ICP/BVD/OOB
ORIGINAL:
ENGLISH
~ERCOUNTRY SEMINAR ON CHOLERA Sponsored by the •
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Suva, Fiji 15-20 January 1979
REPORT
NOT FOR SALE
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PRINTED AND DISTRIBUTED BY THE REGIONAL OFFICE FOR THE WESTERN PACIFIC . OF TaE WORLD HEALTH ORGANIZATION Manila, Philippines March 1979
NOTE
The views expressed 1n this report are those of the consultants and participants in the Seminar and do not necessarily reflect the policy of the World Health Organization
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This report was prepared by the World Health Organization Regional Office for the Western Pacific for Governments of Member States in the Region and for participants in the Intercountry Seminar on Cholera, held in Suva, Fiji from 15 to January' 1979.
CONTENTS
1•
INTRODUCTION EPIDEMIOLOGY
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. .. .. . . .... .... . . TREATMENT, PREVENTION AND CONTROL . .. . .... .. ... . ... . DIARRHOEAL DISEASES IN GENERAL .... . .. . .... . .. . .. . .. . .... ... . . ... .. . RESEARCH NEEDS IN THE REGION .. . .... .. . . ..... . SUMMARY AND CONCLUSIONS . LABORATORY DIAGNOSIS ,.
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ANNEX 1 -
LIST OF PARTICIPANTS, TEMPORARY ADVISERS, CONSULTANTS, SECRETARIATS, OBSERVERS AND ,. ,. " ,. " ,. INTERPRETERS ,. ,. ,. ,. ,. ,. ,. ,.
ANNEX 2 ANNEX 3
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1.
Iln'IIODUCTIOH
Tbe seminar oonsisted ot a general part (15-18 January), cOllpr1sins epidea101ogy, laboratory diagnosis, olinical aspeot, treatment and oootrol measures and a praotical training oourse on laboratory diagnosis (16-2O January). Thirty-nine participants from eighteen countriea took part in the seminar.
A list ot partioipants, oonsultants, temporary' advia,rs, observers and The seminar was conduoted in English and Frenoh languages. WHO staff is attaohed (Annex 1).
Dr Charles Roes-Saith, WHO Progra.me Coordinator, addressed the participants on behalt ot the WHO tor the Western Paoitio Regional Direotor, Dr Franoisoo J. ny, and explained the purpoee ot tbe seminar on cholera in the South Paoitic in view of reoent introduotion ot the disease in tbe area and the need tor discussion and adoption ot an ettective strategy based on sound teohnioal knowledge to oontrol cholera and diarrhoeal diseases and promote regional cooperation in this field. The Minister tor Health, Fiji, Mr Ted Beddoes, ottioially welooaed the pertioipants to Suva and reminded tho of the reoent introduotion ot cholera in the South Paoifio which should be discussed in the spirit ot international comprehension and oooperation in order to aOhieve a ooordinated and well-oonoeived progrBlBe of cholera oontrol and its prevention. He wished the seminar suocess and deolared it open.
2.
EPIDEMIOLOGY
Salient epidemiological teatures ot the diaease and various enVironmental taotors which play a role in the tranllll1ssion of oholera and the neoessity of epidemiologioal inquiries in order to understand the mode ot tranamission and tor the application ot appropriate oontrol measures were presented. Sinoe ecological and sanitary oondition, tood habits and other faotors difter tram oountry to oountry the need to study the oommon .ade ot transmiSSion in this partioular geographical area was emphaaized. In the disoussion that tollowed i t was pointed out that specifio information about the role of various foods conaUDIed in the South Pao1tic area would be very valuable. The clinical symptoms of typical cases were described. It was pointed out that Vibrio oholerae biotype el tor may cause many oases of mild diarrhoea and asymptomatio infection which can only be oontirmed by bacteriological examination.
