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External Quality Assessment of 

Sputum Smear Microscopy in 

Tuberculosis Laboratories in 

Sughd, Tajikistan 

 

Eva Chang1, Fabio Luelmo2, 

Zamira Baydulloeva3, Marija 

Joncevska4, Guljamol Kasymova5, 

Oktam Bobokhojaev5, Tom Mohr6 

 
1Harvard Medical School, Boston, MA, USA; 
2TB Control Programmes, Geneva, 

Switzerland; 3Quality Health Care Project 

Tajikistan; 4Project Hope; 5Republican Centre 

of Population Protection from Tuberculosis 

Tajikistan; 6Quality Health Care Project 

Kazakhstan  

 

Vol. 4, No. 2 (2015)   |   ISSN 2166-7403 (online)  

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Abstract 

Introduction: Tajikistan has a laboratory network with three levels of tuberculosis (TB) laboratories. The external quality 

assessment (EQA) of sputum smear microscopy was implemented in 2007. The objective of this study was to evaluate the EQA 

system and identify potential performance improvement strategies in TB microscopic laboratories in Sughd, Tajikistan. 

Methods: This is a cross-sectional study based on retrospective record review and secondary data analyses on Acid-Fast Bacilli 

(AFB) microscopy data and EQA reading results collected between the first quarter of 2011 and the fourth quarter of 2013. 

Descriptive analyses were conducted to examine the overview of microscopy laboratories activities, EQA results, and laboratory 

performance.  

Result: Of the 123,874 smears examined between 2011 and 2013, 11,522 (9.30%) were re-checked by the EQA system. The 

population TB screening rate rose from 0.46% in 2011 to 0.57% in 2013, and the case positivity rate decreased from 6.98% to 

4.80%. The regional EQA results showed a reduction in high false-positive, high false-negative, and low false-negative errors. 

False-positive errors had decreased from 0.13% in 2011 to 0.07% in 2013, and false-negative errors from 0.91% in 2011 to 0.15% 

in 2013. Regional sensitivity of smear microscopy, when compared to re-checking controller, increased from 88.2% in 2011 to 

97.2% in 2013. The regional specificity level remained relatively stable at above 99%. 

Conclusion: Our study found that a decreasing trend of case positivity rate from 2011 to 2013 in Sughd, though the overall 

laboratory workload was on the rise. In addition, EQA results showed an overall error reduction and an improved sensitivity of 

smear microscopy in the region. The overview of microscopic laboratory activities and the actual evaluation of the EQA system on 

sputum smear microscopy complement each other in providing a better picture on the progress of TB laboratory strengthening. We 

recommend similar approaches to be adapted by future evaluations on TB microscopic laboratories, particularly among countries 

of high burden. Interactive training and feedback loops are crucial to improving TB surveillance in Tajikistan. 

Keywords: external quality assessment, tuberculosis, sputum smeal microscopy, Tajikistan 

 

External Quality Assessment of 

Sputum Smear Microscopy in 

Tuberculosis Laboratories in Sughd, 

Tajikistan 

 

Eva Chang1, Fabio Luelmo2, Zamira 

Baydulloeva3, Marija Joncevska4, 

Guljamol Kasymova5, Oktam 

Bobokhojaev5, Tom Mohr6 

 
 

1Harvard Medical School, Boston, MA, USA; 2TB 

Control Programmes, Geneva, Switzerland; 
3Quality Health Care Project Tajikistan; 4Project 

Hope; 5Republican Centre of Population Protection 

from Tuberculosis Tajikistan; 6Quality Health Care 

Project Kazakhstan  

 

