l l ICP/BVM/009 21 February 1983
ENGLISH ONLY
~STERN PACIFIC ADVISORY COMMITTEE ON MEDICAL RESEARCH SUB-COMMITTEE ON DIARRHOEAL DISEASES THIRD MEETING Convened by the
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
t
Manila, Philippines 15-16 November 1982
Not for sale Printed and distributed by the
REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, Philippines
N~E
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The views expressed in this report are those of the members of the Sub-Committee on Diarrhoeal Diseases of the Western Pacific Advisory Committee on Kedical Research and do not necessarily reflect the pOlicies of the Organization.
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This report has been prepared by the World Health Organization, Regional Office for the Western Pacific for Governments of the Member States in the Region and for those who participated in the Third Meeting of the Western Pacific Advisory Committee on Medical Research, held in Manila, Philippines, on 15-16 November 1982.
CONTENTS
1.
INTRODUCTION
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1
2.
REVIEW OF PAST ACTIVITIES OF THE SUB-COMMITTEE AND IKPLEMENTATION OF ITS RECOMMENDATIONS BY THE SECRETARIAT .............................. " " ...... " .. "" ........ " " .... " ............ " " .......... .. 2
3.
PRESENT STATUS OF SOME COLLABORATIVE CDD RESEARCH PROJECTS IN THE REGION .............................. " ................ " ...... " ........ " ................ " .. ..
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3.1 3.2 3.3 3.4 3.5 3.6
Etiological structure of diarrhoeal di8eases with special reference to young age groups - Viet Nam ••• Epidemiological study on infantile diarrhoea and gastroenteritis - New Caledonia •••••••••••••••• Evaluation of the oral rehydration programme for treatment of diarrhoea in Southern Highlands Province - Papua New Guinea •••••••••••••••••••••••. Study of the epidemiology of diarrhoeal diseases - Philippines ••••••••••••••••••••.•••••••• Project proposals from China and Republic of Ko~ea •••••••••••••••••••••••••••••• Other projects ••••••••••••••••••••••••.••••••••••••••
4 5 5 5 6 6
4.
SUMMARY OF DISCUSSIONS AND PLAN OF ACTION 4.1 4.2 4.3 4.4
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4.5 4.6 4.7
Behavioural research .•••••.•.•.•.•••••.•••••••••••••• Epidemiology training •••••••••••••••••••••••••••••••• Environmental health research ••••••••••..••..•••••••• Qualityassessment •••••••.•.•••••••••••.••••••••••.•• Interaction between research workers and CDD programme managers ••••••••••••••••••••••••••••• Review of research applications ••••••••••••••.••••••. Principal investigators' meeting ••••••.•.••••••••..••
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5.
CONCLUSIONS AND RECOMMENDATIONS ANNEX 1 -
........................... LIST OF TEMPORARY ADVISERS AND SECRETARIAT ...... .................................................. • • • • • .. .. • .. .. .. • .. .. • • .. .. • • • • • .. .. • • • • .... • • .. • SUB-COMMITTEE
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ANNEX 2 - AGENDA
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ANNEX 3 - REPORT ON THE PAST ACTIVITIES OF THE ANNEX 4 - ACTION TAKEN ON RECOMMENDATIONS FORMULATED BY THE SUB-COMMITTEE AT ITS SECOND MEETING ANNEX 5 - RECOMMENDATIONS OF THE NATIONAL WORKSHOP OF HYGIENIC TREATMENT OF NIGHT S01L, BEIJING, PEOPLE'S REPUBLIC OF CHINA, DECEMBER 1981 ANNEX 6 - SUMMARY OF COLLABORATIVE COD RESEARCH PROJECTS RECEIVING SUPPORT FROM WHO OR UNDER REVIEW ••.••••••••••••.••.•••••••••.•.•. 33
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1.
INTRODUCTION
The Sub-Committee on the Control of Diarrhoeal Diseases of the Western Pacific Advisory Committee on Medical Research was set up in 1979 and haa since met twice in April 1980 and in April 1981. The objectives of the third meeting held in Manila, on 15-16 November 1982, were the following: (1) (2) (3) through site visits, to assess the problems, constraints and achievements of selected COD research projects in the Region; through progress reports, to review the status of other ongoing COD research projects in the Region; to review the progress achieved and difficulties encountered in implementing recommendations formulated by the Sub-Committee in 1981 ; to recommend a further plan of action.
(d)
The list of participants in the meeting and its agenda are appended in Annexes 1 and 2, respectively. The meeting was opened by Dr H. Nakajima, Regional Director, of the WHO Regional Office for the Western Pacific, who commended the Sub-Committee for its past achievements. He expressed the hope that the third meeting attended by some of the principal investigators of projects receiving support from WHO, or under consideration, would be one 9tep further towards the formation of a core of scientists and research workers, around whom. diarrhoeal disease research would continue to expand. Dr H. Nakajima expressed concern, however, that too often, research projects were not linked closely enough with the national CDD programmes. Thus, these projects were not always aimed at investigating specific programme issues and, as a result, their outcome was of minimal relevance to the establishment or revision of national programme strategies. Dr H. Nakajima emphasized the need for diarrhoeal disease research to become more of a problem-solving activity, rather than a mere academic exercise which neither the countries nor WHO could afford. Referring to these opening remarks, Dr C, Kidson, the Chairman of the Sub-Committee, acknowledged the need for diarrhoeal disease research to focus more on concrete issues related to control programmes. He recalled the structure of the research component of the WHO CDD programme. The task assigned to the Sub-Committee was to advise the Regional Director on the promotion and development of the health services aspects of this component, the biomedical research aspects being dealt with at global level. Recognizing the importance, at the early stage of national CDD programme development of providing baseline data for programme formulation, Dr C. Kidson stressed the need to complete the ongoing studies on the etiOlogy of diarrhoea and, as soon as possible, to make use of this information, stimulating research on the more complex and challenging operational issues which can only be answered through health services and behavioural studies.