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In the discussion it was mentioned that a cholera-like olinioal picture, may also be caused by several other pathogens among which enterotoxigenio !. ~ may be particularly important and oommon. The evolution of the 7th pandemio caused by y. oholerae biotype el tor that came out of its endemio focus believed to be in the island of SUlawesi (Celebes) in Indonesia in 1961 and -its spread during the last 17 years involving oountries in Asia, Africa and EL'rope was described. It was pOinted out that 80 tar, 88 oountries have reported oholera and that olassioal cholera-has been almost oompletely replaoed by el tor in the Indian suboontinent. In 1978, eight countries were infeoted for the first time, thus indicating that the ourrent pandemic has not yet seen its end. Epidemiologioal features of cholera due to el tor vibrio in some of the countries in different geographioal areas were illustrated. Attention was drawn to the fact that the disease 1s spreading fast as it oauses many eore oases of mild disease and of aSYMptomatio infeotlon which remain mobile end undiagnosed. Experienoe in other regions has shown that the introduction of the disease into a country therefore cannot be prevented. The trend of the disease to remain endemic after having caused epidemic spread in a newly affected country where other diarrhoeal diseases are frequent, was pointed out. Outbreaks in such areas may at times be attributed to new introduction but thpy most probably represent an epidemic recrudescence in an endemio situation. Experience has shown that case fatality rate tends to be higher at the beginning of an epidemic, when control measures are not properly organized, but it drops drastically when logistics for management of the patient are well set up. It WBS pointed out that cholera may be jntroduced from practically any area of the world, and that South Paoific countries appear to be highly reoeptive in view of the high incidenoe of diarrhoeal illnesses, cultural and food habits and unhygienio environmental oonditions. During the disoussion it was p01nted out that although infeotion and transmission among looal population oould oocur when oarriers or oa~es would go to areas where spread Is more likely to ooour, or would beoome involved in specifio activities, like food handling, water works, etc., local surveillanoe aotivities oould reduce the risk of such transmission. The two most recent epidemics in the Gilbert Islands and Nauru in the Region have exhibited different epidemiological patterns; this example was used to illustrate that it 1s not possible to predict when cholera might appear in a country, nor how an epidemic, following introduction, might behave in a particular country in this region.
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3.
LA80RITORY
OTAr.NO~T~
3. 1 /JeneraJ Tn this co~onent of the semtnar, 14 lahoratory workars from 13 . countrtes of the Regton parttcip1lted. The ",eneral p"oll;ra_ was p1annl!d 1.n such a III'lnne" that they couli! part! c~ pate 1n ':.he mOl'lt i.lllportant l'Ies!!Ilons on eptdemio'ngy wHhout missing laborAtory w","I<. Th" need W'l'l emphaslzed for Jahorat", .. v -iiAp:nnsls "or d.. t."Ct.1N1 or rtr!!lt cases, fo .. det.ection of ca .... ie ..s ~n~ rn .. an epi~emiolop:lca1 stu~v t.o ~etermine the mode 0" trAnl'lm 1 ssion of ch""e r " ~th .... t~an for conf'~tion of ellch case t.hat occnr!! during Iln nuth .... '1k alreafiy known to hI! due to V. cholerae. 3.2 Pl"8ctical t ..a1.nl ng 1n 1 aboratory
p ..ocec'u!"es
The programme of the p"acticR1 work included preparation of cult.urI! media requtl"P.d for thts purpose and of hact.e"i 0!ogicA1 examl.nl!.t.i.on of' Vl!... t",us specime'1s fnr V. cholerae. The t""lntng concentMlted on sImple but; IlpproprlRt.e technlqUl!s-ror I'!nU.p.ctlcn of' "peci.mp.nll, transport.at1on, en .. lchment, plating f",r is",lat1.on And ifientiflcAtion of °he o..p;an1.sm. St..ess WAS 1ai~ on essential prol'!e~ures fo" quick iso'at'on and tdenttf1catton of V. cholerae fo .. "arly t11.agnMis or ca..es And car"'ers under the prevall i.iig circumstances in t.he , ah",r"t.o .. ies of the ~out.h PR('t fi c regi.on. Tt. w:\'" IIn" ..... 11 np.ti "nd the pa.. ttoipant:l'I rea 117:ed t.hat the laboMltory dlagnos{", of chnle ..a I.I! not dt rrt cult but tt. ; s "lIl'Ien!: tal to learn the !!Iimple tl'!chnlqup.s and b", p1"P.pared with t.h!' ml'!dl.~ anti !tera to PArra ..... th'" diagnosis as rapidly 1I!t po.~l!tble for qui.cl< :lppl1clltfon of thp. control measures. It was explained that the cha"actp,~izRtton of' the stratns, P..~. phage-typtng, hiotyp1.ng and I!vl'!n 'Iero-t.ypl ng m~v bl! done by the Wl'O collaboratIng Cl'!ntres or by other referf!nce laboratories 1n t.he Regton and that such informat~on is not '>s"ential ro" 1.mplementatton Clf' cont~ol activities. Af'tp.r having gone through the standa"tI pl'Ocedu~s w~th ~own cultures, the partiCipants had to pr",cess unknown specimens Por isolat.i.np: V. cholerae. They also CBl"l"l.M out silllPle test!'! 11.kl! the strtnp; test, ox1 ""lie-t."l'It and chicken-cell haem~gp:'.uti.nl!.tl.on t'lst anrl we ..... t.old of t.h'l\.r u~"s. Tn adtli t.l on to t.he p.."ctl.CRl work, II "'Imhel" t)f' demonst ..",ti ons we"", 81",.anged wMch lnc}udl'!d iso'ation of V. cho1f'!l'I!Ie f!"Om water, i.l'Iol"ti.on of y. parahaemolytlcus, 111!'k field microscopv Anti tP.St f(ll" d1frf'!l"f'ntiating classicl!.l r1"Oll ,,1 tl)r biotype of y. oholp."ae (h'o-typing).