Research 

Tuberculosis (TB), an air-borne disease caused 

by Mycobacterium tuberculosis, is the second leading 

cause of death from an infectious agent in the world.1 In 

2013, there was an estimated nine million new TB cases 

globally, and the burden of the disease has hit the low- 

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and middle-income countries most heavily.1 Early and 

accurate TB detection is crucial to effective TB control 

and care.2 Despite the substantial advancement in TB 

diagnostic and monitoring tools in the past two decades, 

sputum smear microscopy remains the most common and 

economical method in the most affected countries.1,2 

Classical smear microscopy, an antiquated test of 130 

years, directly identifies Acid-Fast Bacilli (AFB) in 

Ziehl-Neelsen (ZN) stained sputum under a light 

microscope.3 Simple and inexpensive to adopt, 

microscopy of sputum smears is particularly suitable for 

peripheral laboratories based at primary health clinics or 

district hospitals to quickly  detect infectious pulmonary 

TB cases.3 Patients suspected of having pulmonary TB 

are recommended to have at least two sputum specimens 

for microscopic examination.4 As a result, strengthening 

laboratory capacity and network to promote good-quality 

microscopy-based case detection and management has 

been gaining high priority in the global TB agenda.5 The 

need to establish comprehensive laboratory external 

quality assessment (EQA) programs under the National 

TB Programs (NTP) in order to evaluate laboratory 

performance on AFB microscopy were fully recognized 

by the global health community. The International Union 

Against Tuberculosis and Lung Disease (IUATLD) 

published the guidebook of EQA for AFB microscopy in 

2002.3 Yet, little research on the evaluation of EQA 

systems in TB microscopic laboratories has been 

conducted in resource-limited countries.5  

Tajikistan is a landlocked Central Asian country 

that used to be a member of the former Soviet Union. The 

collapse of the Soviet Union and a half-decade civil war 

(1992-1998) shortly after the independence of the 

country heavily damaged both its economy and health 

infrastructure,6,7 giving rise to a re-emergence of a TB 

epidemic that peaked around 2001.8 In a population of 

8.2 million people, Tajikistan had an estimated 

prevalence of 12,000 TB cases in 2013.8 The country is 

also one of the 27 high burden countries of multiple drug-

resistant TB (MDR-TB); 1 approximately 13% of new 

patients and 56% of the retreatment TB patients were 

reportedly MDR-TB cases.8 Tajikistan has a well-

organized government laboratory network since its 

formative years (refer to Supplement Figure S1).5 Three 

levels of TB laboratories operate under the umbrella of 

the Republican TB Center (RTBC) at the central level.5 

Provincial TB centers form the intermediate level of the 

laboratory network in the three administrative “oblasts” 

of the republic: Sughd, Khalton, and Gorno-Badakhsan 

Autonomous Oblast (GBAO).5 Districts of Republican 

Subordination, a fourth oblast in Tajikistan is centrally 

managed by the RTBC. The microscopic laboratories are 

on the peripheral level at the city/district TB dispensaries 

and primary healthcare clinics. The Sughd Oblast 

(Sughd) is located in the northwest of Tajikistan with a 

population of 2.2 million people in 2012.9 Sughd has the 

largest network of TB laboratories in the country with 

one oblast-level and 22 peripheral laboratories. The 

oblast first launched the EQA system for AFB 

microscopy in March 2004 with a grant awarded by the 

Global Fund. Although outputs of the EQA strengthening 

work had been consistently monitored and evaluated in 

funded projects, no operational research was conducted 

to investigate the actual performance of the EQA system. 

Our study aimed to evaluate the EQA system and identify 

potential performance improvements strategies in TB 

microscopic laboratories in Sughd, Tajikistan. 

 

Methods 

Description of EQA strategy 

In Tajikistan, the government TB laboratories 

follow the WHO guidelines and grading system of 

microscopic diagnosis for all AFB smear microscopy 

readings (refer to Supplement Table S1 and Table S2).10 

As of 2014, directly observed treatment short course 

(DOTS) program operates in all 84 microscopic 

laboratories in Tajikistan. Appropriate quality control 

procedures are in place in all three levels of TB 

laboratory service. The staff had been trained in 

conventional and advanced methods of TB diagnosis and 

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had successfully completed two rounds of EQA provided 

by Project HOPE. Currently, the RTBC is responsible for 

coordinating the AFB microscopy network. Quality 

assurance of smear microscopy services has been 

implemented with donor assistance since 2007. The 

collected EQA results are analyzed annually and reported 

to the NTP management where corrective measures for 

quality improvement are planned.  

