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Overview of Syphilis Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should: 1.Understand of the global epidemiology of syphilis and congenital syphilis 2.Describe the stages of syphilis infection 3.Clinically identify the signs of infection 4.Understand syphilis transmission and the risk during pregnancy
Overview of Syphilis Syphilis is a sexually transmitted infection Caused by a bacteria, Treponema pallidum Initial infection causes a genital ulceration – Raised painless lesion Genital ulcer disease can be caused by other organisms as well – Herpes simplex, Haemophilis ducreyi (chancroid)
Epidemiology Syphilis is a major public health problem An estimated 12 million new cases of syphilis occur worldwide each year The majority of infections occur in the developing world including Latin-America, sub-Saharan Africa and Southeast Asia Untreated syphilis in pregnancy is associated with spontaneous abortion, stillbirth, perinatal death, premature delivery, low birth weight, or congenital syphilis
WHO estimates 12 million new cases of syphilis occur worldwide each year 140, ,000 4 M 10, ,000 4 M 3 M 100,000
Syphilis Prevalence In [Sub-Saharan Africa/ Latin America/ South- East Asia], the prevalence of syphilis infection ranges from [lowest estimate]-[highest estimate]% In [Enter name of country], the prevalence of syphilis is [enter national prevalence]%
Modes of Transmission Syphilis is transmitted through – Contact with the genital ulcer – Mother to child (vertical transmission) during pregnancy – Blood transfusion
Clinical Presentation Syphilis presents in multiple stages – Primary, secondary, early latent, late latent and tertiary Primary syphilis presents as a painless ulcer – Mainly on external genitals, vagina, anus, or rectum In women, the ulcer may be deep in the vagina and go unnoticed – Can also be on fingers, lips, or mouth
Primary Syphilis Primary syphilis occurs 3 weeks after infection (9- 90 days) Primary syphilis is characterized by a painless, indurated ulcer (or chancre) After 1-5 weeks, the ulcer spontaneously resolves without treatment This stage is highly infectious
Secondary syphilis The bacteria have spread to all organs and body fluids Symptoms develop 1-5 weeks after the ulcer Characterized by a generalized rash Symptoms spontaneously resolve after 2-6 weeks This stage is also highly infectious
Early Latent Syphilis Asymptomatic Occurs <1 after infection Less infectious than primary and secondary syphilis Vertical transmission can still occur
Late latent syphilis Occurs 2 years after initial infection and may last the patient's lifetime Asymptomatic Lower risk of transmission during this stage than earlier stages of infection
Tertiary Syphilis Occurs anytime after secondary syphilis and may not occur at all Result of widespread infection during secondary syphilis Symptoms include gumma (lesions) of the skin, muscles, eyes, bones Also includes cardiovascular syphilis and neurosyphilis
Congenital Syphilis Causes stillbith, miscarriage, and preterm labour Babies born to syphilis positive mothers may have low-birthweight, abnormal liver or spleen development, anemia, jaundice, lesions on the palms and soles, or neurological problems Only half of newborns infected with syphilis can be clinically identified at birth
Infectivity of Syphilis 1° > 2° > Early Latent > Late Latent & 3° Primary Ulcer Rash on palms & soles Asymptomatic, <2 years Asymptomatic, >2 years Gumma, Neurosyphilis, Cardiovascular syphilis
Conclusions Syphilis is a major health concern and causes stillbirth, low-birthweight babies and congenital syphilis Syphilis is transmitted through contact with a genital ulcer, through sexual intercourse, vertically from mother to baby during pregnancy or through blood transfusions Syphilis has multiple stages
Questions for Participants Have you ever seen a case of syphilis? – Was it primary, secondary or tertiary syphilis? Have you ever seen a baby with congenital syphilis?
References WHO. The elimination of congenital syphilis: Rationale and strategy for action health/publications/congenital_syphilis/strategy_congenitalsy philis.pdf. Accessed January 24, 2008http://www.who.int/reproductive- health/publications/congenital_syphilis/strategy_congenitalsy philis.pdf. Accessed January 24 Aiken CG. The causes of perinatal mortality in Bulawayo, Zimbabwe. Central African Journal of Medicine 1992; 38:
Syphilis Testing Technologies Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Describe the difference between a test that detects bacteria and a test that detects antibodies. 2.Understand the definitions of antigen and antibody. 3.Describe the main characteristics of treponemal and non-treponemal tests. 4.Describe the characteristics and benefits of rapid diagnostic tests.
Syphilis diagnostics Diagnosis of syphilis infection is based on detection of: 1.Treponema pallidum bacteria 1.Antibodies
Detection of Bacteria The following diagnostic tests diagnose syphilis infection based on the detection of the Treponema pallidum bacteria: Microscopy Dark field Fluorescent
The Immune Response Antigen (Ag) – Is a substance recognized by the body or immune system as foreign – It may be the whole organism or part of it (protein, lipids, ect.) – An antibody is produced by the immune system in response to the detection of an antigen Antibody (Ab) – A protein produced in response to an Ag – The antibody will attack the Ag as part of the immune response
Syphilis Antibody Response Two types of antibodies are produced during a syphilis infection 1.Treponemal Antibodies 1.These are produced against an Ag specific to syphilis 2.Non-treponemal Antibodies 1.These are produced against a non-specific Ag, reagin/ cardiolipin 2.Reagin/ Cardiolipin is also produced when tissue is damaged during infection (Tb, malaria), auto- immune conditions (rheumatoid arthritis) or pregnancy
Syphilis Antibody Response Clinical stages of syphilis primary lesion secondary lesion primarysecondary latenttertiary *IgM – ELISA or FTA-ABS 19S or immunoblot 100 % 80% 60% 40% 20% FTA-Abs IgM* treated TPHA untreated VDRL /RPR Time (weeks) 2 10time (years)
Detection of the Antibody Serological tests for syphilis diagnosis detect either the treponemal or non-treponemal Ab Treponemal tests detect the antibody specific to syphilis Non-treponemal tests detect the reagin/ cardiolipin antibody that is produced during syphilis infection but is not specific to syphilis
Types of Treponemal Tests 1.Agglutination Assays (TPPA, TPHA) 2.Fluorescent Assays 3.Treponema pallidum Immobilisation (TPI) test 4.ELISA Assays 5.Western Blot 6.Chromatographic tests (POC)
Treponemal Tests Detect antibodies specific to T. pallidum antigens They become positive early in infection Can be used to: – Confirm a clinical diagnosis, OR – Confirm positive result for non-treponemal test Remain positive for many years, even after successful treatment Detect life-time syphilis exposure
Treponemal Tests Most are limited to research laboratories – POC tests are the exception Samples have to be transported to established labs Results are not available for several days or weeks Individuals may not return for results – Resources are wasted – Positive may not be treated leading to adverse pregnancy outcomes or onward transmission
How to Perform TPPA/ TPHA Add sample diluent to wells 1-4 Add serum sample to well number 1 Mix and transfer to well number 2 Repeat this process to well number 4 Mix and discard same volume transferred from well 3 Add unsensitized RBCs/ Gelatin particles to well number 3 Add sensitized particles/ RBs to well 4 Read results in a light box after incubation
Fluorescent Treponemal Antibody Test
Simple Treponemal Tests Rapid Syphilis Tests (RST): Are simple to perform Can be used at primary health centres, at the point of care Give results in less than 30 minutes Use whole blood, collected from a finger prick Enable treatment to be give the same day as testing
Simple Treponemal Tests Like all treponemal tests, RSTs: Detect antibodies specific to T. pallidum Can be used early to detect infection Remain positive even after successful treatment
Simple Treponemal Tests Important for control programmes Use whole blood, serum or plasma Can be integrated into other programmes (VCT, PMTCT, STD, ANC) Have high sensitivity (85-98%) – This is a measure of the ability of a test to detect infection Have high specificity (93-98%) – This is a measure of the ability of a test to exclude infection
Format of RST Strips Cassettes (ex. SD Bioline)
Performing RST Follow the manufacturer's instructions or a national SOP SOP or Standard Operating Procedure provides detailed instructions on how to perform the test NOTE: Written SOPs should always be available at each testing site, and must always be followed when performing testing