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A grOup discussion on laboratory procedures was held when the participants had an opportunity to discuss aboLJt organization of laboratory work and clariry their doubts. Participants were provided with a small amount of diagnostic serUM to enable them to be prepared to identify y. cholerae when required as almost all of them have TCBS media in the laboratories. I In the surveillance of diarrhoeal diseases and cholera the appliCation of laboratory techniques for detection of enteric pathogens is essential as this may lead to an early deteotion of the introduction of V. cholerae and timely application of control measures. It was also emphasized that the laboratory'technOlogy for diagnosis of cholera is rather simple and that it is possible to introduce it in all institutions even in those with minimal facilities for bacteriological work.
During the discussion, the merits and demerits ot different methods used in detection ot y. cholerae in water and sewage were poInted out and the laboratory workers among the partiCipants were urged to do practical work to acquaint themselves with the recently developed simple but appropriate techniques.
4.
TREATMENT, PREVENTION AND CONTROL
4.1
Treatment
Treatment of cholera was presented and discussed in great detail in view of recent advances and their significance. It was pointed out that the treatment based on understanding ot pathophysiology is not only effective but is also simple and inexpensive if facilities are organized beforehand. Cases can be treated In hospitals, statio health centres or by mobile teams in rural areas by sub-professional health workers with some initial training provtded facilities are available. A simple guideline for treatment of cholera with oral and intravenous rehydration was provided and discussed. It was emphasized that use of antibiotics is not essential but they are;very helpful as they shorten the duration of illness and period of vibrio excretion and reduces the need for I. V. fluid. The basio principles of oral rehytlratton and usefulness of this simple measure were outlined and attention was drawn to the WHO publIcations and other scientific literature. The great advantages, because of the ease of its administration and its low cost, were compared with the prevailing use of I.V. rehydration practices. Details on the appropriate composition ot the oral rehydration flUids, as well as on oare in its preparation and handling, were stressed •. It was explained that sucrose can be used if glucose is not available and that education on dietetic management must be inoluded when providing oral rehydration.
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Durt"lp; the d!scu!'lsion, participAnt!'l Axp,""s""d lIIuch Interest and wanted to know more about the availability Ant! lor!!l pl'Otluct1on of' the package/! tngredients. '\'hey were informed of the iOi.,t. IfHO/uN:r.rEF progr,,_ on promotion of national d'la!"rhoeal tllseases cont~o1. progrn.lIIlII<'Js. Poss1.bPtt.y of a risk assoclato,d with the administrati"n of this sugar-contal.n'.ng oral rehydration fluId to dtabetics wa!'! consi"l"~e" to be 10w thoup;l> no studtes have yet been done. The composition of green coconut water and ~easons for its inadequacy to be used in place of the rec~ded fluid wa!'! pointed out. During the session on gr"up dtscusslon '\ !'!tmple "et of guideli.nes "or treatment of cholera, distributed at the beginning of the wo~k!'lhop, was discussed in detail. It was felt that f'urt.her simplificatIon and their adaptation according to local resources anrl technical stand~rtls should be necessary. Promotion of oral rehytlratton and other aspects of the WHO programme on dia~hoeal diseasl"s control was aga! n "1 :'Icussed by -.he part 1.cipants. rt was pointed out that t~ programme will help nationaJ health workers in surveillance and control of cholera. 4.2 Preventton
Severa 1 inquiries were put forward tlurl np; tile p:roup tliscuss1.on on epitlemiology about Possible means avatlab1e to a country for prevention of introduction of cholera. It was pOinted out that no known !'Icientinc means are as yet avaUable to achieve this and ~eve"Al suggAstions were offered to prevent or at least min1mIze tile sprea~ ~nd ravages of ch01e~ witll1n a country. The d"sirab1.ltty of enVironmental 1'IIIrveHlance activities ·WllII underline~, with spec1.rtc reference to sewage, ni.ght soil, shell fish sampling for V. cholerae as detection of V. cholerae in envlronmental specim",ns wUl help tn creattng a lertness-alllonp; the health of"rtcials concernetl. III!sic p...tnciples and procedures of 811~v.. 1l1Ance were descrIbetl with a special emphasIs on necl"ssary linkages between info"""t~on ga-.heN!d and oontrol measures undertaken. It wall stressed that cholel"ll sUl"Vl"il..1'\nce shOUld he an integral part of an exisl;ing programme of surveillance of c"1ftIIlUni.cahle tl1sell"es although rlexlbili ty for greater !!l!Ip~as1.s towards il "peat fie dillease (11k!! cholera) aocording to the epidemiological situation was !'Itrongly recommended. It was also pOinted out that the success of' R 8urveill'.lnce programme was closely Hnked ~·tth clear and simple methodology for ~ata collection an~ processing. • Several pR"ticipants commented tlur'rtl': the dlsculI"1.on that at times diffIculttes tn communtclltlon, shortllp;e o~ trllinerl personnel ~nd tranllportation hallPer surveil 1ance actl vt ~.1 e,.. RlDphas1s 'fBS put on the need for eArly notification of cl1.nica11y sUllpectl"1 cases of cholera, not only becRlI!'IP of requirements contained in the International Health Regulattons (1969) but also for Internattonal and bilateral cooperation and for mutual benef"H,. among South Paciffc countries by timely exchange of information to help eAch other in their preparedness to meet the threat of cholera.