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Following these opening remarks, the meeting reviewed the paat and current activities generated by the Sub-Committee, discussed selected projects which were receiving support or were planned, undertook a site visit to research project led by Dr C. Saniel in Alabang, near Manila, and formulated a plan of action, which is reflected in a series of recommendations. 2. REVIEW OF PAST ACTIVITIES OF THE SUB-COMMITTEE AND OF THE IMPLEMENTAtION OF ITS RECOMMENDATION BY THE SECRETARIAT
In an attempt to situate health services research on diarrhoeal diseases in the context of research needs for health for all by the year 2000, Dr Y.U. Paik, Chief, Research Promotion and Development, WHO Regional Office for the Western Pacific, introduced a paper on national health research programme planning. He stressed that the concept of health for all by the year 2000 implied dealing with a broad range of issues which event far beyond the medical care area and required far more than biomedical research. These might be related to such matters as the organization snd funding of primary health care within the communities, the organization of support services, the social evaluation of available technologies, the adjustment of the list of essential drugs for each level of the health system, the development of a health information system more relevant to managerial needs, etc. All these issues were relevant to the control of diarrhoeal diseases. Health research required to be reoriented so as to establish new goals and ensure a balanced development of biomedical, behavioural and health services research so that it can make an effective contribution to the solution of problems impeding attainment of health for all. Sharp boundaries did not exist between these three research areas which formed the spectrum of health sciences. Immediately relevant to the scope of work of the Sub-Committee, the aims of health services and behavioural research were mainly to make health technologies, the product of biomedical research, available to treat, control and eliminate disease, and to restore function or minimize disability. The need for a multi-disciplinary approach to research, and the rapid increase in costs made it necessary fOT each country
to formulate a national policy for health research which would lead to an improved utilization of resources and, just as important, to the utilization of newly acquired knowledge in the health development managerial process. A paper, introduced by Dr Y. Kaneko (Annex 3), summarized the past accomplishments of the Sub-Committee since its inception in 1978 and its first meeting in 1979. He described the research management structure of the CDD programme at the global and the regional level. Research priorities had been set during the first meeting of the Sub-Committee, while prototype of research protocols had been drafted at the second meeting in an attempt to standardize and improve the quality of study proposals in relation to four priority research topics. A number of steps had been taken by the Sub-Committee and by the secretariat to publicize CDD research among countries and areas in the Region which had the capability to contribute to both biomedical and health services components of the WHO programme. Since the creation of the Sub-Committee, 16 research grant applications had been received by WHO from the Region, five of which had been funded at the global
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both biomedical and health services components of the WHO progrsmme. Since the creation of the Sub-Committee, 16 research grant applicstions had been received by WHO from the Region, five of which had been funded at the global level, six at the regional level, while the remaining five were under consideration. There had been more than 30 letters received from workers in the Region expressing interest in conducting research but in many of these cases, the ?roposed research topic did not fall within the set priorities, the study proposal submitted was not sufficiently elaborated to deserve consideration, or correspondence between WHO and the applicant had not resulted in the submission of a comprehensive protocol. Referring to a report on action taken on recommendations formulated by the Sub-Committee at its meeting in 1981 (Annex 4), the secretary of the Sub-Committee, Dr D. Tarantola, stressed that the pace of development of diarrhoeal disease research was adjusted to that of the national CDD programmes. As many of the existing CDD programmes had just been formulated and were at their initial implementation stage, it was anticipated that the various programme issues encountered in these programmes would lead to the submission of research proposals aimed at identifying possible causes of and solutions to these problems. Meanwhile, the secretariat had been able to implement most of the recommendations of the Sub-Committee either through the global or regional offices. One of the recommendations with which the secretariat had had difficulties concerned the promotion of environmental health research in relation to Control of Diarrhoeal Diseases, and the preparation of a model protocol. This was an extremely complex field and the first step towards implementing such activities might well be the application of a Minimum Evaluation Protocol for the International Drinking Water and Sanitation Decade which had been prepared by several WHO Headquarters units, including the CDD unit. Another activity which had contributed to such development was the conduct of a national workshop on the hygienic treatment of nightsoil, held in Beijing, China, in December 1981, which responded to the need to promote environmental health research in general, and in particular to involve Chinese scientists in this undertaking. China was a country where the diarrhoeal disease morbidity problem prevailed whereas diarrhoeal disease mortality, was kept at a relatively low level. Several other activities had been carried out in China to expand CDD research efforts in this country, as recommended by the Sub-Committee. Overall, the recommendations of the Sub-Committee had been found to be concrete and feasible but more time was required than was originally anticipated to raise the level of diarrhoeal disease research to the desired level both in terms of number of proposals and their quality. Dr C. Kidson, Chairman of the Sub-Committee, reported on his attendance at a meeting on operational resesrch on the control of diarrhoeal diseases held in Geneva on 20-21 April 1982. This meeting, organized by WHO Headquarters, had been attended by participants from all the regions of WHO. The major topics of the meeting were: (1) methods for determining regional research priorities; (2) possible ways to stimulate research proposals; (3) methods for the assessment and monitoring of research proposals; and (4) coordination of activities between the global and regional offices in relation to diarrhoeal disease research.
- 4 The meeting was particularly useful in identifying possible means for promoting, ~nitoring and evaluating research, some of which differed from one region to another. The final report on the meeting l included specific recommendations which were brought up in the course of the ensuing discussions during the Sub-Committee meeting. 3. PRESENT STATUS OF SOME CDD RESEARCH PROJECTS IN THE REGION
The principal investigators of research projects on diarrhoeal diseases and members of the Sub-Committee who had performed on-the-site visits to such projects presented a progress report.