RST Procedure Prepare the testing area and put on gloves and gown/ apron Remove the test cassette from the foil pouch Place it on a flat surface and label it with the client/ patient number Add patient specimen (serum/ whole blood/ plasma) to sample well S Add diluent buffer to sample well S Read the results after the specified time Enter results on record form/ register Dispose of all materials in biohazard waste/ sharps container
Advantages of Rapid Tests Do not require equipment Simple and rapid Use whole blood, serum or plasma Require minimal technical skills Can be performed at the Point of Care (POC) Increase access to testing Increase coverage of testing and treatment Results are easy to interpret
RPR vs. Rapid Tests RPR (non-treponemal test)Rapid Syphilis Test (treponemal test) Can be used to distinguish active from past treated infection Cannot distinguish active infection from past treated infection Test of cureMeasures lifetime exposure to syphilis Serum/ plasmaWhole blood/ serum/ plasma Needs laboratory facility & trained personnel Can be done in primary health care settings Test only takes 8 minutes but patients often need to return for results and treatment Results in less than 30 minutes and treatment can be given at the same visit Interpretation of results requires a high degree of training and experience Results are simple to interpret Reagent needs refrigerationTest and reagents can be transported and stored at room temperature False negative results due to prozone effect and biological false positives No prozone effect or biological false positives
Interpretation of RST Results Unable to distinguish between active infection and past treated infection A positive RST result indicates the client/ patient has been exposed to syphilis during their lifetime [REFER TO NATIONAL GUIDELINES FOR FURTHER GUIDANCE ON CONFIRMATORY TESTING, TESTING ALGORITHMS, AND TREATMENT STRATEGIES]
Syphilis: Proposed Testing Algorithms No RPR testing available : RPR testing available : positivenegative treat Blood RDT + -/- Blood RDT +- negative RPR + - positive Re-test in 6 wks treat +
Non-Treponemal Tests T.pallidum infection produces non-specific antibodies (non-treponemal antibodies) These are detected by non-treponemal tests (RPR, VDRL) Non-treponemal (reagin/ cardiolipin) antibodies arise from: – Lipoidal antigens that are the same on bacterial cells and host cells
Types of Non-treponemal Tests Flocculation – Antigen-antibody complex – Ag-Ab complex remains suspended (visible) – Ex. RPR, VDRL, TRUST Complement Fixation Test – Wasserman reaction test
Rapid Plasma Reagin (RPR) Relatively simple Requires equipment and skill to perform and interpret results – Results are subjective Less sensitive than Treponemal tests in early syphilis infection Tend to be negative during late syphilis After successful treatment, becomes negative (Test of Cure) Prozone effect causes false negatives Other infections cause biological false positives
Rapid Plasma Reagin (RPR) Test Sensitivity: 85-95% Specificity: 95-98% Cost/test = $ 0.2 Needs electricity for: centrifuge shaker reagent storage Requires training Humid atmosphere
Non-treponemal Tests Detect non-specific antibodies formed during syphilis infection Examples: – Rapid Plasma Reagin (RPR) – Venereal Disease Research Laboratory (VDRL)
Use of Diagnostic Tools for the Prevention and Control of Syphilis RPR Rapid TPHA EIA Diagnosis + +* + + Screening + +* +/- + Tx efficacy Re-infection? Surveillance * can be used with whole blood
Non-treponemal Tests Detect non-specific antibodies formed during syphilis infection – cardio-lipin antigen eg. Rapid Plasma Reagin (RPR) eg. Venereal Disease Research Laboratory (VDRL)
Questions for Participants Have you ever performed a syphilis test and if so, which one? Was it a treponemal or non-treponemal test? How user-friendly do you think it was?
Treatment of Syphilis Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Describe the recommended and alternative treatment and dosage for an adult with syphilis infection 2.Describe how to manage an infant born to a mother who tested positive for syphilis during pregnancy 3.Describe how to manage the partner of a syphilis positive individual 4.Describe the potential reactions to the recommended and alternative treatment for syphilis 5.Describe the potential risks and adverse outcomes if treatment is not administered
When Do You Treat A Patient? If a pregnant woman tests positive for syphilis If a patient at the STI clinic tests positive for syphilis If a patient at the delivery ward tests positive for syphilis
When Do You Treat A patient
How To Treat Syphilis Before treating a patient, it is important to provide them with counseling – Explain what a positive result means and the risk of transmission to a partner or baby – Explain the treatment options available and that syphilis is a curable disease – Obtain consent from the patient
Counseling 1.REVIEW Pre-test information 2.HELP the patient understand the meaning of the result – A positive result means you are infected with syphilis – Syphilis can be cured with antibiotics – Syphilis infection can harm your unborn baby 3.DISCUSS any immediate concerns and ANSWER any questions – Having syphilis once does not mean you will not get it again – You can still be re-infected after successful treatment – You should not have sex until the syphilis sores are completely healed
Counseling 4.ENCOURAGE safer sex practices in preventing reinfection and/or transmission – Use condoms – Have long-term relationships where neither of you have other partners – Limit your sex partners 5.ADVISE on telling partners – You should tell all your sexual partners that your are positive for syphilis and that they should go to a health clinic to be tested and treated [REFER TO NATIONAL GUIDELINES] 6.FOLLOW-UP Services – You should be tested for HIV infection – You should come in to be tested again in XXX weeks [REFER TO NATIONAL GUIDELINES] – You should have regular STI check-ups
How To Treat Syphilis The National Guidelines recommended treatment for an adult testing positive for syphilis is: [All patients with a positive test result should be treated regardless of treatment history in a previous pregnancy] IMPORTANT: Treatment should be given on the SAME DAY as Testing
How to Manage Partners [REFER TO NATIONAL GUIDELINES FOR PARTNER MANAGEMENT] DETAIL IF THE PARTNER IS TO BE TESTED AND TREATED ONLY IF POSITIVE, OR PRESUMPTIVELY TREATED AS A CONTACT WITHOUT TESTING
How To Treat Syphilis REFER TO NATIONAL GUIDELINES FOR ALTERNATIVE TREATMENT REGIMENS IF A PATIENT IS ALLERGIC TO PENICILLIN DETAIL THE MEDICATION, DOSAGE, AND DURATION OF THE ALTERNATIVE TREATMENT REGIMEN AND METHOD OF ADMINISTRATION (ORAL, IV, INJECTION)
How To Treat Syphilis Infants born to mothers who tested positive for syphilis during pregnancy need to be treated according to the National Guidelines REFER TO NATIONAL GUIDELINES DESCRIBE THE MEDICATION, DOSAGE, DURATION OF REGIMEN, AND ADMINISTRATION (ORAL, IV, INJECTION) DESCRIBE THE ALTERNATIVE MEDICATION, DOSAGE, DURATION OF REGIMEN, AND ADMINISTRATION (ORAL, IV, INJECTION)
Infants with Congenital Syphilis Infants born with the signs and symptoms of Congenital Syphilis need to be treated according to the National Guidelines DESCRIBE THE MEDICATION, DOSAGE, DURATION OF REGIMEN, AND ADMINISTRATION (ORAL, IV, INJECTION) DESCRIBE THE ALTERNATIVE MEDICATION, DOSAGE, DURATION OF REGIMEN, AND ADMINISTRATION (ORAL, IV, INJECTION)
Syphilis Treatment Age Group Recommended regimen Alternative regimen Remarks Adult syphilis Adults (including pregnant women) Congenital syphilis Infants born to mothers who tested positive for syphilis Infants with signs and symptoms of congenital syphilis
Penicillin Allergy: Anaphylactic Shock All patients must be asked for a history of allergy to penicillin Clinical Features: sudden collapse, hypotension, excessive sweating, thin pulse Differential Diagnosis: other causes of shock, including bleeding and severe dehydration
Management of Anaphylactic Shock Determine and remove the cause Keep the patient warm Secure the airway Restore the BP – lay the patient flat and raise his/her feet REFER TO NATIONAL GUIDELINES FOR FURTHER INFORMATION
Management of Anaphylactic Shock REFER TO NATIONAL GUIDELINES DESCRIBE THE MEDICATION, DOSAGE, DURATION OF REGIMEN, AND ADMINISTRATION (ORAL, IV, INJECTION) DESCRIBE THE ALTERNATIVE MEDICATION, DOSAGE, DURATION OF REGIMEN, AND ADMINISTRATION (ORAL, IV, INJECTION)
Questions for Participants Have you ever had to treat anaphylactic shock? Can you describe how you identified it? How did you manage it? What was the outcome? In your experience, how do people react to hearing that they have syphilis?