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The need for clear instructions to peripheral health units on how and when to report was underlined. The importance of simple sanitary measures combined with health education and training of health personnel which can be very ~ffective in the reduction of the incidence of cholera was underlined. There is a need for priority to be given to appropriate sanitation projects which are. cost effective in the long run, the benefit of w~ich goes much beyond the control of diarrhoeal diseasps and cholera. The motto "Be prepared" is relevant and simple sanitary measure appropriate to the respective island situation can be introduced for immediate usage as well as for the long-term pro~rammes. Appropriate technology for respective islands should he realistic, financially feasible and acceptable to the community. Results of many studies that have heen undertaken to evaluate the currently available cholera vaccines were presented, which have shown t.hat they are only of limited effectiveness and for a short period. It was pointed out that immunization may give a false "sense of security". Experience gathered from different areas of the world on the limitation of mass vaccination for cholera controls was presented and advantages of organizing treatment faCilities and of implementation of simple sanitary measures from cost benefit point of view were emphasized. It was mentioned that though in general, the decision on immunization l.s political rather than technical, the health administration can, with correct technical information, help develop a technically sound policy. Most of cholera vaccines available today are not of acceptable potency and use of the limited national resources for vaccination can hardly be technically justified. 4.3 Chemoprophylaxis has been the subject of many studies, particularly with tetracycline. It was pointed ~ut that this drug has to be given in repeated doses for several days to be effective which is very difficult to ensure in practice. This drug is also not recommended for pregnant women, those with liver and kidney diseases and children. Indiscriminate use may also lead to increased drug resistance. Sulfadoxine. a long acting sulpha dru~. can be given in one single dose but is less effective. Doxycycline in one single dose of 300 mg may also be used but is slightly less effectivp than tetracycline given in multiple doses. It was mentioned that chemoprophylaxis is probably useful only for application on close contacts of cholera cases or in selected p;roups of populati<Jrl especially wi thou t any p08sibi 11 ty of Improvement of sanitation and of provision of trpstment. 4.4 Though health education i.e regarded an s major stratellY in both epidemic and endemic situations, in the excitement of a cholera outbreak it often receives less attention than it deserves as health personnel are pressed into a variety of activities to contain the situation. Activities should begin during the preparatory stage or even earlier. Target p;roups
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should be identified and strategies designed to enable behaviour changes to take place in the community. There is a need to educate health workers at different levels on the need and strategIes to control. diarrhoeal diseases and cholera. Many factors hinder the implementation of oertain basio health measures because oommunities are not well informed of the facts about how the disease spreads and even health personnel may have oonnicting ideas. 4.5 Control in general
It was mentioned that none of the cholera control strategies has yet been individually evaluated properly in practice beoause several measures are usually applied simultaneously. However, as countries are gaining experience, fewer countries than in previous years are now requesting vaocines; elllPhasis on mass chemoprophylaxis is also deoreasing. 4.6 Outbreaks in Gilbert Islands, Guam and Nauru Participants from Nauru and Guam described their experience in control of the outbreaks of cholera in their respective countries. Though mode of transmission in Nauru had not conclusively been identified, it appears to be a protraoted outbreak being transmitted through food. In Guam the mode of transmission was found to be through contaminated salt fish called Padas which are eaten unoooked. In the case of Nauru, attention was being paid to sanitary measures like cheoking water supplies, private wells and soreening cesspits in infected areas as well as on education of the public. In the G1lberts outbreak, the transmission of cholera was thro,ugh the water system on Tarawa. A surveillance unit was set up promptly. Treatment of water supplies was given first priority. Cholera cases were treated by intravenous and oral rehydration and tetracycline. Prophylactio treatment of immediate contaots of cholera cases with tetracyoline was instituted. An inter-island traffio ban was imposed during the early part of the outbreak. Sanitation and methods for the disposal of human excreta were improved. The consumption of raw shell fish from the lagoon was discouraged. Mass vaCCination was also carried out though importanoe was not placed on it. Throughout the outbreak health education was given much importance. 4.7 International restrictions, regional plan
PartiCipants expressed concern about the difficulties experienced by travellers when faced with excessive restrictive measures imposed by some countries in the Region following the appearance of cholera. It was generally agreed that suoh restrictive practices at airports and seaports could be very damaging to international goodwill and there was no scientific evidence of their impOSition being able to prevent introduction of cholera into any country.
