Biomarker Field Manual (English, French)

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This document is part of the Demographic and Health Survey’s DHS Toolkit of methodology —— —
for the MEASURE DHS Phase III project, implemented from 2008-2013. ù i ii

This publication was produced for review by the United States Agency for International
Development (USAID). It was prepared by MEASURE DHS/ICF International.

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 In the 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 In the 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;

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

e 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 ......ccccssccerecessceeseeesceesceesceesceesceesceusceeseeuseeeeeeeeseensees 4
OVERVIEW OF BIOMARKER COLLECTION .........scsssssssssseessssessssssssssesssessssessesssssesesssssssesseseusessssssssesousnseseseesnenss 4
ELIGIBILITY..........ccccccesssssssssssssssesssssssessssssseessessseesseesseesssesssesssesesessesessesseeesseesseesesesseeseeesseesseessesssesseesssssseeseess 5
INFORMED CONSENT ..........cccssssssssssssssssessssssssssecsssssssesssesssecssessessesesssessssssssssssesseesseessessseessesssessseessesssessesseess 8
CHAPTER 2: ANTHROPOMETRY ........:::ssscesseeesnessneesnensneesneesnsessnensneesneesneesneesteeesneeseeeseeeees 11
MATERIALS AND EQUIPMENT FOR ANTHROPOME TRY. ........cccccccssessssseessesecssssesecsscceeecssscesecsssessecesacesecesageas 11
PROCEDURES AND PRECAUTIONS BEFORE MEASURING ...sssssssssssssssnnnnnnnnnnnnnnnnnnnnnnsnnnsnnnnnnnnnnnnnnnnee 11
STEPS FOR MEASURING WEIGHT AND HEIGHT/LENGTH..........ssccsssccsssecscsceesscessseensseeesscessseeessseessseessseenseees 13
MEASURING WEIGHT ..........ccccccssssssssssssscssessseeseesseessecsecceesessecsseeseesesecseceeeseseeesescasscasscasscassccsscesscasscanseansegas 13

CHAPTER 3: GENERAL PROCEDURES FOR COLLECTING CAPILLARY BLOOD DROP

SAMPLES Wisk scavacececercussvauaveunavyceduseedsdanssagudasivacatduadsvacspauitsriedhidadstaud sdastdddrantioecteedaat raaittaniy à 23
MATERIALS AND SUPPLIES FOR PERFORMING FINGER OR HEEL PRICK ....... cc ccccccessseeeessseesssssscsecenscesceesseees 23
STEPS IN OBTAINING CAPILLARY BLOOD FROM THE FINGER ..........ccccssssssssssssssssssssssssscescesscesscssscssscesssessseees 24
STEPS IN OBTAINING CAPILLARY BLOOD FROM A CHILD’S HEEL.............sccccsssseccessseesessseeesesseeeesesseeeesssseeeeees 27
GOOD BLOOD COLLECTION PRACTICES..........csccssssssssssssssssssssssssccssccsscssscssscessccsscssscesscssscesscsssessscssscssscssseeses 29
CHAPTER 4: ANEMIA TESTING... .cccccescseeeseeesneesteeesneeseeesneeseeeseeeseeeseeeseeeseeeseeeseeeseeeseeeees 30
MATERIALS AND SUPPLIES FOR ANEMIA TESTING ..........cccccccscsssssecsseseescssecssseseeseseccecsesscesecssaeesaessacssacsegaggs 31
COLLECTING BLOOD AND TESTING FOR ANEMIA .......cccccccccseccsccsceeseeeeesseeseeseeeeseeseeeeseeeeeeeseeeseeesseeseeseseseseenns 33
PRECAUTIONS TO TAKE DURING ANEMIA TESTING... ccccccccsccsssesseesseessesssseceseeseeccsseesacesecseaeesacssacesecssgegas 38
PROVIDING ANEMIA TEST RESULTS AND REFERRALS FOR SEVERE ANEMIA............ccccccssssesesesssssccesncsseceseeeas 39
CHAPTER 5: DBS COLLECTION FOR HIV TESTING ..........ceessseeseeesteestenseneneeaeeeanenenenenees 40
MATERIALS AND SUPPLIES FOR DBS COLLECTION FOR HIV TESTING... nnnnnnnsssssssssssnssnnsnnnnnnnnennnnnnse 41
DBS COLLECTION PROCEDURE ...........ccccccssssessesssessessecssecssseseeeesecesecsecceeeseseesesseescseccesacssncassccssccsscasscasseanggaaes 44
PRECAUTIONS TO TAKE DURING DBS COLLECTION FOR HIV TESTING ...ssssssssssssnnssnnnnnnnnnnnnnnnnnnnee 49
STORING AND TRANSFERRING THE DRIED BLOOD SPOTG............ssccsssssssssssssssssssssssssssccesccsscesscssssssscesssesseeees 50
CHAPTER 6: BIOHAZARDOUS WASTE DISPOSAL .........c:cseesseeeseeesneesteesneeeneeeeenenenanenenees 53
MATERIALS AND SUPPLIES ...........cccccccsseenssesssesseesseesecesececeesesessecsseceeeceeecessesseceecceeccesscggscasscgssccsscasscasseasgaggs 53
PROCEDURES FOR FIELD DISPOSAL OF BIOHAZARDOUS WASTE ....ssssssnnnnnnennnnnnnnnnnnnnnennnnnnnnnnnnnee 53
APPENDIX A: ANEMIA BROCHURE ...........0 jj jj tlt ltl lt nn nln nnn linn 57
APPENDIX B: COMBINED PROCEDURE FOR ANEMIA TESTING AND COLLECTING