Figure 1 shows the algorithm of smear 

evaluation and blinded re-checking of EQA system in the 

TB microscopic laboratories in Sughd. Tajikistan 

adopted the lot quality assurance system (LQAS) for its 

slide sampling strategy with a pre-specified relative 

sensitivity of 80% and zero acceptance number of errors.  

 

Figure 1: Algorithm of stepwise rechecking of the EQA 

system in Sughd10 

 

Each year, the National Coordinator at RTBC 

calculates the needed sampling size for each laboratory 

based on reported slide positivity rate from the previous 

year. Oblast and peripheral laboratory staff are notified 

of the needed number of slides to be submitted for 

blinded re-checking for each laboratory. Peripheral 

laboratory staff are responsible of the initial slide 

preparation, proper slide storage, and physical delivery of 

all collected slides to the Oblast Laboratory Coordinator 

during the quarterly re-training sessions. In Sughd, the 

Oblast Laboratory Coordinator then conducts blinded, 

random sampling of the AFB smears. The selected AFB 

smears are blindedly re-examined by the first re-checker 

at the oblast laboratory using the same technique and 

number of fields as used in the peripheral laboratories. 

Slides yielding discrepant results between the peripheral 

and oblast laboratories are blindedly re-read by a 

different re-checker at the oblast laboratory or at RTBC, 

if necessary. The implementation of blinded re-checking 

is monitored closely by the National Coordinator. The 

final reading result is reached by the two agreed readings 

out of the three blinded readings. EQA reading results are 

forwarded to the National Coordinator for data 

compilation, entry into the EQA database, and reporting. 

The National Coordinator conducts quarterly oblast visits 

to provide feedback to the oblast and peripheral 

laboratories as well as the original technicians. Table 1 

lists the classification of reading errors as defined by the 

EQA system.3 

 

Table1: Classification of errors3 

 

Study design 

We conducted a cross-sectional study on the 

EQA system of AFB smear microscopy among the 

government TB laboratories in Sughd, Tajikistan based 

on retrospective record review and secondary data 

analyses. Due to resource constraints, the evaluation was 

not expanded to the national scale. This study did not 

require ethics review as no human subjects were 

involved. Quarterly AFB smear microscopy data and the 

corresponding EQA reading results, collected from the 

26 TB laboratories in Sughd (two were in operation for 

shorter than one year), between the first quarter of 2011 

and the fourth quarter of 2013 were extracted from the 

NRL microscopic laboratory and AFB smear microscopy 

EQA databases. Database entries were verified against 

the paper-based EQA reports submitted by the 

laboratories. Entries missing source documentation were 

excluded from the analyses. The population served by 

each laboratory was estimated by the residential 

population of each corresponding district/municipality as 

reported by the Agency of Statistics under President of 

the Republic of Tajikistan.9 For districts/municipalities 

that had more than one peripheral laboratory, annual 

service population was estimated by dividing the total 

district/municipal population by the number of active 

laboratories in each specific year period.  

Data analyses 

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Descriptive analyses, including t-based 

confidence interval computation, were performed to 

examine the overview of microscopic laboratories 

activities in Sughd in terms of case positivity rate and 

laboratory workload. Both regional and laboratory-

specific measures were calculated. The oblast laboratory 

(No. 1), due to its distinctive role in the EQA system, and 

the two peripheral laboratories (No. 24 and 25) that 

operated shorter than one year, due to their lack of yearly 

trend, were excluded from the laboratory-specific 

analyses. Nonetheless, we included data from all these 

laboratories in the regional-level analyses. 