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It was poInted out tlmt a valid vaccinAtion certlfjcate does not prove tl\llt. t,hp. holder of thA certlficat.e ls not" <'nrrlcr AS the cholera vaccine does not protent against the carrier-stilt". it tl' also dIfficult to ensure administratIon of multiple doses o~ tetrany~llne required t.o cure the carrier-state. A work plan for organizing cholera cc>ntrol activities in the Region was developed as an outcome of a discussion group and distributed to the participants to help in development of their own work plan according to their own needs and available resources. It was also recognized that prompt notification on the appearance of the disease in a country to WHO is essentIal for the promotion of bilateral and international collaboration in cholera control. It was suggested that this proposal should be brought to the attention of national policy-making health administrators in the Region to encouragE' early notification and development of a regional collaboration.
5.
DIARRHOEAL DISEASES IN GENERAL
In view of the similarity between cholera and many other acute diarrhoeas in mode of transmission, underlying phYsiological derangements, clinical manifestations and in the requirements for treatment and for control. the need for a national programme for diarrhoeal diseases ,control was stressed. The importance of diarrhoeal diseases as a health problem and their intimate relationship with malnutrition and the recent research developments which permit development of such a programme were also described. It was pointed out that a multidisciplinary programme is therefore being developed by WHO in close collaboration with UNICEF for technical cooperation in national programme development which should consist of implementation of the strategies that are already well known and tested, the development of new strategies by promoting research and national manpower development by the training of health workers both in research and in application of the stratey,ies. Of the available strategies, oral rehydration was agreed to be the most appropriate one to be applied now to reduce diarrhoeal-related malnutrition and mortality. The importance of the national diarrhoea control programme in the control of cholera and other enteric diseases was also discussed. WHO is providing consultants to help in national programme formulation in the Region as an integral part of their existing country health programme so that available health services may be utilized for implementation. The proposed outlines of a national programme and also that of the regional programme were presented and discussed.
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ParUcipants expressed interest in clovp.lopment of educational material suUshlp. for the Rep;lnn for promotion 'lnd Implem'lntat.ton of this programmp. The need for dev'llopment or or~l rehydration packaaes of suitable s1ze and for finding containers of appropriate capacity for preparation of oral fluid were discussed. Most of the participants felt that this programme will receive high priority in their countries; two countries, however. mentioned that the mortality due to diarrhoeal diseases in their countries is not very high, but they would like to promote oral rehydration to facilitate treatment of the cases particularly in the remote areas.
6.
RESEARCH NERIlS Hl THE REGION
As epidemioloiical patterns of cholera differ in various parts of the world, it is conSidered necessary to undertake research on the modes of transmission in the Region and on the survival of V. cholerae in various local foods, particularly shell fish. Studies should also be carried out 1n areas free of cholera at present on mode of transmiSSion of diarrhoeal and other enteric diseases.
7.
SUHMARY AND CONCLUSIONS
7.1 Thirty-nine participants from 18 countries took part in ~he intercountry seminar on cholera (15-20 January), which was held in English and French. 7.2 This seminar was mainly an educational. activity to provl.de the technical information on cholera control and to share the experience gained in other countries of the world in order t.o assist the health administrations in the Region in developing technically-sound strate~ of cholera control.. 7.3 It also included a practical training course on laboratory diagnosis of cholera in which 14 laboratory workers from 13 countries participated. The general programme was planned in a manner so that these work~rs could also attend the important sessions.
1.4 Important topics on epidemiology, cUnical "eatures, clinical management, laboratory diagnosis and various preventive and control measures were preSented using audiovisual aids extensively. Rach presentation of the topic was followed by a discussion.