3.1
Etiological structure of diarrhoeal diseases, with special reference to young age groups - Viet Nam
The progress report on this project which had been in operation for the past year was presented by Professor Dang Duc Trach, the principal investigator. This community-based study was being conducted in Tu-Liem District, some 15 kilometer from Hanoi, with the specific objectives of: collecting epidemiological data on the distribution, morbidity and mortality patterns of diarrhoeal diseases; determining the enteropathogenic bacteria among diarrhoeal cases, espacially in the younger age group. The data collected during the first year included geographic and demographic characteristics, water supply, sanitation and environmental conditions, morbidity due to diarrhoea, mortality due to diarrhoea and other causes, seasonal distribution and identification of etiological agents. The preliminary data indicated that while mortality in children under five years due to diarrhoea had declined within the three years from 34% to 14%, the overall mortality in children under five years bad remained stationary. It was reported tbat in 1983, studies would include identification of rotavirus and determination of the heat-stable (ST) enterotoxin-producing (ETEC).
10perational Research - Status and Future Plans. Report of an Informal Heeting - Geneva 20-21 April 1982. W~O Document CDD/OPR/82.l.
- 5 The principal investigator of the project had applied for support for a second year. 3.2 Epidemiological studl on infantile diarrhoea and gastroenteritis New Caledonia
The progress report on this project, which had been in progress for the past year was presented by a member of the Sub-Committee, Dr C. Kidson, who prior to th~ meeting had made a site visit to the project. The objective of the project was to study the etiology of diarrboea and gastroenteritis in cbildren under five years, using epidemiological, parasitological, bacteriological, virological and serological data in the affected and control groups. Cultural and socioeconomic information was also collected. Based on these data, it was intended to propose a strategy for diarrhoeal diseases prevention and control. Preliminary data indicated that E. coli was the most common bacteria and the rotavirus the most common virus isolated. The other most common disease associated with diarrhoea was otitis media. It was reported that paracentesis for otitis abruptly cleared the diarrhoea. The project had been well conducted, both epidemiological and laboratory protocols being satisfactory. It was recommended for a second year's support. 3.3 Evaluation of the oral rehldration programme for treatment of diarrhoea in Southern Highlands Province - Papua New Guinea
It was reported that this project had been revised by the principal investigator along the lines suggested by the external reviewers. The project had been recently supported and was at its initial stage of implementation. The objectives of this project were to; study the contribution of oral rehydration therapy to the reduction of mortality due to diarrhoea in children; assess the health workers' skills in the treatment of diarrhoea; assess the extent of morbidity due to diarrhoea in children; determine the community's knowledge, attitude and practice in relation to diarrhoeal diseases. This project was based at the Tari Researcb Unit under tbe Soutbern Highlands Rural Development Project, which intended to study four main diseases occurring in the area - pneumonia, malaria, pig-bel and diarrhoea. 3.4 Study of the epidemiology of diarrboeal diseases - Pbilippines
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The progress report on this project whicb had been in operation for the past year was presented and a site visit arranged by the principal investigator, Dr M.S. Claudia Saniel of the Research Institute for Tropical Medicine. The project area, a peri-urban area of Alabang within Metropolitan Manila was visited by the participants attending tbe Sub-Committee meeting.
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The project was intended to be a two-year community-based study on the epidemiology and etiology of diarrhoeal diseases in children under five years of age. The project area visited was a fairly homogenous community belonging to three socioeconomic groups: upper, middle and lower. The project had been collecting data on environmental sanitation, water supply, feeding practices and incidence of diarrhoea, using standardized pre-coded questionnaires which had been pretested. Standard laboratory procedures had been used to identify etiological agents from the SWABS collected by field workers, who visited households under study twice a week. The preliminary data collected showed that the etiological agents isolated from diarrhoeal cases and matched controls did not differ significantly. However, diarrhoeal diseases were more common in the lower socioeconomic group. 3.5 Project proposals from China and Republic of Korea (1) China - Diarrhoeal diseases in children: study of etiological agents and efficacy of traditional Chinese medicine therapy_
This proposed study, presented by the principal investigator, Dr Liu Xian-yun, was to be conducted by Children's Hospital of Shanghai First Medical College in collaboration with tbe Hygiene and Epidemic Prevention Centre of Shanghai. Preliminary data collected by tbe investigator sbowed that Shigella, rotavirus and campylobacter were important etiological agents in diarrhoeal diseases in cbildren under five years of age and that treatment with the Chinese traditional medicine was equal in efficacy if not superior to western medicine in stopping tbe diarrboea and duration of the diarrboeal episode. This proposal was under review for the support. (2) Rapublic of Korea - Identification of the etiological agents of acute bacterial enteric infections in paediatric diarrhoeal patients in the Republic of Korea.
This proposed study was presented by the principal investigator, Dr Kwang Wook Ko of Department of Paediatrics, Department of Microbiology, College of Medicine, Seoul National University. The proposal for two-year's support was intended to be a collaborative study in the etiology of diarrhoeal diseases involving the Departments of Paediatrics and Microbiology in the urban areas of Seoul and centered on several paediatric clinics serving the middle class population. It was proposed tbat a revised proposal be submitted, expanding the study population by including communities with a lower socio-economic status. 3.6 Other projects
The status of other projects was briefly presented by the secretariat. A summary of sll projects receiving support or under considerstion is provided in Annex 6.
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4.