The results of the EQA blinded re-checking 

system were evaluated based on the proportion of high 

false-positive (HFP), high false-negative (HFN), low 

false-positive (LFP), low false-negative (LFN), and 

quantification errors. Sensitivity and specificity were 

calculated, along with respective t-based confidence 

intervals, to demonstrate the AFB smear reading 

performance of the peripheral laboratories relative to the 

final EQA re-checking (controller) results. Data were 

analyzed using Microsoft Excel (Microsoft Office Excel 

XP) and Stata 12 software (StataCorp LP, College 

Station, TX).  

 

Results  

Out of the 264 expected quarterly EQA reports, 

11 were missing from nine peripheral laboratories. These 

11 missing reports could possibly be archived in other 

district files by error. Due to the lack of source 

documentation and verification failure, their associated 

quarterly data were excluded from our analyses. From the 

first quarter of 2011 to the fourth quarter of 2013, TB 

microscopic laboratories in Sughd examined a total of 

123,874 smears, among which, 11,522 (9.30%) were re-

checked by the EQA system. The proportion of the 

population screened had increased from 0.46% in 2011 

to 0.57% in 2013. Table 2 gives an overview of the 

regional and laboratory-specific activities during the 

study period. While the population in Sughd was steadily 

on the rise, its case positivity rate had gradually 

decreased from 6.98% (95% CI: 6.50-7.49%) in 2011 to 

4.80% (95% CI: 4.44-5.17%) in 2013, possibly 

signifying the reduced incidence or prevalence of TB as 

reflected in WHO global reports. Nonetheless, the overall 

laboratory workload, reflected by the number of smears 

examined, grew by 19.5%. On the laboratory level, No. 

2, 16 and 23 showed the highest case positivity rates in 

Sughd while No. 10, 8 and 5 had the heaviest workloads. 

 

Table 2: Overview of annual service population, case 

positivity rate, total number of smears and total number 

of slide rechecking from 2011 to 2013 among TB 

microscopic laboratories in Sughd, by laboratory  

 

Annual EQA rechecking results, as shown in 

Table 3, reported regional reduction in HFP, HFN and 

LFN errors. The lowest number of errors was achieved in 

2012. Overall, the percentage of FP errors had decreased 

from 0.13 in 2011 to 0.07 in 2013, though zero FP error 

was achieved in 2012. The region also saw a reduction of 

FN errors from 0.91% in 2011 to 0.15% in 2013. On the 

individual laboratory level, only ten laboratories (45.5%) 

achieved the NRL’s zero-error standard in 2011. This 

measure was improved with eighteen laboratories 

(81.8%) in 2012 and sixteen laboratories (72.7%) in 2013 

achieving zero-error.  No.18 had the highest number of 

errors in 2013 (one HFN, two LFP and one QE). Only 

No. 3 and 7 displayed small rising trends of errors (from 

zero to one and from zero to two, respectively). No. 11, 

10, 13 and 20 showed the most improvement in error 

elimination.  

 

Table 3: Annual EQA rechecking results by laboratory 

 

The performance of TB smear microscopy in 

Sughd is shown in Table 4. Based on the EQA rechecking 

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results, we reported an increased regional sensitivity 

from 88.2% (95% CI: 83.4-92.0%) in 2011 to 97.2% 

(95% CI: 94.3-98.9%) in 2013 (highest at 97.4% (95% 

CI: 94.7-98.9%) in 2012). The regional specificity level 

remained relatively stable: 99.9% (95% CI: 99.6-100%) 

in 2011, 100% (95% CI: 99.9-100%) in 2012 and 99.9% 

(95% CI: 99.8-100%) in 2013. The positive predictive 

values and negative predictive values remained stable 

through the three years (Table 4). Among all low 

performers in sensitivity were No. 7 (71.4%), 14 (80%), 

3 (85.7%), and 21 (90%). They all displayed 

deteriorating trends in sensitivity over the three years. 

No. 23 (98.9%) and 18 (99.0%) were the only two 

laboratories which scored less than perfect in specificity 

in 2013, though both remained high. 