DBS FOR HIV TESTING... lll lll ln nn nnn nnn nnn nnn nnn nnn nine 58
APPENDIX C: DRIED BLOOD SPOT (DBS) TRANSMITTAL SHEET .........:::sseeeeeeeeeeeeeeees 65
APPENDIX D: VOT VOUCHER... .c:cccessseeesneesneesneesneesneesneesneesnecsneessneeseeeseeeseeeseesseeeseeesneeees 67

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:

e 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:

Column (1) Line number

Column (2) Name

Column (4) Sex of household member

Column (7) Age of household member

Column (9) Identification of eligible women, (women age 15-49)
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
USUAL RESIDENTS AND | RELATIONSHIP RESIDENCE MARITAL ELIGIBILITY
VISITORS TO HEAD OF
HOUSEHOLD

STATUS

Please give me the names | What is the

Did

How old | What is CIRCLE | CIRCLE | CIRCLE

of the persons who
usually live in your
household and guests of
the household w ho
stayed here last night,
starting with the head of
the household.

AFTER LISTING THE
NAMES AND RECORDING
THE RELATIONSHIP

AND SEX FOR EACH
PERSON, ASK
QUESTIONS 2A-2C

TO BE SURE THAT THE
LISTING IS COMPLETE.

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

relationship of
(NAME) to the
head of the
household?

SEE CODES
BELOW.

hae
usually
live
here?

(NAME)
stay
here last
night?

is
(NAME)?

IF 95

OR MORE,

RECORD
"95".

(NAME)'s
current marital
status?

1= MARRIED
OR LIVING
TOGETHER
2 = DVORCED/
SEPARATED
3 = WIDOWED
4 =NEVER-
MARRIED
AND
NEVER
LIVED
TOGETHER

LINE
NUMBER
OF ALL
WOMEN
AGE
15-49

LINE
NUMBER
OF ALL
MEN
AGE
15-49

LINE
NUMBER
OF ALL
CHILDREN
AGE0-5

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 INHOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS
IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

LINE NUMBER FROM COLUMN 11

NAME FROM COLUMN 2

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

What is (NAME)'s birth date?

CHECK 203:

CHILD BORN IN JANUARY

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

214 | 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).