SUMMARY OF DISCUSSIONS AND PLAN OF ACTION
Following the presentation of each working paper and the visit to the research project in Alabang, and during the last session of the meeting, the Sub-Committee commented on a number of issues and made suggestions on possible ways to approach them. The discussions may be categorized and summarized as follows: 4.1 Behavioural research
This was recognized as an area where CDD research was still weak. There could be several reasons for this: the shortage of experienced research worker in this field in the Region; the complexity of the task; the specificity of research projects, which had to be specifically designed for each community to be studied. This research area was nonetheless one of the highest priority areas if the control of diarrhoeal diseases was to reach its d~sease reduction objectives by developing prevention and control activities which, for the most part would have to be implemented by the community. Several approaches were proposed in order to improve the situation. A number of potential consultants could be identified to assist research workers in formulating study protocols, or to design a standard protocol. A more practical solution might be to prepare a position paper on behavioural aspects of diarrhoeal disease research and distribute it to interested workers. Mention was made of the newly established Sub-Co. .ittee on Behavioural Research of WPACMR and of various documents published on behavioural research by WHO Headquarters and the Regional Office for South-East Asia. These documents would be made available to member. of the Sub-Committee and to intereated resesarch workers. Mentioned waa alao made of a manual on behavioural reaearch prepared by Nebana in London. It was guidelines, consultants quality of, 4.2 agreed that the collection and distribution of relevant manuals, position papers, prototype protocols and the provision of would be helpful in publicizing the need for, and improving the behavioursl research.
Epidemiology training
Members of the Sub-Committee attributed the scarcity of sound field-based research projects to the shortage of trained epidemiologists in several countries in the Region. possible ways for the CDD programme, and for WHO as a whole, to improve the situat~on included the organization of long- and short-term courses in epidemiology, the award of fellowships, particularly for those who had submitted a research proposal or demonstrated interest in this subject. The Sub-Committee, which noted that a course on the epidemiological aspects of diarrhoeal disease research, held at the ICDDR, B, Dacca, Bangladesh, had been attended by participants from the Region, recognized the constraint that the programme val facing in calling for more epidemiological expertise in a world where this science was suffering from a severe shortage of trained manpower. Nevertheless, with its clear-cut objectives, the momentum it had gained, and its appealing research component, the WHO CDD programme could actively contribute to the strengthening of epidemiological services in countries. The secretariat was requested to continue to coordinate with relevant WHO units in training epidemiologists and stimulating them to participate in research efforts.
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4.3
Environmental health research
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The Sub-Committee took note of the various act1v1t1es which had been implemented or were planned to promote and undertake research into the environmental aspects of diarrhoeal diseases. Both the ongoing projects in the Philippines (Dr C. Saniel) and Viet Nam (Professor Dang Duc Trach) included the collection of environmental health data. As there were many confounding variables, however, the practical utilization of such data was very difficult. The Sub-Committee reiterated its previous recommendation that the secretariat should endeavour to develop a model protocol. A first step to acquiring first-hand knowledge of the problems and constraints in developing such a protocol might be the field trial of the ''minimum evaluation protocol" for the International Drinking Water and Sanitation Decade, which was still in a draft form and was due to be finalized early in 1983. The Sub-Committee noted that there was satiSfactory coordination between the control of diarrhoeal diseases and environmental health programmes and hoped that this coordination would be specifically pursued in the research field. 4.4 Quality assessment
Most of the projects currently rece1v1ng support from WHO were investigating the etiology of diarrhoeal diseases. The usefulness of undertaking such studies at the initial stage of national CDD programme development was recognized, although it was clear that little new knowledge with meaningful implications for national programme planning could be expected at this time. These studies and others conducted outside the Region had demonstrated the need for standardization of research methodologies and quality assessment. The production of guidelines for a 'multicentre study" on the etiology of diarrhoea, the preparation of a manual on laboratory teChniques and the preparation of a prototype protocol for studies on the etiology of diarrhoea were all positive factors in overcoming the above constraints. There was a need now to identify institutions within the Region which, as a WHO collaborating centre or otherwise, could act as reference centres for quality assessment. It was further noted that the two global scientific working groups on virology and microbiology were encouraging the development of simple diagnostic teChniques, well adapted to field use. The Sub-Committee encouraged the secretariat to publicize such developments, which could contribute to the improvement of diarrhoeal disease research. 4.5 Interaction between research workers and CDD programme managers
It was agreed that, although diarrhoeal disease research had received special emphasis in WHO only recently, it was not too early to establish mechanisms for more closely linking this research to national control programmes. The Sub-Committee noted that, in the case of the projects receiving support in the Philippines and in Viet Nam, the principal investigators were actively participating in their respective national focal groups on Control of Diarrhoeal Diseases. This was to be encouraged as the isolation of research workers from public health planning had hampered both research and programme development.