 

Table 4: Percentage of sensitivity and specificity of 

smear microscopy, by laboratory 

 

Discussion 

In their review on the roles of laboratories and 

laboratory systems in effective TB programs, Ridderhof 

et al., called for more operational research to be done in 

TB laboratories in the field in resource-limited settings to 

support evidence-based laboratory practice.5 Evaluations 

of EQA systems and/or blinded random re-checking 

strategies in TB microscopic laboratories had been 

conducted in various countries with high TB burden.6-8 

Our study performed the first evaluation on the EQA 

system and the performance of the TB microscopic 

laboratories in Sughd, Tajikistan since system 

implementation.  

Our study found a descending trend of case 

positivity rates from 2011 to 2013 in Sughd, which 

suggested a regional decline of TB prevalence, while the 

proportion of population being screened for active TB 

expanded. This finding is consistent with the stable, 

national trend of decline in TB prevalence and incidence 

since 20028, as published by WHO. This could possibly 

be attributed to higher community awareness of TB and 

more proactive contact tracing strategies over the past 

decade. Although earlier a Knowledge, Attitude and 

Practice (KAP) survey conducted jointly by Project 

HOPE, WHO Tajikistan, and Sino Project/Swiss Center 

for International Health in 2005 and 2008 indicated room 

for improvement in raising public awareness of TB, the 

two surveys showed improved knowledge of TB 

symptoms among respondents over a 3-year period.6 A 

qualitative study in 2006, consisting of 13 focus group 

discussions among 43 community members, echoed that 

overall knowledge of TB symptoms was accurate among 

community members.11 Since then, the country has 

implemented various initiatives of patient support groups 

and community leaders training in expansive scales. Such 

joint efforts of the NTP and non-governmental 

organizations might contribute to the climbing case 

notification rate from 2004 to 2010.8 However, since 

2010, Tajikistan started to see declining trends in both 

case notification and incidence rates.8 As systematic 

screening for active TB has been gaining momentum in 

Central Asia, we anticipate the rising TB screening rate, 

accompanied by the steadily declining TB incidence and 

prevalence, to persist with extended local effort in 

advocacy, communication, and social mobilization 

activities.  

Our study also showed that sputum smear 

microscopic laboratories in Sughd had achieved total 

error reduction over these three years, in spite of 

mounting laboratory workload. Effective reduction in 

microscopist workload was named the top priority in 

improving reading quality in previous studies.7,8 

Although our study did not include direct measures of 

laboratory workforce, we noted that high staff turn-over 

and emigration of skilled workers continued to challenge 

local programs in maintaining human resource capacity. 

As a significant increase in microscopist workforce in the 

region remained unlikely during the study period, the 

observed error reduction might be an outcome of stronger 

interactive training and feedback loop established as part 

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of the EQA system in Sughd. Overall, the peripheral 

laboratories in this region saw substantial improvement 

in the sensitivity of AFB smears in TB detection while 

maintaining high specificity levels. HFN was the most 

frequent error type found in peripheral laboratories in 

Sughd, followed by LFP being the second most common 

error type.   

One limitation of our study was that many 

pieces of EQA data entries in the NRL database were 

excluded due to missing source documents. Coordinators 

at RTBC confirmed that all entries were made based on 

the paper-based reports; however, misfiling of 11 original 

quarterly reports was possible. Corrective actions that 

aim to enhance the local filing system for the EQA 

reports will not only promote data accuracy but also 

allow future evaluations on other Tajik regions and/or 

time periods to be completed more efficiently.  

With WHO’s recent recommendations on 

systematic screening for active TB,12 continuous 

monitoring, through laboratory data, on the population 

TB screening rate, case positivity rate, and number of 

smears performed gives crucial information on the 

progress of systematic screening, the trend of TB 

prevalence, and the status of laboratory workload both at 

the individual laboratory level and the regional level. Our 

study computed these three indicators along with the 

EQA errors and AFB microscopy performance analyses. 

We believe that the overview of microscopic laboratory 

activities and the actual evaluation of the EQA system on 

sputum smear microscopy complement each other in 

providing a better picture on the progress of TB 

laboratory strengthening. We recommend similar 

approaches to be adapted by future evaluations on TB 

microscopic laboratories, particularly among countries of 

high burden.   