NAME FROM
COLUMN 2

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

Groups [DBS
eligible for - [Height/ [Anemia |

: [Weight] : collection for
biomarker length] testing] x

LU x HIV testing]

collection
Children age
0-5 months . 3
Children age
6-71 months à ë 5
Women age
15-49 years . s A ‘
Men age 15-
[49] years à a : a

“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.

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:

a description of the objectives of the test

basic information on how the test will be conducted
assurances about the confidentiality of the results

a specific 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 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 in a 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.

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

e 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

o 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;
o 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;

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

If consent was granted, proceed with blood collection.

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.

e 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.

3. 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.

? The 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.

. 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.

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

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

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

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

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.

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

. 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.

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.

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.

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

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).

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

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

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.

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.

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.

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

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.

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

e 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?
e Check to see if the scale is switched on. Ask the adult to step off the scale

and step gently on the weighing platform.
e Check to see if the switch is in the “ON” position
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):

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.

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 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:
e Knees together and feet
together
e Knees together and feet
apart Whichever

touches first!
e Knees apart and feet
together

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

Ibustration 1
Child Height Measurement

HEADPIECE FIRMLY ON HEAD

RIGHT HANO ON SHINS: HEELS satis
BACK AND BASE OF BOAR’

QUESTIONNAIRE AND PEN ON CLIPSOA
ON FLOOR OR GROUND oe

BOOY FLAT AGAINST BOARD

_ ON KNEES
LT
4 <

MEASURER ON KNEE

MID-AXILLARY LINE

10.

12.

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).

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

Measurer: Ask the child to 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 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).

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

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.

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.

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:

Measurer or Assistant: Place stration 2

Child Length Measurement

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

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).

4 PEL D OVER EARS
‘ae ays rt BASE OF BOARD
LR

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.

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 together

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.

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 together

Measurer: Ask the person to look straight anead. 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.

Measurer: When the person’s
position is correct, lower the
headpiece on top of the head
(Arrow 12) making sure to Standing Height of Adults*
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.

Illustration 3

Measurer: Immediately
record the measurement on
the questionnaire. Record an
adult’s height measurements
in Question 217/246. If the
adult’s height was not
measured, record the

Arttropeesetry as Part of Hocsebelé Surveys", 1.3. Shorr, The Weeld Back, Wastingtos, D.C., (in press

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

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

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
Measure weight
Record weight in Q216/245
Measure height
Record height in Q217/246

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:

e 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.

e 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 with adults (depth of puncture
is 2.4 mm).

slr
Safety Lancet,

Figure 3.1 Examples of safety lancets

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

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

e 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”.

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

2. Select and prepare the prick site

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.

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.

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

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

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.

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.

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.

Puncture sites

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

Figure 3.2 Fingers for blood collection

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.

Ensure that the correct size lancet is Fiqure 3.3 Clean the finder

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.

o Do not remove the blade slot cover Figure 3.4 Parent assisting with child
from the adult or child lancets
other than as instructed above, as this may cause the blade not to pierce
the skin.

3. 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 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).

Figure 3.5 Placement of adult lancet

. Collect the blood drops

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 are shown in Figure 3.7.

Figure 3.6 Placement of child lancet

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). Puncture sites
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 finger

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

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

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.

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).

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.

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.

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

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

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

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.

3
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.

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:

Iron deficiency from inadequate intake of foods containing iron, such as red meat;
Intake of foods that contain non-bioavailable iron;

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.

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:

e 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 microcuvette

e 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 respondents
Hb results are recorded and classified Figure 4.2 HemoCue Hb201+ photometer
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:

Record on the microcuvette container the date the container is first opened;

Remove from the container only those microcuvettes required for immediate testing;

Remove the microcuvettes by holding the side opposite the tip;

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.

St l'on

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 holder

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.

COLLECTING BLOOD AND TESTING FOR ANEMIA

Children: Follow the procedure below to test children for anemia:

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.

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

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.

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.

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 é Le.
capillary action. The chamber needs
to be filled completely (Figure 4.4).
Never “top off’ the microcuvette.

ce ' 7
PTS
Instead, if the microcuvette is not
completely filled, use a fresh

ge. DS
| ;
| be | ) .
ya ; Lé
microcuvette and fill it with the next =”

blood drop that forms. Finger prick

sé

« 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.