Integration of Services Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives At the end of this module, participants should be able to: 1.Describe the current patient flow at their clinic 2.Describe when and where rapid syphilis testing would take place 3.Provide three examples of how syphilis testing could be integrated with other services
Integration Rapid syphilis testing will be introduced to facilities already offering several testing services Integrating services can reduce the work load of HCW and make it easier to perform multiple tests Other rapid testing services are ideal for RST integration
Integration & Patient Flow Patient Flow describe how patients move throughout the facility to receive services Each Facility will have it's own unique patient flow Integration of services will differ at each facility according to its patient flow
ANC Clinic: Patient Flow Patient flow at an ANC clinic offering HIV rapid testing services and no syphilis testing services
ANC Clinic: Patient Flow Patient flow at an ANC clinic offering HIV and syphilis rapid testing services without integration
ANC Patient Flow: Integrated Approach Patient flow at an ANC clinic offering integrated HIV rapid testing services and syphilis testing services
Possibilities for Service Integration HIV PMTCT HIV PICT or VCT Rapid Malaria Testing Hb Testing Other diagnostic tests requiring a finger-prick of blood draw
Integrated Patient Flow DESCRIBE WHAT INTEGRATION OF SERVICES WILL OCCUR IN YOUR PROGRAMME DESCRIBE HOW SERVICES WILL BE INTEGRATED IN YOUR PROGRAMME
Integrated Patient Flow CREATE A DIAGRAM SHOWING PATIENT FLOW FOR THE SERVICES THAT WILL BE INTEGRATED WITH RAPID SYPHILIS TESTING THIS SHOULD BE DONE IN THE SAME STYLE AS ABOVE THE DIAGRAM SHOULD HIGHLIGHT WHERE INTEGRATION IS GOING TO OCCUR IN THE CLINIC INSERT DIAGRAM ON THIS SLIDE
Health Care Worker Responsibilities Continue to provide clients/ patients with a high degree of care Continue to follow the SOPs for each test procedure Continue to provide clients/ patients with
Possible Challenges Mixing up tests (forgetting which is which during testing) Mixing up buffer reagents Incorrect entering of results in register Timing
Solutions Be well prepared for testing Have each SOP present on the testing bench If the test cassettes have a similar appearance, label them (ex. "HIV" and "syph") Keep the buffer reagents next to the test kit during test Have the register near the testing bench and carefully transfer results Prepare both tests simultaneously and start the timer when the buffer reagent is added to the first test
Questions for Participants What services does your facility currently integrate? What opportunities are there for further integration? In your experience, has integrating services been beneficial for the health care provider? For the client/ patient? Why?
Safety at the Testing Site Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Define safety 2.Identify potential hazards associated with rapid syphilis testing 3.Describe how to dispose of biohazardous materials 4.Describe the safety precautions which need to be observed when testing for syphilis
Performance Objectives By the end of this module, participants will be able to: 1.Adhere to personal health and safety practices 2.Maintain a clean and organized workspace 3.Disinfect and dispose of infectious materials 4.Take appropriate actions following accidental exposure to potentially infectious specimen 5.Follow written safety procedures and keep proper safety records
What Is Safety? Safety is the state of being safe and protected from danger, harm, or infection
Why Is Safety Important? Coming in contact with human blood or blood products is potentially hazardous Safety involves taking precautions to protect yourself and the client against infection All specimens should be treated as potentially hazardous
What Else Needs Protection? Other people who may come in contact with testing by-products The testing materials The environment (from hazardous material)
Universal Precautions Every specimen should be treated as though it is infectious
Apply Safety Practices Throughout the Testing Process Before Testing (Pre-analytical) – Specimen collection – Specimen preparation – Specimen transport Testing (Analytical) – Testing After Testing (Post-analytical) – Disposal
Develop Personal Safe Work Habits Wash hands before and after testing specimens Wear a fresh pair of gloves at a lab coat or apron Dispose of contaminated sharps and waste immediately after use
Develop Personal Safe Work Habits Pipetting by mouth is strictly forbidden Never eat, drink or smoke at the test Do not keep food in the laboratory refrigerator Do not leak anything in the lab (ex. pen, pencil)
Maintain Clean & Orderly Work Space Keep work areas clean and organized Disinfectant work surfaces daily Restrict or limit access to test area when working Keep supplies locked in a safe and secure area Keep emergency eye wash units in working order and within expiry date
Take Precautions to Avoid Needle Stick Injury What can cause needle stick injury? Lack of concentration Inexperience Lack of concern for others Improper disposal of sharps
Dispose of Used Sharps in Special Containers Sharps
Do's and Don't of Waste Disposal DO NOT: break, bend, re-sheath or re-use lancets, syringes or needles DO NOT: shake sharps containers to create space
Do's and Don'ts: Sharps and Waste Containers 101 What's wrong with this picture?
Never Place Needles or Sharps in Office Waste Containers 102
Sharps Containers Must Be 103 Placed near workspace Closed when not in use Sealed when ¾ full
Do's and Don't of Waste Disposal DO NOT EVER place needles or sharps in office waste containers DO: place sharps containers near workspace DO: close sharps containers when not in use DO: seal sharps containers when ¾ full
Policy for Handling Sharps The user is responsible for disposal of sharps Must dispose of sharps after each use Must place sharps in sharps containers Do not drop sharps on the floor or in the office waste bin Place sharps container near your workspace Seal and remove when container is ¾ full Dispose of all waste appropriately
Incineration of Waste Incineration is burning of contaminated waste to destroy and kill micro-organisms Incineration is: – Effective against potential re-use – Protects the environment and nearby communities – Must be supervised
Disinfect Work Areas Use an approved disinfectant (ex. JIK) Disinfectant: – Kills germs and pathogens – Keeps work surface clean – Prevents cross-contamination – Reduces risks of infection
In Case of a Spill or Splash Wear clean disposable gloves Immediately and thoroughly wash any skin splashed with blood Large spills: Cover with paper towels and soak with 0.5% Jik and allow to stand for at least 5 minutes Small spill: Wipe with paper towel soaked in 0.5% Jik Discard contaminated towels in infectious waste containers
In Case of an Accident What types of accidents can happen? – Potential Injury (needle sticks, falls) – Environmental (splashes, spills) – Equipment damage What should you do? – Report to your supervisor immediately Assess and take action – Record using form Monitor situation
Action Plan for Implementing Safety Practices Identify hazards Establish and implement safety policies and procedures Conduct safety specific training – Must be a priority – Communication is key Perform regular audits or assessments
Safety Documentation Full safety requirements for testing blood/ serum specimens are very detailed Any site performing testing should have a complete set of country guidelines Every staff member should read and understand the safety manual before being allowed to work Everyone is responsible for personal safety and the safety of their co-workers All procedures should be posted or visible in the workspace
Questions for Participants What is safety and why is it important? What is the universal precaution you must take when dealing with specimens? Is this something that you observe at your job? What safety procedures do you have in place at your clinic or laboratory? Have you ever encountered a spill? How did you manage it?
Preparation for Testing Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.List and identify all the supplies required to perform rapid syphilis testing 1.List and identify all the components of a test kit for rapid syphilis testing
Guidelines For The Use of RSTs Do NOT: Use kits beyond the expiry date Use damaged kits, materials or supplies Re-use tests, materials or supplies Expose kits to direct sunlight Mix lot numbers Use Reagents from one kit with those of another
Guidelines For The Use of RDTs Do: Use old kits first Use a test immediately once opened
Preparing for Testing Before performing a syphilis test, staff should review the following checklist: Do you know what test you are going to perform? Are all supplies and materials needed to perform the test arranged on your workspace? Have you read the SOP? Have you counter-checked the sample against the working list?