 

Acknowledgements 

The authors are grateful to the staff of the 

USAID Quality Health Care Project for their support. 

The assistance provided by the Project HOPE office and 

the National TB Program in Tajikistan is gratefully 

acknowledged.  

 

Authors’ contributions 

Eva Chang contributed to the concept, protocol, 

analysis, and writing of the manuscript. Fabio Luelmo 

contributed to the study concept and protocol 

development. Zamira Baydulloeva, Gulfamol 

Kasymova, and Oktam Bobokhojaev contributed to the 

data collection. Marija Joncevska critically revised the 

article. Tom Mohr contributed to the protocol, 

implementation, and supervision of the study. 

 

Competing Interests 

None of the authors has any conflict of interest 

to declare. 

 

Funding 

The study was funded by the USAID Quality 

Health Care Project Tajikistan and Project HOPE. The 

Quality Health Care Project is funded by the U.S. Agency 

for International Development under Contract No. AID-

176-C-10-00001, beginning September 2010. The 

Quality Project is implemented by Abt Associates Inc. 

and its subcontractor, namely, Project HOPE. 

 

References 

1. WHO. Global tuberculosis report 2014. 2014. 

2. New diagnostics working group of the Stop TB 

Partnership. Pathways to better diagnostics for tuberculosis. 

2009; 

http://www.finddiagnostics.org/export/sites/default/resource-

centre/reports_brochures/docs/BluePrintTB_annex_web.pdf. 

Accessed December 12, 2014. 

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http://www.finddiagnostics.org/export/sites/default/resource-centre/reports_brochures/docs/BluePrintTB_annex_web.pdf
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CHANG 

 

 

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3. The Global Laboratory Initiative. A Roadmap for Ensuring 

Quality Tuberculosis Diagnostics Services within National 

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5. Ridderhof J, van Deun, A, Kam, M,  Abdul, M. Roles of 

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72996986.pdf. Accessed December 12, 2014. 

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11. Ayé R, Wyss, K, Abdualimova, H, Saidaliev, S. . Illness 

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Table 1: Classification of errors3 

Result of 

technician 

Result of Controllers 

Negative 1-9 AFB/100f 1+ 2+ 3+ 

Negative Correct LFN HFN HFN HFN 

1-9 AFB/100f LFP Correct Correct QE QE 

1+ HFP Correct Correct Correct QE 

2+ HFP QE Correct Correct Correct 

3+ HFP QE QE Correct Correct 

*Note. LFP = low false-positive, HFP = high false-positive, LFN = low false-negative, HFN = high false-negative, 

QE = quantification error 

  

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Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Table 2: Overview of the annual service population, case positivity rate, total number of smears, and total number of slide 
rechecking from 2011 to 2013 among TB microscopic laboratories in Sughd, by laboratory 

