CONFIRMATORY REFERRAL GUIDELINES

ANNEX 1:
INSTRUCTIONS FOR CONFIRMATORY REFERRAL OF BLOOD SPECIMENS
FOUND REACTIVE TO TRANSFUSION TRANSMISSIBLE INFECTIONS
(HIV/HBV/HCV/MALARIA)
Effectivity: February 22, 2014 | Revision Date: May 1, 2016 | Version: 4

1. PURPOSE
This document provides instructions for the confirmatory referrals of blood specimens found
reactive to HIV, HBV, HCV and Malaria. It also provides instructions for the testing performance
validation of blood service facilities.

2. METHOD
a. SCOPE
All blood units and components found reactive to HIV, HBV, HCV and Malaria shall
be sent to the RITM TTI-NRL
i. Segregate and label all reactive blood units and components found reactive to
HIV, HBV, HCV and Malaria in a clearly designated and safe area. Keep
refrigerated at 2-4°C.
ii. For components which has already been separated, send only the bag containing
the plasma (i.e. platelet concentrate, fresh frozen plasma, cryoprecipitate)
iii. In the event of an unconscionable delay in shipment, freeze an aliquot of 10 mL
plasma at -20°C or lower and send within two (2) weeks (within the National
Capital Region) or within one (1) month (for regional blood centers)
iv. For Malaria confirmation, send a Dried Blood Spot. (See Annex 6. Preparation of
Dried Blood Spot)
v. HBV Samples tested using the following kits with an optical density (OD) or
sample/cut off value (S/Co), which exceeds the set cut-off points, should no
longer be sent for confirmation (Table 1). (See Annex 1: Department Circular No.
2012-0198)

Table 1. HBV Cut-Off Points

ASSAY REAGENT KIT CUT-OFF POINT
Abbott AxSYM HBsAg (S/Co) ≥ 34.9
Roche cobas Elecsys HBsAg (S/Co) ≥ 20.46
Abbott Architect HBsAg (S/Co) ≥ 34.32
BIO-RAD Monolisa HBsAg ULTRA (OD/COV ≥ 20.1125

1. Blood service facilities using these kits should accomplish and submit the
HBV Quarterly Referral Report form. (See Annex 2: HBV Quarterly
Report Form)

CONFIRMATORY REFERRAL GUIDELINES 1

 vi. Blood units that have been screened reactive to Syphilis should no longer be sent
for confirmatory testing. (See Annex 3: Department Circular No. 2013-0132)
vii. Blood units that have been tested reactive by methods that do not conform to the
guidelines herein shall not be accepted for confirmatory testing. (See Annex 3:
Department Circular No. 2013-0132)
viii. All referring blood service facilities are required to accomplish and submit the
TTI Quarterly Report Form. (See Annex 4: TTI Quarterly Report Form)

b. DOCUMENT REQUIREMENTS PRIOR TO SHIPMENT

i. A completely filled-out Confirmatory Request Form should accompany each
specimen for proper documentation. (See Annex 5: Confirmatory Request Form)
1. Ensure that the information on the confirmatory request form matches
the information on the blood unit and dried blood spot.

c. SAMPLE REJECTION CRITERIA

i. Specimens are UNACCEPTABLE for confirmation if they fall under any of the
following criteria (NOTE: TTI-NRL shall NOT test rejected samples):
1. General Criteria
a. Discrepant samples
Aliquoted sample or blood bag labels SHOULD be IDENTICAL
to the information provided in the confirmatory request form.

Table 2. Example of Discrepant Labels

CORRECT INCORRECT
SAMPLE 2012-123456789 2012-123456789
LABEL
REQUEST 2012-123456789 12-123456789
FORM

SAMPLE J.D.C J.D.C

LABEL
REQUEST J.D.C Juan dela Cruz
FORM

SAMPLE 12345 (MGH) NVBSP 12345 (MGH) NVBSP

LABEL
REQUEST 12345 (MGH) NVBSP (MGH) NVBSP 12345
FORM

b. Sample labels not clear. (Refer to section 2-E-II-3 for Proper

Sample Labeling)
c. Illegible handwriting on Confirmatory Request Form. (Write
legibly in BOLD letters)
d. Samples with an optical density reading that exceeds the set cut-
off value. (Refer to section 2-A-IV)