Heel prick

« 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).

Figure 4.4 Filling the microcuvette

Step 2:

Step 3:

Step 4:

test result:

Step 5:

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).

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 the gauze pad
against the prick site until the blood flow Figure 4.5 Placing the
has stopped completely. microcuvette in photometer

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.

Obtain the hemoglobin level:

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 4.6).

Record the hemoglobin level and

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 no value to record because the
child was not present, the
parent/responsible adult refused to

Figure 4.7 Hemoglobin level displayed on the
consent to the test, or there was HemoCue photometer and as it should be

some other problem, record the recorded on the Household Questionnaire
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.

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).

[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:

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.

. Forarespondent age 18-49 or a respondent age 15-17 who has been ina

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.

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

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.

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.

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.

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

4. 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:

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

O © © © 0

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.

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.

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/di, 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.

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

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 hands, or other environmental
contaminants can affect HIV testing. Use Figure 5.1 Filter paper card
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

circles when blood is collected. TT ET ERreUr
cumin TU Olen ED
e Bar code labels: because the HIV testing in TONER DUT D iii man
the [COUNTRY] DHS is anonymous, LL CL LT UOT QC TE LT
respondent names are never written on the Te CR LITE CD LLC HAT
filter paper cards. Instead, bar code labels are QUE TC TL RL LE LL Hinman
used to identify the DBS samples and link QUIL AI LL LL hdl
them to the interview data. You will be lal Qi. du:
provided with sheets of “peel-off” adhesive bar MPa nee nn
code labels (Figure 5.2). The barcodes are
arranged in rows; the codes on each label are | Il II
the same across one row. A different row of Y8B3L
bar code labels is to be used for each Figure 5.2 Bar code labels (sheet and
respondent for whom a DBS sample is individual).
collected.

e Drying box: a plastic box with a cardboard rack positioned inside.
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 desiccant packets Soa TON
alone. ©
o There are three circles on the humidity %
indicator card (Figure 5.4). If the circle at DESICEANT O\
the bottom of the card (labeled 30%) TES \
turns pink, it indicates a relatively high WARNING
level of humidity and is a warning to tS
carefully monitor the humidity level. If AVG METAL CONTRE
the middle circle (labeled 40%) turns
pink, replace the desiccant packets and Figure 5.4 Humidity indicator card

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].

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.

[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. Forarespondent age 18-49 or a respondent age 15-17 who has been ina

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.

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):

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.

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.

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 preprinted 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.

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 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 be allowed to soak
through and completely fill the
circle (Figure 5.6).

Figure 5.6 Filling up the pre-printed circle
on the filter paper card

«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 at least three

circles on the filter paper card

(Figure 5.7). TN

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

If the blood flow stops or
decreases before you fully

- Figure 5.7 Fully-filled circles without
saturate the three circles, you layering or caking

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 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 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.

« 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.

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

. 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].

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.
e 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.

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

e 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), which is also
unacceptable. The blood should not Figure 5.8 Supersaturated (top) and serum rings
extend beyond the pre-printed area, (bottom) DBS samples are unacceptable
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.

e 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.

e 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.

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:

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
collected (Figure 5.9). Note that
the Cluster Sample (zip-loc)
Bag itself should also contain a Figure 5.9 Packaged DBS Samples
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 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.

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.

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.

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

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.

[WHEN PREPARING THIS MANUAL FOR A SPECIFIC SURVEY AND THE SURVEY
CALLS FOR COMBINED ANEMIAIHIV 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.

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:

Kerosene

Four percent sodium hypochlorite solutions

Matches

Spade or other tool for digging a small pit

Ziploc-type polyethylene bags

Forceps

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 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:

5 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.

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.

7
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).

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).

Figure 6.4 Digging a pit for bag

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

> LS
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 6.8 | Pouring kerosene on bag

Step 9: Burn the polyethylene bag containing the

biohazardous materials in the pit (Figure 6.9).