Laboratory 

Number 

Service population Case positivity rate (%) Number of smears 

examined 

Number of slides 

rechecked 

2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 

2 54333 55100 55877 15.03 12.78 13.62 2226 2232 873 58 112 25 

3 54333 55100 55877 1.60 3.73 2.30 1683 1838 1782 201 73 150 

4 54333 55100 55877 1.43 3.17 1.45 727 686 1129 90 92 166 

5 102000 104600 107266 6.35 5.94 6.40 4211 3602 3859 145 201 165 

6 135400 138000 140650 5.41 4.39 5.01 2926 2280 3473 141 201 208 

7 46500 47300 48114 0.87 1.33 1.10 691 1266 1659 104 304 309 

8 232200 236900 120848 4.88 3.47 2.82 4277 3926 4602 141 284 248 

9 224100 229700 235440 8.99 9.97 4.45 1104 1266 1782 96 118 73 

10 251000 257900 264990 8.58 5.62 5.50 3812 4503 5273 102 78 105 

11 40600 41500 42420 7.14 3.57 2.29 490 480 635 88 132 191 

12 28400 29400 30432 3.68 4.85 5.37 498 588 1106 129 129 293 

13 136300 140000 143800 9.27 7.67 5.18 510 888 633 155 123 140 

14 139500 143300 147204 3.73 2.33 0.30 1073 1572 3135 170 225 172 

15 60800 62500 64248 2.83 6.79 1.97 1452 1113 964 95 252 130 

16 21100 21600 22112 17.79 3.13 8.33 552 128 52 40 81 28 

17 116600 119400 122267 5.30 3.73 2.25 2648 2664 3507 209 193 198 

18 114000 116700 119464 2.71 2.33 2.90 2373 2081 2514 206 156 213 

19 34900 35800 36723 2.82 1.26 1.63 739 1051 818 135 239 277 

20 159050 162550 110751 4.47 2.14 2.23 1691 2815 2502 365 298 319 

21 159050 162550 110751 3.50 0.47 4.35 680 724 561 244 306 444 

22 72000 73100 74217 4.90 6.06 5.22 394 394 500 83 162 283 

23 14400 14700 15006 17.97 12.14 13.71 572 650 693 44 76 99 

Regional 

(95% CI) 

2251700 2302700 2354855 6.98  

(6.50-7.49) 

5.64 

(5.22-6.09) 

4.80 

(4.44-5.17) 

38437 39452 45985 3063 3866 4593 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Table 3: Annual EQA rechecking results, by laboratory 

Laboratory 

Number 

Type of errors 

HFP HFN LFP LFN QE 

2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 

2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

3 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 

4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

5 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 

6 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 

7 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 

8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

9 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 

10 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 

11 0 0 0 5 1 0 0 0 0 0 0 0 1 0 0 

12 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

13 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 

14 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 

15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

16 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

18 0 0 0 3 0 1 0 0 2 2 0 0 0 0 1 

19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

20 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 

21 0 0 0 0 2 0 1 0 0 0 0 1 0 0 0 

22 0 0 0 2 3 0 0 0 0 0 0 0 0 0 0 

23 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 

Regional 2 0 0 21 6 6 2 0 3 7 1 1 1 0 1 

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CHANG 

 

 

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This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Table 4: Percentage of sensitivity and specificity of smear microscopy, by laboratory 

Laboratory 

Number 

Sensitivity (%) Specificity (%) Positive Predictive Value (%) Negative Predictive Value (%) 

2011 2012 2013 2011 2012 2013 2011 2012 2013 2011 2012 2013 

2 100 100 100 100 100 100 100 100 100 100 100 100 

3 100 100 85.7 100 100 100 100 100 100 100 100 9903 

4 100 100 100 100 100 100 100 100 100 100 100 100 

5 94.4 96.2 100 99.2 100 100 94.4 100 100 99.2 99.3 100 

6 89.5 100 100 100 100 100 100 100 100 98.4 100 100 

7 NA 100 71.4 100 100 100 NA 100 100 100 100 99.3 

8 100 100 100 100 100 100 100 100 100 100 100 100 

9 96.2 100 100 100 100 100 100 100 100 98.6 100 100 

10 78.6 100 100 100 100 100 100 100 100 96.7 100 100 

11 58.3 88.9 100 100 100 100 100 100 100 93.8 99.2 100 

12 100 100 100 100 100 100 100 100 100 100 100 100 

13 80.0 100 100 100 100 100 100 100 100 97.9 100 100 

14 87.5 100 80.0 99.4 100 100 87.5 100 100 99.4 100 99.4 

15 100 100 100 100 100 100 100 100 100 100 100 100 

16 NA 100 NA 100 100 100 NA 100 NA 100 100 100 

17 100 100 100 100 100 100 100 100 100 100 100 100 

18 58.3 100 92.3 100 100 99.0 100 100 85.7 97.5 100 99.5 

19 100 100 100 100 100 100 100 100 100 100 100 100 

20 89.7 100 100 100 100 100 100 100 100 99.1 100 100 

21 100 66.7 90.0 99.6 100 100 85.7 100 100 100 99.3 99.8 

22 50.0 82.4 100 100 100 100 100 100 100 97.5 98.0 100 

23 100 100 100 97.4 100 98.9 83.3 100 85.7 100 100 100 

Regional 

(95% CI) 