Checklist of Materials and Supplies
Gloves Single use disposable gloves Latex or polypropylene Without evidence of holes or tearing 120
Alcohol Swabs 121
Cotton Gauze or Cotton Balls 122 Single-use, hazardous waste disposal
Sterile Lancets 123 Single-use, hazardous waste disposal
Pipette Transfer Pipette 124 Automatic Pipette
Timer 125
Standard Operating Procedures and forms. 126
Labeling Pens & Writing Pens Labeling Pens (Markers) 127 Writing Pens
Sharps container / Disinfectant Jar 128
Proper Disposal of Contaminated Materials 129
Waste Disposal 130
Jik and Container or Spray Bottle 131
Examine Test Kits Display test kits used in-country Examine the different components found in each of the Rapid Test kits, for example – Desiccant packet – This is not used when performing the test. It only serves to keep the packet contents dry before use. It should be discarded when the test kit packet is opened. – Buffer solution – Required by some kits 132
Organize Your Work Area 133
Questions for Participants What is each of these items used for: – Gloves – Alcohol swabs – Cotton balls or gauze – Sterile lancets – Pipette – Timer – Standard operating procedures – Marking pens – Sharps disposal bins – Disinfectant jar – Jik 134
Questions for Participants 135 List the components of a Rapid Syphilis Test Kit:
Orientation to Rapid Syphilis Testing Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives At the end of this module, participants should be able to: 1.Describe how to perform a finger prick 2.Describe how to perform a rapid syphilis test 3.Interpret the result of a rapid syphilis test
Performing a Finger-Prick ENTER THE STEPS FROM THE PROGRAM- SPECIFIC SOP FOR PERFORMING A FINGER PRICK
Performing a Finger-Prick INSERT THE STEPS FROM THE PROGRAM- SPECIFIC SOP FOR PERFORMING A FINGER PRICK
Rapid Syphilis Testing INSERT THE STEPS FROM THE PROGRAM- SPECIFIC SOP FOR PERFORMING A RAPID SYPHILIS TESTING
Rapid Syphilis Testing INSERT THE STEPS FROM THE PROGRAM- SPECIFIC SOP FOR PERFORMING A RAPID SYPHILIS TESTING
Rapid Syphilis Testing INSERT THE STEPS FROM THE PROGRAM- SPECIFIC SOP FOR PERFORMING A RAPID SYPHILIS TESTING
Rapid Syphilis Testing INSERT THE STEPS FROM THE PROGRAM- SPECIFIC SOP FOR PERFORMING A RAPID SYPHILIS TESTING
Interpreting the Results INSERT THE INFORMATION FROM THE SOP ON HOW TO INTERPRET THE RESULTS OF A RAPID SYPHILIS TEST (POSITIVE, NEGATIVE, INVALID) DETAIL WHEN TO REPEAT THE TEST (INVALID RESULT ONLY)
Documents and Records Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Tell the difference between a document and a record 2.Explain the rationale for maintaining documents and records 3.Provide examples of documents and records kept at the test site 4.Describe how to properly keep and maintain test site documents and records
What are Documents and Records? Documents WRITTEN policies, process descriptions, procedures, and blank forms Used to communicate information 147 Records Information captured on worksheets, forms, charts and computer databases RECORDS
Documents Are the Backbone of the Quality System Verbal instructions are often: Not heard Misunderstood/ Misinterpreted Quickly forgotten Ignored Policies, standards, processes, and procedures must be written down, approved, and communicated to all concerned.
Record-Keeping Proper record-keeping makes quality management possible Record-keeping allows a test site to: – Communicate accurately and effectively – Minimize error – Monitor quality system – Assist management in: Developing plans & policy Monitoring and evaluating programs – Stock management – Enhance Operational Research
On-site Records Records that should be kept on-site include: Specimen transfer logs Syphilis request/ client test result Lab/ Test register Accident records Personnel records Worksheets Temperature logs Equipment maintenance logs Inventory records Quality assessment: – Monitoring reports – Retesting reports – Corrective action
Good Record-Keeping Understand the information to be collected Record the information every time; at the right time Record all the information Record the information in the same, standard way every time
Records: Permanent, Secure, Traceable Permanent: Keep books bound Number pages Use permanent ink Control (limit) storage Secure: Maintain confidentiality Limit access Protect from environmental hazards Traceable: Date and sign every record
Should be indexed to allow for easy retrieval of data Should be stored to minimize deterioration Logbooks Are Cumulative Records of Test Site Operations
Client/ Patient Records Should be completed when the client/ patient is present Writing should be legible All records should be signed and dated by the responsible HCW Should be stored in a secure location for patient confidentiality
Retaining Records The length of time records should be stored at a facility depends on: National policies Secure storage space at a test facility
Key Messages Written policies and procedures are the backbone of the quality system Complete quality assurance records make quality management possible Keeping records facilitates meeting program reporting requirements 156
Exercise! Which of the following are documents and which are records? Country testing algorithm Safety manual Clinical test results SOPs Manufacturer test kit inserts Summary form of findings from monitoring report
Exercise! Which of the following are documents and which are records? Report of corrective actions Temperature log (blank form) Daily maintenance log (completed) Stock cards and stock book (completed) EQA specimen transfer log (completed)
Questions for Participants What are some examples of documents and records maintained at your facility? How long are records kept at your facility? Does your facility have enough secure storage space to store records? Why do you think all records should be signed and dated?
Standard Operating Procedures Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Describe the importance of an SOP 2.Describe when an SOP should be used and where it should be stored 3.Give five examples of SOPs
Standard Operating Procedure SOPs are written procedures which describe how to perform an activity SOPs should be located directly at the working place Only the current version should be present SOPs should describe how procedures work and not how they are supposed to work SOPs should be written or thoroughly reviewed by instrument's operators
Standard Operating Procedures Describe how to perform various tasks in a testing site Provide step-by-step instructions Assure: – Consistency – Accuracy – Quality – Standardization
Importance SOPs define how to carry out protocol specified activities Standardizing techniques facilitates comparison of results Essential component of a quality system
Content of SOPs Unique SOP number and version number Page number and total number of pages Objectives/ purpose of the SOP Scope Responsibility Principle Procedures/ instructions Reference
Content of SOPs Safety Storage Specimen collection Specimen storage Test requirements (pre-test) Validity of test Interpretation of results
Content of SOPs For equipment testing an SOP should contain: Performance acceptance criteria Recommended corrective actions Template for continuous entries of test results and corrective actions
Controlled Documents SOPs are controlled documents SOPs must be approved for use in-country SOPs must have document control features SOPs must be kept up-to-date
Manufacturer Product Insterts Do not rely solely on manufacturer product inserts Product inserts do not provide specific information for test sites Examples additional material include: – Materials required, but not in the kit – Materials in the kit that may not be used in some settings – Specific safety requirements – External quality control requirements
Examples of SOPs SOP: Performing a Finger Prick SOP: Performing a Rapid Syphilis Test SOP: Re-constituting Dried Tube Specimen SOP: Testing with a Dried Tube Specimen SOP: Routine Quality Control Testing SOP: Proficiency Panel Testing SOP: Monitoring
SOPs At the Test Site Daily routine schedule/ duty roster Country testing algorithm Safety manuals – Safety precautions Blood collection: – Fingerprick, venipuncture, DBS Test procedures Quality Control and Quality Assurance Procedures Internal assessments Reordering of supplies and test kits Equipment use and maintenance
SOPs Must Be Followed Why is it important to follow SOPs? What are the consequences if you don't?
Questions for Participants 1.In your setting, who writes the SOPs? 2.What is your opinion on this arrangement in your setting? 3.Peter photocopied an SOP and gave the copy to a friend who is not working in his office. Is there anything wrong here?