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7.5 Group discussions on each sspect were also arranged for free excbange of information; two films were shown. 7.6 Attention was drawn to the similarities between cholera and other acute diarrhoeas, a much more serious health problem, during each presentation and disoussion. One whole day was devoted to explain the WHO programme on diarrhoeal diseases oontrol w~ich is being developed in collaboration with UJICEF and how a national programme on diarrhoeal d1aeases can help in cholera surveillance and control in addition to its immediate benefit in reduoing diarrhoea-related mortality and malnutrition. 7.7 A work plan for organizing national cholera control activities was prepared and provided to the partioipants. 7.8 It was also felt neoessary to undertake research on the possible modes of transmission of cholera in the Region and on survival of !. oholerae in various local foods particularly shell fish. 7.9 Considerable time and attention was given to convince the participants that Baking travellers oarry a valid cholera vaooination oertifioate or making them take tetracycline will not enable any health administration to prevent introduction of cholera into the country. Realizing the limitation ot these prooedures which can lead to suppression of infoJ'lllllUon, the participants felt that early notifioation on the coourrenoe of the disease in a country will help in the develo~ent of better international, regional and bilaterial collaboration which will enable the countries to get prepared for better oholera surveillanoe and control ,and suggested that this proposal be brought to the attention of the policy-making health administrators for appropriate action. '
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AMIIEX 1
LIST OF PARTICIPANTS, TEMPORARY ADVISERS, CONSULTANTS, SECRETARIAT, OBSERVERS AND INTERPRETERS
I. AMERICAN SAMOA
PARTICIPANTS
Dr Tofiaa Liaiga Associate Public Health Offioer LBJ Medical Centre Pago Pago Mr Tupua Faul~lo Laboratory Technologist Department of Medioal Servioes PagO Pago
COOK ISLANDS
Mr Aratangi Laboratory Technician Ministry of Health Rarotonga Dr George Koteka Director of Public Health Ministry of Health Rarotonga
FIJI
Mr liasrat Ali Divisional Health Inspector, Central Ministry of Health Government Buildings ~
Dr Joseph Fot Divisional Medical Officer, Central Ministry of Health Government Buildings Suva Hr Ra.1endra [Wllar Parmar
Technioal Officer Cl~ss I Pathology Laboratory Ministry of Health Government BuHdings Suva Mr J.R.N. Rao Chief MedIcal Officer Ministry of Health Govern.ent Buildings ~:
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Annex 1
FRENCH POLYNESIA
Dr Pierre Delebecque Medecin-Chef du Service d'Hygiene territorial et quarantenaire Direction de la Sante publique Papeete Tahiti Dr Rougier Yanni-ck Chef du Laboratoi~e central de Biologie medicale de l'Hopital de Mamao Papeete Tahiti
GILBERT ISLANDS
Mr Kantaia Teburae
Laboratory Tec~nician Ministry of Health and Community Affairs Bikenibeu Tarawa Mr Neeri Tiaeki Health Inspector Ministry of Health and Community Affairs Bikenibeu Tarawa
GUAM
Mr Luis Pablo Flores Acting Public Health Laboratory Director Department of Public Health and SOCial Services Agana Dr Robert Haddock Territorial Epidemiologist Department of Public Health and Social Services Government of Guam Agana
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Annex 1
NAURU
Dr Uki Thoma
Acting Director of Health and Medical Services Department of Health
!!!!!:!! Mr Randerok Dowabobo
Laboratory Technician Department of Health Nauru NEW CALEDONIA Dr Jerome Guelain Directeur Adjoint, Institut Pasteur de Noumea Noumea Dr Albert Harsallon Adjoint Technique au Directeur de la Sante et de l' Hygiene NOUllea NEW HEBRIDES Mr FranCOis Admont VAT Biologiste Hopital G Pompidou Port Vila Mr Augustine Bani Medical Laboratory Technician Vila Base Hospital Ministry of Social Services Port Vila Dr Michel Ducorps
Medical Officer Santo Hospital Ministry of Social Services ~ Dr Paul M. Fenton
General Outies Medical Officer Vila Base Hospital Ministry of Soeial Services Port Vila NIUE Dr Abustus Mitikuleana MedIcal Officer Health Department Niue Islands
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Annex 1
PAPUA NEW GUINEA
Mr
S11as Bomai Health Inspector (Quarantine) Department of Health Vanimo West Sepik Provinoe Dr Joseph Igo Senior Medioal Offioer (Pathologist) Department of Health Port Moresby Dr Joseph laven Medioal Registrar Nanga Base Hospital Rabaul
SAMOA
Dr Faleniu Asaua Chief National Health Laboratory Services Health Department Apia HI'
Haka Simanu Sapolu Assistant Micr obiologist Department of Health Apia Tipi Chief Inspector Department of Health Apia
HI' Suega
SOLOll)N ISLANDS
Dr Obed Alemaena Medical Officer Ministry of Health and Medical Services Honiara HI'
Nicholas Kikini Laboratory Technician Central Hospital Ministry of Health and Medtcal Services Honiara George LuilQo Assistant Health Inspector Ministry of Health &Medioal Services Honiara
HI'
- 15 -
Annex 1
TOKGA
Mr Salesi Finau Health Inspector Ministry of Health Nuku'alofa Dr Laumeesi MaIolo Acting Senior Medical Officer, Public Health Ministry of Health Nuku'alofa
Mr Viliami Pakalan Laboratory Technician Ministry of Health Nuku'alofa TTPI Mr
Carl Dannis Area Sanitarian for TT Eastern District Deparblent of Health Services Ponape Dr Isao Kisino Medical Officflr Deparblent of Health Services Saipan Mariana Islands
TUVALU
Mr Faiatea Fab Latasi Pathology Laboratory Tuvalu Central Hospital Funafuti Dr Jacques I.acosta Chef de Servl~e de Sante du Territntre des Iles Wallis et Futuna Hopi tal de Sia Matautu Wallis Islands
WALLIS .. FUTUNA
Mr Kelekolio Fotofili Laborantin a l'Hopital de Sia Hopi tal de Sia Matautu Wallis Islands
- 16 -
Annex 1
2.