Figure 6.5 Making a hole in the bag

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

Figure 6.7 Putting waste paper on top of bag

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

Figure 6.9 Burning contaminated materials

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

Figure 6.1 ertaining 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.

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:

headaches

dizziness

poor appetite

heart palpitations

shortness of breath

SSSS©

Why is anemia dangerous?

Anemia is dangerous because:

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.
lack of iron in the diet

TEST RESULTS
Date
WEIGHT, HEIGHT, and HEMOGLOBIN
MEASURES
Name Name Name Name
WEIGHT (kg)
HEIGHT (cm)
HEMOGLOBIN (g/dl)
Hemoglobin level (grams per decilitre)
Diagnosis Severe Moderate Mild Normal
Anemia Anemia Anemia
Children 10.0-
<6 years <7.0 7.0-9.9 10.9 11.0 +
Women
not <70 | 7099 | ‘100 | 120+
11.9
pregnant
Pregnant <9.0 9.0-9.9 10.0- 110+
women : par 10.9 :
12.0-
Men < 9.0 9.0-11.9 129 13.0 +

How can anemia be prevented?

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: You 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.

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

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.

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.

o 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.

o 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.

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

o 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.

o 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.

o 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.

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.

o 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.

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:

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 Figure 5.5 Large drop of blood
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).

Step 2: Position of Filter Paper Card

Step 3:

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.

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. a
Again, avoid milking or ll) lil WM
squeezing the finger. eu:

If the blood flow stops or
decreases before you fully
saturate 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.

Figure 5.6 Fully-filled circles without
layering or caking

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 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 filled com- Figure 5.7 Filling the microcuvette

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.

13:

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).

Record the hemoglobin level in Question
240/268. If a hemoglobin measurement was
not obtained because the respondent was

pletely (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 new
sample.

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

After the blood drop collection, wipe
any remaining blood from the prick
site with a sterile gauze pad. Press
the gauze pad against the prick site
until the blood flow has stopped
completely.

Figure 5.9 Filling up the pre-printed circle
Take an adhesive bandage from its on the filter paper card
wrapper and apply it to the prick site.

: Figure 5.10 Hemoglobin level displayed on
not present, did not consent to the test, or the HemoCue photometer and as it should be

there was a technical problem with the recorded on the Household Questionnaire
testing, circle the appropriate code.

14.

15.

16.

17.

18.

19.

20.

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 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.

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 of the day, follow the procedures
described in Chapter 6 for the proper disposal of waste materials.
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 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).
Record the result for blood collection for HIV testing in Question 241/269.
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].

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.

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 CLUSTER NUMBER

SIGNATURE SIGNATURE
CONFIRMING THAT CONFIRMING THAT
PERSON TOTAL EACH BLOOD THE NUMBER OF
SENDING/ COUNT OF SAMPLE IS BLOOD SAMPLES NOTES
RECEIVING TIME TO FILL IN BLOOD PRESENT—SEE MATCHES (NOTE ANY DISCREPANCY
SAMPLES FORM SAMPLES BACK OF FORM ; IN NUMBERS OF SAMPLES)

WHEN CLUSTER IS

TECHNICIAN COMPLETED

AFTER
FIELD TEAM TECHNICIAN HAS
SUPERVISOR DONE HIS/HER

COUNT

WHEN SAMPLES
ARE PICKED UP IN
FIELD

SAMPLE PICK
UP PERSON

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

RECEIVER AT UPON ARRIVAL AT
LABORATORY 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.

DBS TRANSMITTAL SHEET @ack)

Z
O

SAMPLE BAR CODE TECH- LAB NO. SAMPLE BAR CODE TECH- | LAB
NICIAN NICIAN

=
o

een nee >------ Fold ts os oo ne
Ÿ
a |
q À
|
|
|
|
|
15 30

Voluntary Counseling
and HIV Testing
(VCT)

APPENDIX D: VCT VOUCHER

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.

© 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.

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.

END OF BIOMARKER FIELD MANUAL.

CA
.—

—

1/11

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