- 9 The sub-committee discussed several ways to ensure the desired linkage between these two fields. In addition to the inclusion of research workers in national CDD focal groups, as exemplified above, the Sub-Gommittee felt that health workers responsible for national CDD programme planning should be involved in the formulation of CDD research projects, and that periodic feed-back should be provided by research workers to health planners. Possible means of fostering such an interaction could be periodic visits to research sites and meetings of national CDD focal groups. 4.6 Review of research applications
The review mechanism for screening research applications was discussed with a view to maintaining quality control over diarrhoeal disease research. It was felt that the peer review system used in the Region, and within the CDD programme at the global level and in all regions, should be maintained as it complied with both Regional Office and CDD programme structure requirements. The Sub-Committee expressed the desire to playa more active role in this review system and offered its services to review the applications after they had been commented on by WHO internal and external reviewers. The members of the Sub-Committee, on the basis of the application and the comments from reviewers made available to them, would provide their own comments in relation to the decision on funding which, as in the past, would be made by the Regional Office. Although this additional step in the review process might somewhat extend its duration, the Sub-Committee felt that it would be beneficial to both the secretariat (receiving comments from those involved in advising the Regional Director on the develament of diarrhoeal disease res each in the Region) and to themselves, who were more closely kept informed of the development of such research. The Sub-Committee exchanged views On the system established by WHO for awarding "small research grants". Such grants were intended to provide selected research workers with the small financial support necessary enable them to conduct preliminary investigations prior to the submission of a comprehensive research protocol. There had been instances in which workers were unable to formulate such a protocol unless baseline data had been collected. Such collection could however not be carried out unless some financial support was provided. The Sub-Committee felt that, provided the small grant system was used with caution, it could contribute to the improvement of research proposals. However, it was stressed that such a system should not be considered as a quicker and less demanding substitute for the submission and screening, including peer review, of a comprehensive proposal. 4.7 Principal investigators' meetings
Members of the Sub-Committee expressed satisfaction at the opportunity given them to review ongoing CDD research projects in conjunction with their meeting, and to sit at this meeting together with principal investigators of research projects. The latter found it useful to be made more aware of research efforts made at the regional level, and appreciated the opportunity given them to meet colleagues conducting research On similar subjects. The Sub-Committee felt that such meetings should be encouraged in the future. When there was a sufficient number of projects in a country, a national meeting of principal investigators, also attended by national CDD programme management staff, could be organized. The Sub-Committee also felt that
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national interest in COD research in a country would be stimulated if a meeting were held by the Sub-Committee in that particular country. It therefore suggested that its next meeting be again attended by selected principal investigators, and that tbis meeting be beld in a country where researcb required increased promotion. In order to allow tbe secretariat sufficient time to implement its recommendations, tbe Sub-Committee proposed that it should meet in 1984, a progress report only being submitted to WPACHR at its next meeting in April 1983. 5. CONCLUSIONS AND RECOMMENDATIONS
After reviewing tbe current status of tbe research component of tbe diarrhoea diseases control programme in tbe Western Pacific Region, visiting selected researcb projects, and taking into account reports and suggestions made by principal investigators of ongoing or planned projects, the Sub-Committee formulated the following recommendations: 5.1 Noting that behavioural research efforts are still insufficient inspite of their high priority in tbe area of diarrhoeal diseases researcb, the Sub-Committee recommends tbat tbe promotion of behavioural promotion of behavioural research in the Control of Diarrhoeal Diseases should be encouraged by the inclusion/addition of social scientists in appropriate epidemiological studies, by protocol development in such a setting, by the involvement of social/behavioural scientists in the activities of national resesrcb coordination committees, and by consultations, worksbops and other appropriate means. 5.2 Recognizing tbe general need for improved epidemiological skills in diarrboeal diseases researcb in tbe Region, tbe Sub-Committee recommends that training in epidemiOlogy should be encouraged by appropriate means, if possible within the countries concerned. 5.3 Noting that the activity leading to the development of prototype protocols for environmental interventions was not implemented at regional level as tbis was considered a global activity, the Sub-Committee reiterates its desire to have such a protocol prepared, and urges the Secretariat to proceed with this activity, if it is not implemented in the near future at global level. 5.4 Stressing the need to improve quality assessment and standardization of research methodologies, the Sub-Committee recommends that appropriate reference centres for microbiological methodologies should be identified, and quality control programmes should be initiated in laboratories in the Region with the help of the centres and of consultants where feasible. Furthermore, it notes tbe need for the development and diffusion of simple technologies suitable for field use, and urges that this matter be brought to the attention of the appropriate Global Scientific Working Group. 5.5 Recognizing the need for the greater relevance of research programmes to national Control of Diarrhoeal Diseases control programmes, the Sub-Committee recommends that joint formulation of research projects by research workers, bealth administrators and Control of Diarrhoeal Diseases programme planners should be encouraged and periodic feed-back provided by research workers to programme managers.
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l 5.6 In order to enhance the role of the Sub-Committee in the research proposals revi~w process with a view to assessing proposals in the light of research priorities that it has helped to establish, the Sub-Committee recommends that Members should be sent a copy of research proposale for their review, before a final decision on a grant award is made in the Regional Office. Recognizing that research grant applicants in many cases require support in the development of protocols, the Sub-Committee further recommends that the small research grant system should be used to stimulate study/protocol design and to initiate appropriate new projects. Such small research grants should be viewed as a means for the investigators to gain practical experience while developing a protocol but should not be considered as substitutes for collaborative research projects, which call for the formulation and peer review of a comprehensive study protocol. 5.7 Recognizing the value of the participation of principal investigators in the present Sub-Committee meeting, the Sub-Committee recommends that this format should be repeated at its next meeting in order to assist research strategy formulation and development. The Sub-Committee further recommends that, in order to stimulate national research efforts, its next meeting should be held in a country where diarrhoeal disease is a major problem, where research is being conducted, and where the meeting could stimulate the development of a national CDD programme. This meeting could be held immediately before, or after, the 1984 meeting of the Western Pacific Advisory Committee on Medical Research.
- 13 ANNEX 1
LIST OF TEMPORARY ADVISERS AND SECRETARIAT 1.
