Collection, Storage and Transportation of Dried Blood Spots for Infant Diagnosis

1. Collection, Storage and Transportation of Dried Blood Spots for Infant Diagnosis

2. Learning Objectives • Collect Dried Blood Spots (DBS) for HIV testing • Package and store DBS so as to maintain specimen integrity • Distinguish between valid and invalid DBS

3. Step 1 • Equipment • DBS sample collection card • DBS Lab requisition Form • Sterile lancet • Sterile alcohol prep • Sterile gauze/cotton swab • Gloves • Drying rack • Low Gas Permeable zip-lock bag • Desiccant • Humidity indicator card

4. Step 2 • Correctly complete all the information on the requisition form • Keep copy for your records

5. Step 3 • Wash hands and dry thoroughly • Put on gloves • Confirm identity of the infant and write the baby’s name, date of the test and the unique identifier on the filter paper • Do no not contaminate by touching or allowing spillage on the filter paper Jane Doe May 12th 2006 131-3347923-1-1-6

6. Step 4 Choosing the site • Small infants (<9kg) • Puncture the heel. • Do not puncture the fingers; there is risk of hitting the bone. • Larger infants (> 9kg) • Puncture the heel; if callous is visible, you may use the lateral aspect of the big toe. • Do not stick the fingers or small toes; there is risk of hitting the bone. • Fingers are safe in children > 2 years of age

7. Step 5 Do not puncturehere Safe • Draw an imaginary line from midpoint of the big toe to the heel and one from between the 4th and 5th toe to the heel. • Shaded area indicates safe areas for puncture site • Do not puncture the back of the heel or Achilles tendon or the medial aspect of the big toe safe safe Do not puncture here

8. Step 6 • Position baby with foot down • This will help the blood flow more easily • Warm site with soft cloth moistened with warm water up to 410c for 3 to 5 minutes

9. Step 7 • Clean site with alcohol prep • Allow to air dry for 30 seconds • Failure to allow alcohol to dry may dilute the specimen

10. Step 8 • Puncture the toe to a depth less than 2 mm using a sterile lancet

11. Step 9 • Wipe away first blood with sterile gauze pad • The initial drop contains tissue fluid that may dilute the specimen • Allow another large blood drop to form

12. Step 10 • Lightly touch the filter paper to the large drop of blood • Allow to soak through and completely fill the circle • To enhance flow very gently apply intermittent pressure to area above the puncture site.

13. Step 11 • Apply blood to one side of the filter paper only, the side with the printing • Do not layer successive drops of blood or apply blood more than once to the same collection circle • Avoid touching or smearing the spots

14. Step 12 • Fill remaining circles in the same manner with successive drops of blood • If blood flow is diminished repeat steps 10 and 11

15. Step 13 • Inspect card to ensure you have collected enough blood, and the specimen is valid Jane Doe May 12th 2006 131-3347923-1-1-6 Valid Specimen

16. Step 14 • Place filter paper on a horizontal clean dry surface to AIR DRY for at least 3 hours • Keep away from direct sunlight, dust, and bugs • Do not allow blood spots to come into contact with any surface or each other.

17. Step 15 • Place dried DBS cards between sheets of glassine paper so that the DBS cards are not touching each other • Fold ends of the glassine paper

18. Step 16 • Place dried filter paper into Ziploc bag • Add desiccant package • Minimum of 2 desiccant packages per specimen

19. Step 17 • Add humidity indicator card • Remove air and seal bag • Keep packaged DBS (in sealable plastic bags) refrigerated until transported to reference laboratory

20. Step 18 Transportation • Place bag into envelope • Add lab requisition slips and specimen delivery check list • Clearly label outside of the envelope • Transport to central laboratory for processing

21. Step 19 • During transportation do not leave in vehicle, as sun and heat will deteriorate DBS

22. Invalid Specimen Specimen quantity insufficient for testing • Removing filter paper before blood has completely filled circle or before blood has soaked through to second side. • Applying blood to filter paper with a capillary tube • Touching the filter paper before or after specimen collection with a gloved or ungloved hands, hand lotion etc. • Allowing the filter paper to come into contact with gloved or ungloved hands or stances such as hand lotion or powder, either before or after blood specimen collection.

23. Invalid Specimen Specimen appears scratched or abraded • Applying blood with a capillary tube or other device

24. Invalid Specimen Specimen not dry before mailing • Mailing specimen before drying for a minimum of 3 hours

25. Invalid Specimen Specimen exhibits serum rings • Not wiping alcohol from puncture site • Allowing filter paper to come into contact with alcohol , hand lotion etc. • Squeezing area surrounding puncture site excessively • Drying specimen improperly • Applying blood to filter paper with capillary tube

26. Invalid Specimen Specimen appears diluted, discolored or contaminated • Squeezing or milking of area surrounding puncture site • Allowing filter paper to come into contact with gloved or ungloved hands or substances such as alcohol, formula, antiseptic, water, powder etc. before or after blood specimen collection • Exposing blood spots to direct heat

27. Invalid Specimen No blood • Failure to obtain specimen

28. Invalid Specimen Specimen appears clotted or layered • Touching the same circle on filter paper to blood several times • Filling circle on both sides.

29. Invalid Specimen Specimen appears super saturated • Applying excess blood to filter paper, usually with a device • Applying blood to both sides of filter paper.