Supply & Stock Management Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Identify and describe the different supply management tools 2.Understand and appreciate the importance of these tools in commodity management and reporting and ordering supplies in a timely manner 3.Describe the procedures in completing the tools
Stock Keeping Records Track stock on hand Useful for determining consumption in the absence of dispensed-to-user data Track losses and adjustments Track expiry dates Useful tools for accountability problems
Physical Count Process of counting by hand the actual usable quantities of a given commodity available at a given time Recommended at the end of the report period before placing an order
Importance of Physical Count To check that recorded stock card balances match actual quantities on the shelves To verify product quality Identify any losses/adjustments To identify and correct errors in the stock card Accountability
Stock Records Track quantities of goods/ medicines/ test kits dispensed to clients or used in a given period of time Consumption information vital guide for facility re-supply quantities or needs
Stock Cards Should be completed every time a stock is consumed or moved between locations Records: – Balance at the beginning of the day – Quantity consumed, moved or added (if delivery was received) – Balance at the end of the day Stock cards should be signed and dated by the HCW responsible for stock management
Types of Consumption Data Dispensed-to-user data: – Information about the quantity of goods actually put in the hands of end users Issues data: – Information about the quantity of goods moved from one level of the system to another – eg. Store room to facility or pharmacy
How to Order On-time – According to local schedule Sufficient quantity – The quantity of any supply will depend on how often deliveries are received, the turnaround time, and the quantity consumed during one month Correct forms – It is important to submit requisitions for equipment and supplies using national forms and to keep a record at the facility *Turnaround time is how long it takes for an order to be received from the time the request is submitted
Order Quantity Order a sufficient quantity of supplies to cover the period until the next order plus a buffer stock Buffer stock – Quantity of a supply, in addition to that needed for routine patient flow, to prevent stock outs – Should reflect the maximum turnaround time – Does not need to be replaced every month
Example! Schedule: Every 3 months Maximum turnaround time: 2 weeks Remaining buffer stock: 1 week Monthly consumption: 100 tests (25/ week) What quantity of tests should be ordered?
Answer! Facility Consumption= (tests consumed/ month) x (number of months until next order) Buffer Stock= (tests consumed/ week) x (maximum turnaround time) – (remaining buffer stock) Order Quantity = Facility Consumption + Buffer Stock
Answer! Facility Consumption: (100 tests/ month) x (3 monthly ordering schedule) = 300 tests Buffer Stock: (25 tests/ week) x (2 weeks – 1 week) = 25 tests Order quantity: 300 tests + 25 tests = 325 tests
Receiving Supplies When receiving supplies it is important to: Record the date of delivery and quantity of supplies delivery – The record should be signed by the individuals who received and delivered the supplies Check the supplies for damage Store supplies off the floor in the storage room Update the stock card with the quantity of supplies delivered
Storage Room A storage room should have: A lock – To prevent theft A window – For ventilation A window cover – To prevent rain from entering the room Shelving – All supplies should be stored off the floor A thermometer – To monitor temperature Stock cards – All stock cards should be kept with the item
Questions for Participants How often does your facility order supplies? How much buffer stock does your facility maintain? What is the maximum turnaround time at your facility? How much buffer stock should your facility maintain given the maximum turnaround time?
Monitoring & Evaluation Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Define "monitoring" and describe its purpose 2.Define "evaluation" and describe its purpose 3.Describe the key differences between monitoring and evaluation 4.Describe the roles of a HCW and supervisor/ monitor during a monitoring visit
Monitoring Ongoing, routine activity Purpose: – Observe progress – Identify challenges – Come up with local solutions – Provide support to health care facility staff
What to Monitor Personnel & Training Biosafety Facility Documents and Records Quality System Stock and Supply Chain Management
Personnel & Training Every individual responsible for performing rapid syphilis testing should: – Have a certificate or evidence of training at the facility – Be able to describe the goals of the program and quality system
Biosafety Every facility offering rapid syphilis testing services should have in the testing area: – A sharps disposal bin – A lined biohazard waste disposal bin – A protocol for disposal/ incineration of facility waste
Biosafety All staff involved in the testing process should: – Be wearing closed toe shoes – Be wearing scrubs or an apron – Have his/ her hair tied back – Have access to soap and water for hand washing – Have access to gloves
Facility Every facility offering rapid syphilis testing services should have: – A table, counter or lab bench with adequate space for performing testing – Windows or electrical lighting to light the testing area – Access to water – Ability to communicate with referral centers (personal cell phone, facility cell phone, landline, / internet, two-way radio)
Documents & Records Every facility offering rapid syphilis testing services should: – Have a patient or testing register (or both) to record test result and treatment outcome – Store the patient or testing register (or both) in the testing area – Record if partners were treated – Regularly update the register(s) and sign next to test results – Ensure the register (s) are organized and the writing is legible
Quality System Every facility offering rapid syphilis testing should: – Have a dedicated folder for quality system records and SOPs – Have an up-to-date record of proficiency panel testing and routine quality testing results – Document all actions taken in the event of a out-of- specification result (Routine Quality Testing) – Have documentation of the results of the proficiency panel testing and any corrective actions taken – Have quality records signed by a facility in-charge or supervisor
Stock & Supply Chain Management Every facility offering rapid syphilis testing should have: – Locked store room/ cupboard – Complete and up-to-date stock cards for all testing materials – Requisition and delivery records stored in a bound folder – A schedule/ knowledge of order frequency – Knowledge of facility's buffer stock – Current stock of essential supplies for RST
How to Monitor Routinely – Bi-weekly, monthly, quarterly By trained monitor or trained supervisor Using a program specific checklist and interviews with facility staff
How Often to Monitor More intensive after initial test introduction Decreased frequency after 3 months In-line with national and district supervisory visits Depends on available resources and accessibility of facilities
Responsibilities of Facility Staff To record client/ patient information in the national register To record syphilis test result, treatment and partner treatment (if any) in the client/ patient or syphilis testing register To maintain daily stock card and complete requisition and delivery supply records To perform routine quality control testing/ proficiency panel testing as per program guidelines and record results appropriately
Responsibilities of Monitor To routinely visit health care facilities To conduct a monitoring visit in a professional manner, using the checklist as a guide To interview facility staff (experiences with test, supply chain, quality system) To identify any potential barriers/ challenges to testing based on the results of the visit and interviews To work with facility staff to come up with workable solutions to the challenges To provide facility staff with support throughout program implementation
Evaluation Summative process Takes place at the end of a program Purpose is to summarize program project towards meeting objectives and achieving goals Reflects on overall success or failure of a program Does not generate problem solving initiatives
Questions for Participants What support have you received from supervisors or monitors in the past? How has this been helpful? How often is monitoring/ supervising carried out in your district/ region? What is the current role of the HCW and supervisor during the visits?
Quality Control Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning objectives By the end of this module, participants should be able to Define Quality Control Describe trouble shooting List the benefits of QC in rapid testing Differentiate between internal Quality Control and External quality control Describe the process of maintaining QC records 2
What is Quality Control (QC)? Comprises those measures that must be included during each test run to verify that the test is working properly. These are activities performed to detect and correct errors that may occur during testing If an error occurs, do not release or report results until you have corrected the error. 211
Quality Control Internal Control: Included in the testing device or as part of the kit To determine if adequate quantity of specimen has been added to the well 212 External Control: Not included in the test device or kit Specimens labeled with expected result are used to validate the reliability of the test cassette CT S Control Band
External Quality Control Involve the use of known positive and negative or control materials These may be purchased from a manufacturer or made locally ( usually by reference lab) These positive and negative specimens are used to evaluate the accuracy of the test cassette Usually tested periodically in order to ensure the kits are accurately detecting treponemal antibodies 213
External Quality Control Samples Manufactured at Central Laboratory or/ purchased from commercial retailers Store according to SOP or local instructions Record date when opened Use before expiry date Do not contaminate Quality Control Samples are potentially infectious and should be treated with appropriate safety precautions and disposed as biohazardous waste 214
Sources of External Quality Control Samples Store according to instructions Record date when opened Use before expiry date Do not contaminate 215 Commercially prepared Prepared by Reference Laboratory
Frequency of Use: When Should You Test External Control Samples? Once a week, beginning of the week New shipment of test kits Beginning a new lot number of test kits When environmental conditions exceed range needed for stability of kits 216
Invalid Results – What Do You Do? Repeat test using a new test cassette from same kit Repeat test using new test cassette from a new test kit Repeat test using a new test cassette and a new control sample 217
Invalid Results – What Do You Do? If repeatedly invalid: assume problem with test kit or procedure Inform supervisor Take corrective actions Document testing, invalid result, any repeat testing or corrective action taken, sign and date record, have supervisor sign record 218
Troubleshooting Invalid Results 219 No control line or band present ProblemPotential CauseAction Damaged test device or controls Repeat the test using new device and blood sample Proper procedure not followed Expired or improperly stored test kits or controls Check expiration date of kits or controls. Do not use beyond stated expiration date Check temperature records for storage and testing area Follow each step of testing according to SOP Re-check buffer and/or specimen volumes Wait for the specified time before reading the test
Troubleshooting Invalid Results – Cont'd 220 Positive reaction with negative external control, i.e. false positive ProblemPotential CauseAction Incubation time exceeded recommended time (SOP) Re-test negative control using a new device and read results within specified time limit Extremely faint control line The control line can vary in intensity No action required. Any visible line validates the results.