TEMPORARY ADVI SERS
AUSTRALIA
Dr C. Kidson Director Queensland Institute of Medical Researcb Brisbane Cbairman of tbe Sub-Committee of WPACKR Dr Liu Shan Yun Cbildren's Hospital and Paediatric Researcb Institute Sbangbai First Medical College Sbangbai Additional Member of WPACKR Dr Y. Kaneko Professor of Public Healtb and Cbairman, Department of Public Healtb Tobo University. Tokyo Member of tbe Sub-COIIIIIittee of WPACKR Dr Deborah Lebman Director TAR! Researcb Unit P.O. Box 35, TARI SHP. Papua New Guinea Additional Member of WPACKR Dr Mediadora C. Saniel Head Clinical Researcb Division Researcb Institute for Tropical Medicine Alabang. Metro Manila Additional Member of WPACKR Professor Kwang Wook Ko Professor and Cbairman Department of Paediatrics College of Medicine Seoul National University Additional Member of WPACKR
CHINA
JAPAN
PAPUA NEW GUINEA
PHILIPPINES
REPUBLIC OF KOREA
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Annex 1 VIET HAM Professor Dsng Due Trach Vice-Director National Institute of Hygiene and Epidemiology Hanoi Member of the Sub-Committee of WPACMR
2.
SECRETARIAT
Dr Y.H. Paik Chief Research Promotion and Development (Secretary of WPACMR)
Dr C.J. Ross-Smith
Director Disease Prevention and Control Dr D. Tarantola Regional Adviser in Communicable Diseases (Secretary of the Sub-Committee)
Dr H.D. Mehta Medical Officer ICP/EPI/CDD
- 15 ANNEX 2
AGENDA Monday, 15 November 1982 0800 0830 0845 0900 0915 0930 1015 1035
Registration Opening address Address by the Chairman Coffee break Plan of Work Personal/financial matters National health research programme planning Report on past activities of the Sub-Committee on COD of the WP AGKR Report of the Secretariat of the Sub-Committee on the Control of Diarrhoeal Diseases of the WP ACMR, 1981-1982 Report on the Meeting on Operational Research on the Control of Diarrhoeal Diseases, Geneva, March 1982 Adjourn Presentation of reports on ongoing and planned COD research projects (20 minutes presentation, 10 minutes discussion) 1.
Dr K. Nakajima Regional Director Dr C. Kidson
Dr C. Kidson Dr D. Tarantola Dr Y.K. Paik
Professor Y. Kaneko Professor Dang Duc Trach Dr K. Mehta
1055
Dr D. Tarantola
1115
Dr C. Kidson
1135 1330
Progress report and summary of findings on the COD research project - Viet Nam Progress report and summary of findings on the COD research project - New Caledonia
Professor Dang
Due
Trach
2.
Dr C. Kidson
- 16 Annex 2 Monday, 15 November 1982 1330 hours (cont'd) 3. Presentation of study proposal Papua New Guinea Presentation of study proposal - China Presentation of study proposal - Korea Presentation of study proposal - other countries
Dr Deborah Lehman Dr Liu Shan Yun Professor Kwang Wook Ko Dr D. Tarantola
4. 5. 6.
Tuesday, 16 November 1982 0800 Site visit to the CDD research project, Alabang Metro Manila Return to WHO Preparation of plan of work in particular:
Dr M.C. Saniel
noo 1330
activities to further promote CDD research in the Region review mechanism for study proposals 1530 1630 Formulation of recommendations
Dr C. Kidson
Closure
- 17 -
ANNEX 3
REPORT ON THE PAST ACTIVITIES OF THE SUS-COMMITTEE ON THE CONTROL OF DIARRHOEAL DISEASES OF THE WESTERN PACIFIC ADVISORY COMMITTEE ON MEDICAL RESEARCH1 by Profeslor Y. Kaneko Prof.e.or Dang Due Trach Dr H. D. Mehta
1I •• ued a. a working paper, number WPR/RPD/CDD/82.3 end distributed to tho.e who participated in the Third Meeting of the SUb-Com=ittee on the Control of Diarrhoaal ni.ea.e. of the W.stern Pacific Advi.ory Com=itte. on Medical ....arch h.ld in Manila, Philippin•• from lS-16 Nova-ber 1982.
- 18 Annex 3 1. introduction
"
The WHO Control Programme On Diarrhoeal Diseases (COD) was established in the Western Pacific Region in 1978. It includes both services and research components. In 1979, two planning meetings were held, one in Suva, Fiji, the other in Manila, Philippines, in order to draw up the plans for national programmes and for the promotion of research - in particular the operational (field based) research - in the Region. In 1979, the Western Pacific Advisory Committee for Medical Research (WP ACMR) established a Sub-Committee specifically for Diarrhoeal Diseases (COD). The research component of the programme i. designed to meet, and be responsive to, the needs of the health services component, which in turn provides a mechanism for the early application of the research findings. In March 1980, following the recommendations of the Global Advisory Group on Medical Research, a management plan for the research component was implemented, which included the formation, at both the global and regional levels, of Scientific Working Groups (9OGs), composed of scientists from outside WHO, in order to plan and coordinate research activities. Under this plan, the global Scientific Working Groups are responsible for basic research activities, while the regional Scientific Working Groups or analogous groups are responsible for operational research activities. 2. Basic (biomedical) research - global Scientific Working Groups
At present, there are three global .Scientific Working Groups in the areas of: Bacterial enteric infections: microbiology, epidemiology, immunology, and vaccine developments; Viral diarrhoeas; microbiology, epidemiology, immunology, and vaccine developments; and Drug development and management of acute diarrhoeas. The three global Scientific Working Groups met for the first time during 1980 and developed a five-year research work plan and determined the priority areas for research within the plan. The execution of the research plan of each global Scientific Working Groups is the responsibility of its Steering Committee (SC). 3. Operational (health services) research - Regional SWGs
To date, regional scientific working groups (or analogous groups) have been established at the Regional Offices for the Americas, the Eastern Mediterranean, Africa, South-East Asia and the Western Pacific. Ba.ed on the recommendations of various regional bodies, including the respective
- 19 -
Annex 3 regional ACMRs, priorities for research have been developed. Within the operational research area, priorities differ both from region to region and from country to country and depend very much on the needs and activities of the CDD programme in individual countries. However, certain broad priority areas, common to all regions, have been
identified.