TBHPOR&RY ADVISERS Dr Ros,s Sutton Assistant Director-General Medioal Laboratories Branoh Depar~ent of Health Woden. Dr Brian W. Christmas Deputy Director-General of Health (Publio Health) Department of Health P.O. Box 5013 Wellinston
3.
CONSULTANTS
Mrs Cecilia Gomez Senior BacterioloSist Food & Drug Administration Bureau of Research and Laboratories MiniStry of Health Manila Dr Branko CYjetanoYic Institute of Immunology Rockefeller St. 2 41000 Zagreb
4.
SECRETARIAT
Dr D. Buua (Course Director) Medical Officer Bacterial and Venereal Infection Unit WHO Headquarters Geney!\, Chin Wen Tao Consultant, Communicable Diseases Unit WHO R.gional Offioe for the Western Paoific Manila Dr
- 17 -
Annex 1
Dr Gu18eppe r.ubon1 WHO Kp1deaiologist Epidemiological Surveillance Projeot Boroko, Port Moresby (Papua New Guinea) Hr E. Dekel
WHO Sanitary Engineer Suva Hs R. Haessig
WHO Teohnioal Offioer Ministry of Health & Community Affairs Bikenibeu, Tarawa (Gilbert Islands) He M. Leavy
WHO Publio Health Nurse ~
Dr C.S. Lee WHO Medioal Offioer Suva Dr A.D. Rajkovio Regional Adviser on Laboratory Teohnology WHO Regional Offioe for the Western Paoific Manila Dr N.U. Rao WHO Miorobiologist BorOko, Port Moresby (Papua New Guinea) Dr C.J. Ross-Smith WHO Programae Coordinator Suva Dr J.S. Sumpaioo WHO/Short-term Consultant WHO Regional Offioe for the Western Pacifio Manila Dr Tin Maung Maung WHO Medioal Offlcnr WHO Interoountry Rpldemiologloal Survelllanoe Teu for th" r,,,uth Paoif'ic Suva
- 18 -
Annex 1
Dr P.N. Wang WHO Medical Officer Ministry of Health Iu!ru'alofa, Tonga
5•
OBSERVERS
Dr T1III Kuberski Bpideaiologist South Pacific Commission NOUll8a
!fell caledonia
6.
INTERPRETERS
Mrs V. Bouladon-Taylor
18, Selwyn Street North Brighton Victoria 3186 Australia Mr Jean-Daniel Katz 155 Rajvithi Road Bangkok 3 Thailand Manila Ma Nadine Kieffer Ambasaade de France 20 JL Thamri Djakarta Indoneaia
- 19 -
ANNEX 2
PROGRAMME OF LABORATORY WORK
Monday, 15 January As in General Programme Tuesday, 16 January 08.30 - 12.00 1. 2. Orientation Preparation of oulture media, etc. Alkaline peptone media, pH 8.6 Cary-Blair medium, pH 8 •• MEA (meat extract agar) pH 7.6 Make reotal swabs Bacteriologic examination of stool for vibrio a. Colleotion (a) (h) (c) b. Rubber catheter (No. 26-28) Rectal swab Glass rod
3.
Inooulation of transport (holding) medium: Alkaline peptone water cary-Blair .ediua
c. 12.00 - 14.00 14.00 - 15.00
Demonstration of transportation 1n blotting paper strips in sealed plastio envelopes. Lunch Break
Inoculation of plating media and second enrichment: a. b. c. Direct streaking from stool on MEA and TCBS agar plates After six hours enriohment in alkaline pepto~e water at 37 0 C Second enrichment in alkaline peptone water from first peptone.
-20-
Annex 2
15.00 - 16.30
Group discussion on epidemiology as 1n General Programme WednesdaY, 17 January 08.30 - 12.00 1.
Spotting the colonies Identification by slide agglutinatlon of suspicious colonies with Anti-cholera 0-1 group serum and Type specific Ogawa and Inaba sera agar
2.
3. Isolation of agglutinable colony on Kligler's iron agar and slant II. String test Lunch Break As in General Programme
12.00 - 111.00 111.00 16.30
Thursday, 18 January 08.30 - 12.00
1. 2. 3. 4.