2 CONFIRMATORY REFERRAL GUIDELINES

 circle to another due to the
anemia (anemic blood is more
fluid). This is still considered a
valid specimen. Blood has
Valid DBS On the card with MB/KP/120,
completely filled the circle.
Specimen the blood is spreading from one
Notice that the third and fifth
circle to another due to the
circles have been punched
anemia (anemic blood is more
(hence the white area in the
fluid). This is still considered a
middle).
valid specimen. Blood has
completely2. filled
BloodtheUnits and Components
circle.
a. Spilled
Notice that the third and fifthor damaged during storage and transport. (Refer to
Invalid DBS circles have been punchedsection 2-E for proper sample packaging)
Specimen (hence the white area in the
middle).
b. Contaminated samples as a result of spillage or improper
storage.
Valid DBS c. AgedOn samples
the card(i.e. with
storedMB/KP/120,
at 4°C for more than 1 month prior to
This specimen is invalid because quantity of blood is insufficient
Invalid DBS Specimen receipt)
the blood is
for testing. This may have been caused by::
spreading from one
Specimen d. Blood units with intact needles.the
circle to another due to
• Removing filteranemia (anemicblood
paper before bloodhas is more
completely filled
3. circle
Aliquoted Samples
or before blood has soaked through toa the other
fluid). This is still considered
side a. Broken validglass test tubeBlood
specimen. container.
has (The container may break
This specimen is invalidduringbecause
• Applying blood transport
completely
to especially
filled
quantity
filter paper with when
of bloodpacked
the circle. improperly)
is insufficient
a capillary tube
for testing. This may have Notice
been
b. Insufficient that
caused
amount the third
by::
ofwith and
plasma. fifth
(Aliquoted samples are required
• Filter paper comingcirclesinhavecontact been gloved or ungloved
punched
• Removing filter to be at
paper
hands or substances least 10
before
(hence such mL) blood has completely filled
the whiteas hand arealotion
in theor powder,
circle or before blood has soaked through to the other
4.
side
Dried
either Blood
before orSpot
after(See
middle). blood Annexspecimen6: Preparation
collectionof Dried Blood Spot for
Malaria Confirmation)
• Applying blood to filter paper with a capillary tube
a. Insufficient quantity of blood.
Invalid DBS Invalid
•InvalidDBS
DBS
Filter paper coming in contact with gloved or ungloved
Specimen Specimen
Specimen
hands or substances such as hand lotion or powder,
either before or after blood specimen collection

b. Damaged blood sport (scratched or abraded filter paper).

This specimen isisinvalid because
This specimen is invalid
This because
specimen it appears
invalid becausethe
scratched or specimen
quantity appears
of blood clotted
is insufficient
Invalid DBS or
abraded. This may have forlayered. This
This may
been caused
testing. have
have been
by applying
may been caused
blood with by:
caused a
by::
Specimen capillary tube or other device.
•• Touching
Removingthe same
filter paper circle on the
before filterhas
blood paper to bloodfilled
completely drop
several times
circle or before blood has soaked through to the other
c. Insufficiently dried circle
side
• Filling prior toonmailing.
both sides of filter paper
Invalid DBS This specimen is invalid because it appears scratched or
Specimen abraded. This may haveThe been Applying
•volume
caused byblood
of specimen
applyingtowill
filter
notpaper
blood be with
a a capillary
uniform
with between tube
spots
resulting
capillary tube or other device. in errors
• Filter paper during
coming thein testing process.
contact with gloved or ungloved
hands or substances such as hand lotion or powder,
d. Appears hemolyzed, discolored
either before or contaminated.
or after
This specimen is invalid because the specimen was not dry
blood specimen collection
Invalid DBS Invalid DBS
before mailing. DBS must dry a minimum of 4 hours before
Specimen Specimen
packaging and shipping.
Invalid DBS
Specimen

d. TIMING OF SHIPMENT
This specimen TOThis
is invalid RITM
because the specimen
specimen is invalidwas not dry
because the specimen appears
before mailing. DBS must dry a minimum
hemolyzed, of 4 hours
discolored, before
or contaminated. This may have been
As the quality ofand
packaging confirmatory testing isby:dependent
shipping.caused
This specimen
on sample age, these should be send to
is invalid because it appears scratched or
RITM within one (1) week afterabraded.
screening
• Squeezing
tests may
This areordone.
have beenofcaused
“milking” by applyingthe
area surrounding blood with a
puncture
i. Blood
Module 14: EQA – Dried Blood Spots units and components
8 capillary tube
site tested
or for
other HIV
device. using an
Participant antigen-antibody
Manual
2005
combination test kit should be sent within five (5) days as HIV antigen
• Allowing filter paper to come in contact with glove or
deteriorates on storage. However, if a considerable
ungloved delay is anticipated,
hands or substances freezeoranafter blood
either before
Invalid DBS
aliquot of 10 mL plasma at -20°C or lower and send within two (2) weeks.
Specimen
collection
ii.
Module 14: EQA – Dried Blood SpotsFor regional blood8 centers, specimensblood
• Exposing may spots
beParticipant
sent within
to direct one (1) month;
heat
Manual
2005
however, in this case, separate an aliquot of 10 mL plasma and keep samples
frozen at -20°C or lower.
This specimen is invalid because the specimen was not dry
Invalid DBS
before mailing. DBS must dry a minimum of 4 hours before
Specimen
packaging and shipping.

