your name in Column (4) and the date in 
Column (6). Photocopy both sides of this form and return the original to [Implementing Agency]. 


Note: This form will be destroyed under the direction of the Lab Director after all blood sample have been 
completely processed and a final HIV test result has been determined for each usable sample. 


71 


DBS TRANSMITTAL SHEET (ack) 


SAMPLE BAR CODE 


fo} 


Rk H ee RB 
B w N BR 


BR 
uo 


TECH- 
NICIAN 


N 
Oo [le] oo ~N 


N 


1 
N N N N N N N H N BR BR Bb BR 
O © N oO u 5 w an N BR a 


WwW 
o 


SAMPLE BAR CODE 


TECH- 
NICIAN 


42, 


Voluntary Counseling 
and HIV Testing 
(VCT) 


Introduction 


HIV is the virus that causes AIDS and may be 
transmitted through sex or contact with 
blood or from a mother to her baby. 
Confirming whether one is free or is already 
infected with this virus is a crucial step 
towards a confident future. 


Why go for counseling and HIV testing? 


There are many reasons why you should go 
for voluntary counseling and HIV testing: 


© You have questions or worries about AIDS. 
Perhaps someone you know has the disease. 
Perhaps you simply want to know how to 
protect yourself. 


© You or your partner may have been 
exposed to HIV virus without knowing. Many 
people who have HIV look healthy and do 
not know they have the virus. Often when a 
person is infected, their partner or spouse 
may still be uninfected. 


© You and your partner may be planningto 
have a baby. Treatment is available to 
prevent a mother from passing the virus to 
her baby. 


APPENDIX D: VCT VOUCHER 


© You or your partner may have had 
symptoms or a disease that made you 
worried about AIDS. A VCT counselor will 
answer your questions about HIV and AIDS 
so you can protect yourself and your family. 
You may go alone or go with your partner 
and learn your results together. 


© Testing is voluntary — it is your choice 
whether to be tested. 


© VCT is anonymous—no one will take your 
name and your privacy will be protected. 


© Testing is rapid —you will generally 
receive your results within the same hour. 


© Two different, high quality tests are used 
to give you full confidence in your results. 


Where togoforHIV counselingand testing? 


VCT services are now available in many areas 
of [COUNTRY]. 


The list on the back will tell you where you 
can go for VCT. Please present this brochure 
to the VCT centre staff to guarantee that VCT 
services are free for you and your partner. 


73 


END OF BIOMARKER FIELD MANUAL. 


74