Exercise #1: Interpreting Syphilis Rapid Test Results Refer to the handout in your participant manual Read the test results and write your interpretation in the space provided. Time: 2 minutes 221
Quality Control Records Testing Sites Information should include: – A standard worksheet that includes spaces for recording QC results – A separate register for QC results to which Information will be transferred from the worksheet. – A flow chart for Corrective action showing steps followed when the QC results do not read as expected and how to refer problems back to the reference laboratory. – The qualified Officer should regularly review all QC data with responsibility for testing site. 222
Maintaining Quality Control Records 223 WHY? Trouble-shooting Part of routine inventory – proof of reliable test results HOW? Use standard worksheets WHEN? Each time QC materials are tested Record all invalid results and inform supervisor
Quality Control Record: An Example 224
Periodic Review of Records Review of internal control results before accepting test results Review of external control results by test performer Weekly or monthly review of external quality control results by testing site supervisor Periodic audits or assessments 225
Questions for Participants What would you do if your external control tested invalid. Give examples of problems encountered with QC results, how they occurred and how to correct them Why is it important to maintain records of QC results 226
External Quality Assurance & Dried Tube Specimens Rapid Syphilis Testing: Workshop for the Training of HCW [Enter date, location of workshop]
Learning Objectives By the end of this module, participants should be able to: 1.Describe the benefit of DTS 2.Describe the purpose of Routine Quality Control Testing and Proficiency Panel Testing, and the differences between the two procedures 3.Correctly complete all forms required by the quality system
Dried Tube Specimens Dried Tube Specimens (DTS) are vials containing dried out plasma samples Specimens can be syphilis positive or negative, HIV positive or negative, or any combination of syphilis and HIV positive or negative Can be transported and stored at room temperature
Preparation of DTS Manufactured by central laboratory Use syphilis (or HIV) confirmed positive and negative plasma samples Blue dye is added to sample 20ul of sample with dye is distributed into the vial Vial is left under biosafety hood for 24 hours to dry
Preparation of DTS Once dry, vials are labeled, capped, and frozen for long-term storage Vials can be distributed to facilities as part of quality system For transport and short-term storage (2 weeks), DTS can be stored at room temperature
How to Use DTS First need to Re-Constitute: Gently tap the tube to ensure colored pellet is at the bottom of the tube Add buffer using pasteur pipette Cover the tube (close cap) and tap gently to mix Leave overnight at room temperature
How to Use DTS The next day: Mix the specimen by gently tapping the tube The specimen can be now be used for testing Follow the SOP for Performing Rapid Syphilis Testing Record results using appropriate forms
Caution! Gloves and appropriate bio-safety precautions should be taken when handling DTS (re- constitution and testing) The specimen should be treated as potentially infectious
DTS and Quality Systems DTS is a valuable tool in quality systems It can be used for routine quality testing, proficiency panel testing or incoming inspections of test kits DTS can be sent to peripheral labs and facilities because it can be stored at room temperature
Routine Quality Control Uses DTS which are labeled either positive or negative The label also contains lot number and expiry date Vials are called 'known' because the expected test result is know (written on label) before the test is performed
Routine Quality Control: Purpose Purpose: to assess the ability of the test cassette to correctly identify positive and negative samples – Answer the question "Is the test working?" Ensure tests were not damaged during transport to the facility or during storage at the facility
Routine Quality Control: Results If the known positive gives a positive result and the known negative DTS gives a negative result, the tests are said to be "in specification" If the known positive DTS gives a negative result or the known negative DTS gives a positive result, the tests are said to be "out of specification"
Routine Quality Testing: Results The lot number, expiry date, expected result and actual results should be recorded on the appropriate form along with the date, and name of tester and signature of tester If the result is out of specification, the tester should follow the corrective actions steps to determine the problem The actions should be recorded an signed off by a facility supervisor/ in-charge
Corrective Actions If there is an out of specification result, it may be because the test was invalid, the test kit was damaged or the DTS sample was damaged during transport and storage To determine if the problem was with the test cassette, repeat quality testing using a new test cassette from the same test kit
Corrective Actions If the test result is still out of specification, repeat the test using a new test cassette from a different test kit If the test result is still out of specification, re-constitute a new vial of DTS and repeat using a test from the first kit If the test result is still out of specification, do not use either test kit in the clinic and contact the monitor/ supervisor for further instructions If the test result is in specification, this means the problem was with the vial of DTS and not the tests, continue using the tests in the clinic
Routine Quality Testing: Frequency May be performed every week, every two weeks, every month, or for every new kit Frequency will depend on the volume of patients being testing and the rate of test consumption at a facility
Proficiency Panel Testing Also uses DTS DTS labels contain an identification code and expiry date but not the expected test result Purpose: to determine if the facility/laboratory staff member is correctly performing and interpreting the results of a rapid syphilis test
Proficiency Panel May contain up to six DTS May include strong and weak positive samples and negative samples DTS are reconstituted a day before testing Tests should be performed and interpreted according to the SOP
Proficiency Panel: Documentation Date of testing, DTS identification code and expiry date, test result, name of tester and signature of tester are recorded on the correct form Results are submitted to central laboratory Monitor will provide facility with written copy of results and overall score Any corrective actions will be documented in the facility's quality systems folder
Who Should Perform the Proficiency Panel? Should be performed by all facility staff who perform rapid syphilis testing as part of routine care Each person should conduct testing using the panel independently and should not share result The panel is to identify individuals in need of support and is intended as a tool to improve the quality of testing services for the benefit of the client/ patient
Proficiency Panel: Results Facility score can identify individuals or groups of individuals having trouble performing the test or interpreting results Highlights where monitor should focus attention Can be used to identify when and where on-the- job retraining or large re-fresher training workshops are required
Questions for Participants What question is proficiency panel testing trying to answer? What are the key differences between routine quality testing and proficiency panel testing? Do any other programs at your facility have a quality system in place?
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buy Korlym online, order korlym online,
Korlym is an oral tablet containing generic Mifepristone as a crucial component. It is used the termination of pregnancy and this medication shows its effect by blocking the action of a hormone called progesterone.
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The Centre for Wildlife Ecology is a collaboration between Simon Fraser University and Environment Canada. Its mission is:
- to foster high quality, graduate training and research
- to conduct basic and applied research in wildlife ecology
- to provide knowledge and personnel that will help Environment Canada and other agencies meet the challenges of conservation in the 21st century.
NEWS from the CWE
The federal government is proposing to designate the waters around the Scott Islands, a vital haven for seabirds off the northwest tip of Vancouver Island, as a marine national wildlife area. The CWE's long-term research on Cassin's and Rhinoceros Auklets on Triangle Island was instrumental in this recommendation.
CWE PhD student Simon Valdez-Juarez's brilliant photo of a hovering Yellow Warbler netted third prize in "Science Exposed", the national photo competition sponsored by NSERC. In the time between its banding and being captured on camera the tiny, nine gram bird migrated from Canada to Mexico four times!
Collaborative research between the CWE and Environment Canada on the use of biofilm for fuel during shorebird migration is featured in an article in the Vancouver Sun. EC warns that the planned expansion of the Port of Vancouver at Roberts Bank poses "a risk of significant adverse environmental effects" to migratory shorbirds.
Should I stay or should I go? A new paper in the Journal of Field Ornithology by CWE PhD student Eveling Tavera and Dov Lank investigates how migration distance influences whether juvenile Semi-palmated Sandpipers fly to the breeding grounds or hang out on the beaches of Peru during their first summer.


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Programming 3D Applications with HTML5 and WebGL 3D Animation and Visualization for Web Pages
Programming 3D Applications with HTML5 and WebGL: 3D Animation and Visualization for Web Pages By Tony Parisi
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Create high-performance, visually stunning 3D applications for the Web, using HTML5 and related technologies such as CSS3 and WebGL梩he emerging web graphics standard. With this book, you抣l learn how to use the tools, frameworks, and libraries for building 3D models and animations, mind-blowing visual effects, and advanced user interaction in both desktop and mobile browsers.