Examples of these include:
(i) investigations of strategies for oral rehydration therapy and case management;
(ii) etiological studies of diarrhoeal diseases under different ecological and cultural conditions, including studies aimed at identifying the most susceptible population groups and important etiological agents;
(iii) studies to determine optimal approaches to promote brea8tfeeding and preparation of safe, locally available weaning food; and (iv) development of simplified and reliable methods of surveillance. The mechanisms for review and funding of proposals vary .lightly among the regional Scientific Working Groups but they all utilize the process of peer review. Funding of projects is already established and was initiated in 1981. In the Western Pacific Region, a Sub-Committee on Diarrhoeal Diseases of Western Pacific Advisory Committee on Medical Research, established in 1979, fulfils the role of a regional scientific working group. 4. The first meeting
The first meeting of the Sub-Committee on Diarrhoeal Diseases of Western Pacific Advisory Committee on Medical Research was held at the WKO Regional Office for the Western Pacific Region (WPRO), Manila, on 17 April 1980.
The objectives of the first meeting were: (l)
to review the current research component of the WHO programme on the control of diarrhoeal diseases; to identify priorities for research and review management and funding mechanism for research; to make recommendation for future activities.
(2) (3)
With the above objectives in mind, the Sub-Committee members reviewed the overall activities of WHO programme for the control of diarrhoeal diseases and in particular the past and present activities within the research component.
- 20 Annex 3 Further, the sub-co~ittee developed its terms of reference and prepared a plan of work. During the meeting, the sub-committee members reviewed and discussed the research management structure, research priorities, procedure for submission and review of research proposals, available epidemiological data, available research capabilities in terms of scientists and institutions and cooperation and interaction between the scientists and institutions. Based on these discussions, the Sub-Committee members established research priorities for the Region and a mechanism for submission, review, management and funding of research proposals. A work plan was prepared, which included the following: (1)
to compile a list of scientists and institutions actively involved in diarrhoeal diseases research, which list would also include a list of scientists who could act as external reviewers; to encourage scientists to submit research proposals and provide assistance in improving the quality of their research proposals; to strengthen cooperation and interaction between scientists and institutions in the Western Pacific and the South-E•• t Aeian Regions.
(2) (3)
The members of the Sub-Committee were given the responsibility of assisting in implementing the work plan. 5. The second meeting
The Sub-Committee held its second meeting a year later, in April 1981, at WPRO, Manila. The objectives of this meeting were to review the research activities 1n the Region in the past year and develop a plan of work for the following year. The Sub-Committee members focused on the steps taken within the past 12 months to implement the work plan and recommendations of the first meeting. It was considered that significant advances had been made during this period and that the programme was moving ahead in line with the overall recommendations. It noted that information dissemination had been done effectively to promote the programme within the Region and the the list of the scientists and institutions has been prepared. In spite of the active steps taken during the year through the contacts and services of consultants to increase the number of research proposals supported within the Region, the research workers who had expressed a definite interest in submitting applications at the time of contact had failed to submit them. It became clear that many workers in the Region were not fluent in any of the WHO working languages and were often unable to fill in the application forms in a language in which they had difficulties in expressing themselves.
- 21 Annex 3 On the other hand, operational research seemed to require skills that are not frequently taught as compared with biomedical re.earch which can be learnt in laboratories or research institutions. Thus, the workers who submitted applications often lacked knowledge on how to prepare a protocol, design a population sample, prepare a questionnaire and obtain valid information through interviews conducted by field workers with a m1n1mum level of training. Clearly, expertise in operational research was still largely lacking.
In an attempt to improve the situation, advantage was taken of the second meeting of the Sub-Committee on the Control of Diarrhoeal Diaeasea of Western Pacific Advisory Committee on Medical Reaearch to prepare prototype protocols in four priority areas: (a) (b) (c) (d) epidemiology and etiology of diarrhoeal diseases; evaluation of the efficacy and safety of various methods of oral rehydration therapy; cost-effectiveness of alternative treatments of diarrhoea in use within the national programmes; and evaluation of tbe efficacy and safety of traditional medicine (herbal medicine) in the early treatment of diarrhoea.
The Sub-Committee agreed tbat the draft protocols sbould be sent to acknowledged experts in tbe relevant areas for furtber review and comment, and be subaequently sent, at its discretion, by the secretariat to interested researcb workers. It was stres.ed that workers usin, the protocols sbould be made fully aware tbat tbey were only "ex_ple." and tbat they required adaptation to specific situations. • The Sub-Committee also recommended tbat it should continue to work witbin the framework of the terms of reference developed at its first meeting, and develop a plan of work for the following year. l The Sub-Committee further recommended to the Regional Director: to continue its institute strengthening and research collaboration activities; to explore the feasibility of organ1z1ng two workshops which could result in obtaining data on the epidemiology and etiology of diarrhoea within the Region; to call on specialist expertise to prepare a working document to develop protocols for studies on appropriate interventions to control diarrhoeal diseases witb emphasis on food hygiene, safe water supplies, sanitation and nutrition;
IDetails in Final Report, WPACMR, Sub-Committee on Diarrhoeal Diseases, Second Meeting, Manila, Pbilippines, 22-28 April 1982.