88.2 

(83.4-

92.0) 

97.4 

(94.7-

98.9) 

97.2 

(94.3-

98.9) 

99.9 

(99.6-

100) 

100 

(99.9-

100) 

99.9 

(99.8-

100) 

98.1 

(95.3-

99.5) 

100 

(98.6-

100) 

98.8 

(96.5-

99.7) 

99.0 

(98.6-

99.3) 

99.8 

(99.6-

99.9) 

99.8 

(99.7-

99.9) 

 

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CHANG 

 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Figure 1: Algorithm of stepwise rechecking of the EQA system in Sughd10 

 

  

 
Feedback   Feedback     

  

 

 

Peripheral Laboratory 
 

Slide preparation 
AFB microscopy 

Slide storage 

Intermediate Laboratory 
 

Random sampling 
Blinded rechecking  
(First and second 

recheckers, if needed) 

Republican TB Center 
 

Report/Interpretation 
EQA database 
maintenance 

 
 

Blinded slide 
Transporting 

Rechecked 

 
EQA Results EQA Report 

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CHANG 

 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Supplement 

Figure S1: The Structure of Government TB Microscopic Laboratory Network in Tajikistan13 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National TB Reference Center 
Central Level 

Republican 
TB Center 

Intermediate 
Level  

Khujand 
Oblast TB 

Center Lab 
Sughd Oblast 

  

Intermediate 
Level  

Kurgan-Tube 
Oblast TB 

Center Lab No.1 
Khalton Oblast 

  

 

Intermediate 
Level  
Kulob 

Oblast TB 
Center Lab No.2 
Khalton Oblast  

 

Intermediate 
Level  

Khorog  
Oblast TB 

Center Lab  
GBAO 

  
 

Peripheral Level 
 

Soghd Oblast 
 22 

Peripheral Level 
 

Khalton Oblast 
Kurgan-Tube 

15  

Peripheral Level 
 

 Khalton Oblast  
Kulob 

11  
 

Peripheral Level 
Gorno-  

Badakhshan  
Autonomous 

Oblast 
8 

 

Peripheral Level 
 

Dushanbe City 
10 

Peripheral Level 
Districts of 
Republican 

Subordination 
13 

Republican TB Center 
 

Republican Microscopy 
Surveillance Center 

 

Peripheral Level 
Disciplinary 
Department 

Ministry of Justice 
5 

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

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This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Table S1: AFB Smear Microscopy Grading system 

Findings Grade 

No acid-fast bacilli found in at least 100 fields Negative 

1-9 acid-fast bacilli per 100 fields Scanty (report exact figure/100) 

10-99 acid-fast bacilli per 100 fields 1+ 

1-10 acid-fast bacilli per field in at least 50 fields 2+ 

More than 10 acid-fast bacilli per field in at least 20 fields 3+ 

 

  

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CHANG 

 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.230|http://cajgh.pitt.edu 

 

 

Table S2: Laboratory numbers and corresponding laboratory names 

Laboratory 
Number Laboratory Name 

1 Deqmoy 

2 Khujand G 

3 Khujand PHC 1 

4 Khujand PHC 5 

5 Mastchoq 

6 Konibodom PHC 

7 Konibodom Sub  

8 Isfara 

9 Istaravshan 

10 Panchakent 

11 Kairokkum  

12 Chkalovsk  

13 Asht  

14 Gonchi 

15 Zafarobod 

16 Mastchoqi Kuqi 

17 Spitаmen 

18 Rasulob  

19 Shaqriston 

20 Gafurov PHC 

21 Gafurov 

22 Aini 

23 Taboshar 

24 Isfara Chorku 

25 Gafurov Eva  

 

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