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Magnetic separation in microfluidic systems using microfabricated electromagnets - Experiments and simulations
- Affiliations:
1 Department of Micro- and Nanotechnology, Technical University of Denmark
2 Center for Individual Nanoparticle Functionality, Center, Technical University of Denmark
3 Experimental Surface and Nanomaterials Physics, Department of Physics, Technical University of Denmark
4 Department of Physics, Technical University of Denmark
- 10.1016/j.jmmm.2005.01.079
- Abstract:
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- Type:
- Conference paper
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- English
- Published in:
- Journal of Magnetism and Magnetic Materials, 2005, Vol 293, Issue 1, p. 597-604
- Keywords:
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- 2005
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AWEA statement on renewable energy amendments to the transportation bill
March 13, 2012
WASHINGTON— American Wind Energy Association CEO Denise Bode released the following statement today in response to U.S. Senate votes on amendments to the transportation bill that would have impacted the wind production tax credit as well as a number of other renewable energy-related incentives.
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Fostoria Glass
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Hotfrog Singapore provides information regarding The Kingsford Waterbay in Singapore. The Kingsford Waterbay is located at 52 Upper Serangoon View, Singapore Singapore 188671 and provides kingsford waterbay services. Contact them on 6100 4191 or by visiting them on their website http://www.the-kingsford-waterbay.com.
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10 Anson Road #01-12 International Plaza Singapore 079903
160 Paya Lebar Road #05-05/06 Orion @ Paya Lebar Singapore 409022
3 Coleman Street, Peninsula Shopping Centre Singapore 179804
20 Hillview Terrace Singapore 669231
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Protecting yourself from the sun and eating right can help prevent wrinkles, but nothing can stop Mother Nature from smooshing your face together while you sleep. Reverse her wrinkly wrath with today's Groupon: for $49, you get a dermaplaning facial and skincare evaluation at Orange County Plastic Surgery in Rancho Santa Margarita ($130 Value).
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CoupFlip is a marketplace for people to buy and sell deals from "daily deal" (also known as "group buying") sites such as Groupon. On CoupFlip you can buy deals you missed, look for interesting deals in your area, or sell any deal you bought and won't use. The purchase is immediate - pick the deal, pay, download the voucher instantly and enjoy. Every voucher is guaranteed to be authentic by CoupFlip. For sellers, we provide the opportunity to sell your unwanted deal immediately without the hassle of listing your voucher and praying someone comes along and decides they feel like buying it.
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Product DescriptionLinea Catania sofa range mink. Part of the Linea collection, which is exclusive to House of Fraser. The Catania range is upholstered in corrected leather. This range offers twin power recliners in both the 2.5 and 2 seater sofas, with a power recliner chair. The recliner is operated by push button control. Adjustable headrests can be re-positioned manually. Includes fully padded outside arms and outside backs for additional comfort.
- Leather
- Foam fibre wrap filling
- Zig zag springs suspension
- Clean with soft damp cloth
Care Instructions
- Care Instructions: Clean with soft damp cloth
Furniture delivery, Monday to Saturday between 7am and 7pm - £30.
FREE delivery available on all furniture orders over £1500.
Once you've placed your order online or in store, you'll receive a text message, phone call or e-mail inviting you to make a booking for your delivery slot. You'll be offered a selection of delivery dates to choose from. To book a slot, you'll require your order number and postcode. We deliver 6 days a week between 7am - 7pm.
Once your delivery date is confirmed, you'll receive confirmation via text message/email.
For full details of our delivery process and restrictions, please refer to the Furniture Delivery FAQ's page.
Our refund policy does not apply to furniture orders made on our website and you may only return furniture if you wish to cancel your contract with us - please see Cancellations for more details.
- Collect in store
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- UK & Ireland delivery
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EB Newsletters: More Info and Subscribe here
Started by Freckles , Jan 15 2009 07:29 AM
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Posted 15 January 2009 - 07:29 AM
EB produces a range of newsletters, all written by experts and full of advice. You can subscribe to receive them free by email.
Newletters you can choose from:
- Weekly Guide to Pregnancy (delivered weekly)
- Guide to Baby's First 12 Months (delivered monthly)
- Toddler Guide : Baby's 2nd Year (delivered quarterly)
If you are interested go to the link here to subscribe.
NB: If you have any problems receiving or unsubscribing from these newsletters please contact email@example.com
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Mum shares hilarious story about attempting shower sex
As most parents know, finding time for sex post-kids is one of life's not-so-little challenges.
16 things you'll learn on the preschool party circuit
Kids birthday parties sound fun in the abstract but the reality is they often end up an introverts worst nightmare – forced social interaction in the name of good parenting.
The 92-year-old who's a great-great-great-grandmother
A 92-year-old Canadian woman has become a great-great-great grandmother this week after the family welcomed a baby boy.
The Pramrolla mimics a walk in the park to help your baby get to sleep
Simply put the pram brake on, set the wheels on top of the Pramrolla, plug it in and off they go ... or so they think.
Beyonce shares surreal pregnancy photo shoot
Pop superstar Beyonce on Thursday released a slew of photos of herself posing pregnant and nude.
Airport staff order mum to squeeze her breasts to prove she's lactating
A Singaporean mum of two has spoken about her humiliation at the hands of German airport security guards who ordered her to prove she could breastfeed.
How to keep your baby or toddler safe at home
Child-proofing tips that will ensure your home remains a safe haven for curious toddlers and babies on the move.
Told to get rid of their dogs, this expectant couple took the sweetest photos instead
When the couple conceived their first human child they came under enormous pressure to give up their dogs.
Bereaved parents take baby home for 'family time' after death, thanks to cuddle cot
A bereaved mother has spoken about her decision to take her daughter's body home to spend time as a family before her funeral.
'Get off your phone!': the daycare note that's got people talking
A note posted by a US daycare facility has urged parents to get off their phone when collecting their children:
Babysitter's creative 'hands-free' baby carrier hack
We've all been there – you need to hold the baby, but you also need to eat.
Will these be the most on-trend baby names of 2017?
Nameberry has crunched the numbers, predicting which monikers will see a rise in 2017.
Firefighter adopts the baby he helped deliver
Five years ago firefighter Marc Hadden took an emergency call that changed his life.
Mum shares graphic image to highlight importance of rear-facing car seats for kids
A British safety blogger has shared a graphic photo of the damage a seatbelt can do in a car accident in a bid to persuade more parents to use rear-facing car seats for as long as possible with their kids.
Pharrell Williams and his wife welcome triplets
Now that's a good way to start the new year.
Turn yourself into a child's climbing gym with this wearable vest
It's such a neat idea for those living in high density apartment blocks where children may struggle to get enough physical activity.
Bugaboo unveils its new Bugaboo Bee5
The lightweight and compact Bugaboo Bee has been on the scene for a decade now.
The first few weeks of pregnancy: surreal, scary, exciting
It is okay to be worried, nervous, anxious, in love and happy all at the same time.
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Essential Baby & Toddler Show, presented by Blackmores
3-5 March 2017, Brisbane Convention & Exhibition Centre. Get your FREE ticket now. Save $20.
Your child's fine motor skills: what you should know
There is less of a focus on fine motor skills, but they're just as important as others. (SPONSORED)
5 ways music helps your toddler's development
There are at least five other compelling reasons to get musical around your toddler. (SPONSORED)
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With Instructables you can share what you make with the world, and tap into an ever-growing community of creative experts.
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Woodworking clamps
DIY Table Saw Sledge / Sled with Flip Stop Guide
Build a Woodworker's Toolbox
Make a Wooden Soma Cube
Join 2 million + to receive instant DIY inspiration in your inbox.
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Is Agnel Packaging incorrect or missing key business information? Update your Hotfrog listing today.
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Is Agnel Packaging in B-2003, RNA Royale Park, MG Road Kandivali W Mumbai, Maharashtra Maharashtra 400067 your business? Claim your listing and attract more leads by adding more content, photos and other business details.
We have more Packaging services in Maharashtra available on Hotfrog INDIA. You can update your search for Maharashtra Packaging by location, keyword or service options.