CONFIRMATORY REFERRAL GUIDELINES 3

This specimen is invalid because the specimen exhibits serum
rings – in other words, serum becomes separate from cells. This
may have been caused by:
 e. SAMPLE PACKAGING
The blood bank staff must ensure that the specimens are properly packed during transport
so that it will arrive in good condition and will not pose any hazard to human health and
the environment.
Blood units and aliquoted samples should be arranged according to the requested
examination (HIV first followed by HBV, HCV and Malaria). The Confirmatory Request
Forms should also be arranged according to the order the blood units/aliquoted samples
were packed to facilitate a better, faster, safer and orderly receipt.
i. Blood Units and Components
1. Make sure that the needle has been removed from the blood units and
that the tubing is tightly sealed to prevent possible leakage.
2. Place each blood unit or component in a plastic bag and seal tightly.
Label the plastic bag with the name of the referring blood service facility
and requested confirmatory test. (HIV, HBV, HCV, Malaria)
3. Place in a cold transport container and surround with an adequate
amount of frozen ice packs depending on the size of the transport box to
maintain a refrigerated environment (2-4°C) during transport. Extra care
should be taken to prevent hemolysis.

4. Place the Confirmatory Request Form/s in a separate plastic bag to

prevent it from being soiled or contaminated. If possible, collate the
Confirmatory Request Form/s and place them inside a brown envelope
and attached securely outside the transport box.
1 2

3 4

4 CONFIRMATORY REFERRAL GUIDELINES

 5. Document the shipment including the blood unit information, date sent,
name of referring blood service facility, name of shipper, name of
consignee, acknowledgement of courier and receipt at RITM.

ii. Aliquoted Samples

1. Ensure that the sample volume is at least 10 mL.
2. Secure the cap of the specimen tubes tightly and seal with a plastic
paraffin film to prevent leakage.

3. Ensure that the labels or markings will remain securely attached under all
conditions of storage and transport and these are clearly and legibly
labeled with the following information:
a. Blood bag identification/code
b. Serial number
c. Blood type
d. Collection date
e. Requested confirmatory test

4. Insert specimen tubes in appropriate test tube racks to prevent the

specimens being in disarray during transport.

CONFIRMATORY REFERRAL GUIDELINES 5

 5. Place the specimens in a double plastic bag with enough absorbent
material (e.g. paper towel, gauze pads, etc.). Label with the name of the
referring blood bank and date of referral.
1 2 3

6. Place in a cold transport container and surround with an adequate

amount of frozen ice packs depending on the size of the transport box to
maintain the temperature of 2-4°C during transport.

7. Place the Confirmatory Request Form/s in a separate plastic bag to

prevent it from being soiled and contaminated. If possible, collate the
Confirmatory Request Form/s and place them inside a brown envelope
and securely attached outside of the transport box.
8. Document the shipment including the blood unit information, date sent,
name of referring blood service facility, name of shipper, name of
consignee, acknowledgement of courier and receipt at RITM.

iii. Dried Blood Spot for Malaria Confirmation

1. Place labeled dried blood spot filter paper into a sealable bag with a
desiccant. If multiple specimens are to be submitted, stack the filter
papers between sheets of paper to prevent cross-contamination. Use a
sealable bag that should be just the right size to hold the filter paper.
Avoid using bags that are too big to prevent shuffling of the filter paper.

6 CONFIRMATORY REFERRAL GUIDELINES

 2. Ensure that the bags are properly sealed to prevent moisture from
entering.

3. Label the outside of the sealed bag with the following information:
a. Blood bag identification/code
b. Serial number
c. Blood type
d. Collection date

4. Place the Confirmatory Request form/s and dried blood spot package in
the same envelope.

5. Keep packaged dried blood spot (in sealable plastic bags) cool and dry
until transport to the TTI-NRL. (Stability: 1 month stored at refrigerated
temperature; >3 months stored at -20°C).

f. TRANSPORT TO RITM
i. Label the shipment container legibly with a permanent marker and ensure that
the label is clear and not covered or obscured by any part or other attachments.
1. For blood banks in the National Capital Regions, blood specimens may
be sent directly to RITM during weekdays between 0800H – 1700H.
Refrain from sending specimens beyond working hours, Fridays,
weekends and holidays. Only authorized laboratory personnel of
referring blood service facility are allowed to transport/deliver samples to
RITM for referral.

CONFIRMATORY REFERRAL GUIDELINES 7

 2. For regional blood banks, ship the blood specimens through any
accredited courier service that can guarantee delivery to RITM within 24
hours.

ii. Address the shipment to:

TRANSFUSION TRANSMISSIBLE INFECTIONS - NRL

Research Institute for Tropical Medicine
9002 Research Drive, DOH Compound, Filinvest Corporate City
Alabang, Muntinlupa City 1781

TRANSFUSION TRANSMISSIBLE INFECTIONS - NRL

Research Institute for Tropical Medicine
9002 Research Drive, DOH Compound, Filinvest Corporate City
Alabang, Muntinlupa City 1781

iii. Transport boxes should be fastened securely inside the transport vehicle. A spill
kit containing absorbent material, disinfectant, gloves, mask and disposal
container (or biohazard bag) should be present inside.

g. INQUIRIES

Please contact: TRANSFUSION TRANSMISSIBLE INFECTIONS

NATIONAL REFERENCE LABORATORY

Telephone: + 632 807 2628 local 229

Telefax: + 632 808 2552
Mobile: +63 998 459 5982 (Smart) | +63 916 639 3402 (Globe)

8 CONFIRMATORY REFERRAL GUIDELINES