Unknown samples:
plating, enriching, etc.
Confirmatory test by slide agglutjnation from growth on KlIg1er's wIth cholera type specific sera Biochemical tests of isolates Characterization of V. cholerae and El Tor Vibrio: Chicken or sheep cells haemagglutination Polymixin B sensitivity
red
12.00 - 111.00 111.00 - 16.30 16.30 - 17 .15
Lunch Break As in General Programme Laboratory work for plating from enricbment
- 21/22 -
Annex 2
Friday, 19 January
08.30 - 12.00 1.
Reading of reaulta and agglutination Demonstration ot: a. b. c. d.
of
colonies on platea, including
2.
y.
Growth of y. eholerae (elassicpl and £1 Tor), lAG and parahaemolyticus on MEA and TCSS Tests tor phage - suaceptibHity Vogues-Proskauer reaction Haemolysis test
3.
BRcterio]oglcal Isolation ot vibrjo from water Delllonstration: a. b. 10~ alkaline peptone water With lIIillipore tilter
12.00 - 14.00 14.00 - 16.00
Lunch Break Group discussion on laboratory procedures
Saturday, 20 January 08.30 - 11.30 1.
Reading ot results of water examinat.lon Interpretation and diacusaion Delllonstration ot resulta of': a. b. c. Cholera pbAge group IV susceptibility test Voges-Proskauer reaet! on Haemolysis test Closing session.
2. 3.
11.30 - 12.00
(Cottee break tor 15 IIinutes, as :oonvenient during the IIOrning and afternoon seasions).
• ANNEX
3
GENERAL PROGRAMME
~
Day Monday
Time 08.30 09.00 - 10.00 10.00 10.30 - 11.30 11.30 - 12.00 12.00 - 14.00 111.00 - 14.30 14.30 - 15.00 15.00 - 15.15 15.15 - 16.00
Subject Registration Opening ceremony of the seminar Introductory remarks Salient epidemiological features Diagnosis (clinicsl) Lunch break Diagnosis (laboratory) Treatment of cholera Coffee break Film show and discussion Cholera as an international health problem and current global situation Promotion of oral rehydration Coffee break Dr D. Barua Dr D. Barua
15 Jan
Seminar Director & Operational Officer Dr B. Cvjetanovic Dr B. ChristlDBs
Dr R. Sutton Dr D. 9ar:>a
..., ...
16 Jan
Tuesday
OS.30 - 09.00 09.00 - 10.00 10.00 - 10.15
Dr G. Cuboni
Annex 3
~
Day
!!!l!! 10.15 - 11.00 11.00 - 12.00 12.00 - 14.00 14.00 - 15.00 15.00 - 15.15 15.15 - 16.30
Subject Surveillance of cholera and lay reporting Early warning, reporting and international health re~lat10n Lunch break Group disoussion on epidemiology Coffee break Group discussion on treatment Simple sanitary measures Cholera vaocines Chemoprophylaxis Coffee break Health education Ms K. Leavy Dr B. CVjetanovic
Dr Tin Maung Maung Dr B. CVjetanovic and Dr Ross-Smith
Dr D. Barua & Dr B. Christmas Mr E. Dekel
.p-
'" I
17 Jan
Wednesday 08.30 - 09.00 09.00 - 09-30 09.30 - 10.00 10.00 - 10.15 10.15 - 10.45 10.45 - 12.00
Dr B. CVjetanovic Dr D. Barua
Cholera control - Global experience Dr D. Barua Regional experience Dr K. Thoma, Dr Haddock & Dr Tin Maung Kaung Lunch break Organization of cholera control and and work allocation Dr B. CVjetanovic
12.00 - 14.00 14.00 - 15.00
.
"
•
•
Amex 3
~
Day
!!!! 15.15 - 16.30
Subject Group discussion on cholera notification and control Dr Me Dr Dr
D. Barua, HI' E. DIIkel, Leavy, Dr B. Cv.letanovlc, ROIlll-SIIi. th and Tin MaUII8 Maunp:
18 Jan
TlI1rsday
09.00 - 10.00 10.00 - 10-15 10.15 - 11.00 11.00 - 12.00 12.00 - 14.00 14.00 - 15.00 15.00 - 15.15 15.15 - 15.115
Diarrhoeal di8ea8ea 88 a problem and reoent research developments Cofree break
Dr D. Barua
Diarrhoeal diseases control progra.e - Regional Diarrhoeal diseasllB control programme - Rational Lunch break
Dr W. T. Chin Dr J.S. Sumpaico
'" I
N
Group discussion on diarrhoeal diseases prog~ Corree break
Dr
D. Barua and Dr J. Sumpaico
Group disculllllon (cont' d) Conolusion Closlng ses810n Dr C.J. Ross-Smith
15.115 - 16.15 16.15