131, Kakad Industrial Estate Off, L J Cross Road No 3 Mahim Mumbai Maharashtra 400 016
Ambernath E Maharashtra 411 506
Unit, No1, 2, 3 & 4, 2nd Floor, Sachin Industrial Estate, Kolbad, Rd Kolbad Maharashtra 400 601
6, Godavari Bldg, Laxmi Industrial Estate, Vartka Nagar Thane -West Maharashtra 400606
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German Bundesliga Standings
Bundesliga News
Serge Gnabry nets a brace as Bremen beat struggling Wolfsburg
Serge Gnabry scored a first-half brace as Werder Bremen climbed out of the relegation playoff spot with a 2-1 Bundesliga victory against Wolfsburg.
Wolfsburg 1-2 Werder Bremen
Bremen's away win over Wolfsburg earned an important three points amid the relegation battle.
Dortmund's Dembele so far living up to the lofty comparisons
19-year-old Ousmane Dembele has been compared to stars like Cristiano Ronaldo and so far the BVB youngster has done nothing but validate that hype.
Dortmund need Aubameyang in top form
Thomas Tuchel says Dortmund will not achieve their goals this season without Aubameyang in top form.
Bayern Munich winger Franck Ribery on bench vs. Hamburg - Ancelotti
Ribery, 33, has not featured since suffering a strained muscle in his right thigh during training on Jan. 31.
Bayern Munich v Hamburg SV: Preview


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The Little People Disney Princess Songs Palace gives preschoolers a place to play with all their favorite Disney Princesses. The castle comes with Little People versions of Cinderella and Snow White. Place your figures in various areas in the castle to hear the princesses introduce themselves, sing songs, and say other phrases. A fanfare plays every time the front doors open. Push down on the tea kettle in the kitchen for whistling sounds. The castle has seven different play areas, a working elevator, a spinning dance floor, a dining table with two chairs, and a bed. The Little People Disney Princess Songs Palace recognizes all the Little People Disney Princess figures, but the other princess figures are sold separately.
With the Little People Disney Princess Songs Palace, preschoolers can recreate scenes from the Disney movies or make up brand new stories for the princess characters. We love seeing familiar Disney Princesses as Little People figures. These are really cute and will engage preschoolers in lots of imaginative play.
The Little People Disney Princess Songs Palace is for ages 1.5–5.
Three AAA batteries are required but not included.
Adult assembly is required. It took us about 20 minutes to put together. You will need a screwdriver.
3 AAA batteries required
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Composed of totally wood fiber, the double-ground natural mulch offered by Mulch Direct is one of the mulch types that offer excellent nutrition retention for your soil. This type of mulch we offer greatly benefits your cultivation, event more than grass because the double-ground natural mulch decomposes into the soil at a fast rate. Thereby, it holds the ground water with more strength and that is how, nutrition is retained for you soil.
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As the name says it all, the triple shred root blend mulch is made from the roots of plants that
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text: Name: Forever Smooth Electrolysis. Descripton:Are you looking for an alternative to laser hair removal? Not getting the results you thought you would? Hair or skin color not quite optimal for Laser?Electrolysis is the only 100% Permanent hair removal method in existence and has been since Dr. Charles Michel, a St. Louis ophthalmologist, devised this system in 1875. By the way, It's improved a lot since then! Electrolysis is the only approved method of permanent hair removal according to the FDA. Some lasers, but not all, are cleared to advertise "long lasting" hair reduction, but never permanent hair removal. If they do it's false advertising! Electrolysis is safe for all skin and hair types. Even if your skin is very dark and sensitive or very light and sensitive. No matter if you have grey, light, blonde, black, dark or red hair. This treatment will permanently and effectively remove your unwanted hair. Electrolysis can be performed on any part of the body. Including the area surrounding the eye, like the cheekbone and eyebrow where treatments can be tailored to match the shape of the face. Want perfectly shaped eyebrows that you never have to pluck again? Electrolysis is for you. Electrolysis will Never damage your skin to a nerve level like laser can. If you have a laser treatment from a person that is not well trained, you can have nerve damage or even painful burns. With electrolysis you are not radiating your skin (laser is a form of radiation), which can cause nerve damage, burns or hypersensitivity right after the treatment, or worse, permanent skin damage that may appear years after your treatment.By appointment ONLYFREE consultation Cost:$35.00 - half hour$60.00 - one hour$95.00 - one & half hour$120.00 - two hoursNew package deals: 4 hours for $216, 10% off hourly rate8 hours for $408, 15% off hourly rate16 hours for $768, 20% off hourly rate24 hours for $1,080 25% off hourly rate32 hours for $1,344 30% off hourly rate


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Is Commercial Getting Caught Up in Credit Downturn?
In what may be the first hint of trouble for commercial mortgages, it appears as though delinquencies on commercial mortgage-backed securities could be on the upswing, after a period of declining delinquencies. Delinquencies on CMBS in Standard & Poor's-rated CMBS universe were up 12.7% in the second quarter. The New York credit rating agency reports that this is the first rise since December 2003, when delinquencies peaked. S&P credit analysts Larry Kay and Eric Thompson suggest that this spike could be due to the weakness of loans originated in 2006, a period of underwriting excesses. Another factor is a weakening in retail fundamentals.
For retail properties, delinquencies were up 224% in the second quarter, compared to the first quarter.
At the end of the second quarter, $1.65 billion in CMBS loans was delinquent, up from $1.46 billion in the first quarter, S&P reports. It is possible that changes in economic conditions, property fundamentals and incidents such as the 9/11 terrorist attacks can impact property performance and cause an upspike in delinquencies and to control for these other causes S&P looked at a seasonally adjusted delinquency rate.
The analysts report, "In 2005 and 2006, a period characterized by economic stability and improving property fundamentals, the seasonally adjusted delinquency rate increased to 0.8% and 0.12%, respectively. With a sound economy and positive property fundamentals, indications suggest that loan origination practices may be the cause of the higher seasonally adjusted delinquency rates in these two years. Based on our review of vintage-year activity, the industry's concerns regarding more aggressive underwriting (including higher loan-to-value ratios, lower debt service coverages, interest-only loans) in 2005, and more so in 2006, may already be affecting delinquency numbers."
The rating agency is monitoring ratings on 2006 vintage CMBS deals and, while no rating action has been taken so far, is seeing an increasing number of them go delinquent, get transferred to special servicing, or appear on servicer watch lists.
The news of the day is how bad lending practices on subprime residential mortgages have led to a credit crunch in the financial markets as defaults and delinquencies on these loans started to rise as interest rates went up and the securities that the loans back have become less liquid. Early payment defaults are also a concern. Subprime lending has been around for a long time though and what is new this time around is the CDO (collateralized debt obligation) factor. CDOs are pools of debt obligations, including mortgage debt and unsecured corporate debt, that are actively managed. It is difficult to value the mortgage securities that went into CDOs, further clouding the issue.
On the commercial mortgage side, a lot of slicing and dicing has been going on, with loans being carved up and placed into different credit tranches and bought up by investors with different risk appetites. CDOs have been an outlet for many commercial mortgage loan slices, as well as whole loans, and as one Wall Street participant put it at an industry forum, "The ability to keep the CDO beast fed is dependent upon the ability to keep up the asset origination pace to sustain it." It is this sort of demand for loan product that led to excesses in underwriting on the commercial mortgage side.
Underwriting has tightened this year and those excesses now appear to be past, especially with the residential credit crunch serving as an example, but it still remains to be seen what will happen when it comes time to refinance those commercial mortgages. If there is any sort of fallout from bad lending practices on the commercial side, the CDO factor bears watching.
By property type, health care, office and industrial properties saw declines in delinquencies in the second quarter, S&P reports. Lodging, retail and multifamily properties saw a rise in delinquencies. Multifamily had the highest delinquency rate of 0.81% at the end of the second quarter, followed by lodging (0.46%), health care (0.35%), industrial (0.29%), retail (0.15%) and office (0.11%).
The increase of $82.9 million in new retail delinquencies was dispersed across 15 states. Fundamentals in the retail sector have weakened, possibly due to falling home prices and higher gas prices, the S&P analysts surmise. As well, consumer confidence could be impacted by recent terrorist attacks in the U.K. and fears of similar incidents in the U.S. Therefore S&P is anticipating at least a mild slowdown in consumer spending. One area of concern for S&P is the heating up of competition on the Las Vegas Strip, an area that has some CMBS exposure.
(c) 2007 Mortgage Servicing News and SourceMedia, Inc. All Rights Reserved. http://www.bondbuyer.com/ http://www.sourcemedia.com/


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