- 22 -
Annex 3 to continue the use of consultants and short-term training grants to improve research planning and management. A summary of the steps taken in order to impl..ent these recoamendations will be presented later during this meeting by the Secretary of the Sub-Committee. 6. Conclusions
The Sub-Committee has recognized the difficulties and the challenges it faces in promoting operational research in the Region. In spite of the limitations of the research workers in the field of operational research, and through encouragement, information dissemination and provision of the services of consultants, the research component of the COD progr ...e is now taking a promising turn. Since the creation of the Sub-Committee, some 16 research grant applications have been submitted by scientists working within the Region, of which five have been funded at the global level, six at the regional level which several are still under review. The Sub-Committee members, in addition to reviewing the activities and making recommendations to the Regional Director, have also contributed in the preparation and updating of the list of scientists and institutions and the development of prototype research protocols. They have also undertaken field visits to review ongoing research activities. Thus, the Sub-Committee has been a forum for formulating policies and priorities and has also actively contributed towards research proaotion in this ..gion.
• - 23 -
ANNEX 4
ACTION TAKEN ON RECOMMENDATIONS FORMULATED BY THE SUBCOMMITTEE ON DIARRHOEAL DISEASES OF THE WESTERN PACIFIC ADVISORY COMMITTEE ON MEDICAL RESEARCH (WPACKR) 1 by Dr D. Tarantola Regional Adviser in Communicable Diseases Secretary of the WPACMR Subcommittee on Diarrhoeal Diseases
lIssued as a working paper, number WPR/RPD/CDD/82.4 and distributed to those who participated in the Third Meeting of the Sub-Committee on the Control of Diarrhoeal Diseases of the Western Pacific Advisory Committee on Medical Research held in Manila, Philippines from 15-16 November 1982.
- 24 -
Annex 4 INTRODUCTION The Subcommittee on Diarrhoeal Diseases of the WPACMR formulated a set of recommendations at its second meeting in April 1981. This report summarizes the action taken to implement them. Some of these actions were taken at the national or regional level while others, which called for interregional collaboration, were taken at the global level. Overall, the recommendations of the second meeting of the Subcommittee proved to be practical, and their implementation was in most cases possible. It is, however, well recognized that the development of research capabilities, particularly in the field of operational/field-based research, is a slow and difficult process. In most countries where diarrhoeal ~iseases represent a problem, national control progra.mea have been established and a set of operational constraints are being identified while these programmes are going through their initial stages of development. Field-based research has, so far, mostly been aimed at establishing base-line data on the etiology of diarrhoea. As programmes further expand, it is hoped that research will increasingly focul on specific issues which have been identified by the managers of the control of diarrhoeal diseases (CDD) programmes as representing major conatraint. to an effective reduction of morbidity and mortality from diarrhoea. It i. anticipated that by 1983, CDD programme evaluation, covering the manaaerial and technical aspect. among others, will lead to the identification of such constraints. It should be possible at that time to link more intimately operational, in particular health services research, to national prolramme development.
- 25 Annex 4 RECOMMENDATIONS OF TRE SECOND MEETING OF THE SUBCOKKITTEE SUMMARY OF ACTIONS TAKEN ON RECOMMENDATIONS
(1) The central theme of the meeting was the preparation of model protocols in four priority research areas, viz: etiology and epidemiology of diarrhoea, cost-effectiveness of alternative oral rehydration salts (ORS) strategies, and evaluation of the efficacy and safety of ORS and traditional medicine in the treatment of diarrhoea. The Sub-Committee recommended that these protocols should now be sent for external review to acknowledged experts in the relevant areas. Following this, it is recommended that the revised protocols be used, with discretion, to help workers in the Region to formulate research proposals.
(1) The four protocols were sent to internal (WHO) and external reviewers. The drafts were made available in an improved form, together witb the comments of the reviewers, to research vorkers. It is likely that the next revision of the drafts will only be possible once they have been actually tried out and adapted in the light of experience. The prospects for using theae drafts in selected countries are as follows: (a) Etiology of diarrhoea: Philippines, Viet Bam, New Caledonia (b) Cost effectiveness of oral rehydration: Philippines (c) Traditional medicine: China, Philippines. Viet Mam (d) Alternate .. thods of oral rehydration therapy: Malaysia, Philippines.
(2) As a part of its institute strengthening and research collaboration activities, the Sub-Committee recommended that the Secretariat should write to identified institutions and groups in the Region, encouraging them to submit protocols in the priority research areas chosen at the first meeting of tbe Sub-committee on Diarrhoeal Diseases.
(2) A computerized list of some 300 workers and institutions involved in all aspects of the Control of Diarrhoeal Diseases, including researcb, was prepared in 1980 and has been updated twice a year since then. using this list, pamphlets and bulletins have periodically been distributed by the CDD unit at WHO Headquarters. The report of the second meeting of the WPACMR Sub-Committee on Diarrhoeal Diseases Control was mailed to soae 100 workers and institutions selected from the computerized list. The opportunity was also taken through existing media (among others, the Health and Development Newsletter published by the WHO Regional Office for the Western Pacific) to publicize CDD research.
- 26 Annex 4 A circular letter was also sent by Headquarters, based on a li.t prepared by the Regional Office, to all medical research councils in the Region. (3) Because of the lack of comparative data on the epidemiology and etiology of diarrhoea within the Region, the Sub-Committee recommended that the Secretariat should explore the feasibility of organizing two workshops as follows: (a) intercountry collaborative studies on the microbial etiology of diarrhoeal disease at the community level; (b) planning of community-based studies, including the most appropriate delivery and management systems, to ensure that ORS is available to the community at large. (3) The Secretariat explored the feasibility of impleaenting these two activities. Discussions with WHO Headquarters and other regional offices led to the decision to implement these activities on an interregional basis in order to maximize tbeir usefulness: (a) A multicentre study into tbe etiology of diarrhoea is planned at global level, using a standard protocol and based on facilities which would have similar capabilities and would use similar diagnostic procedures. The draft protocol for this study has just become available. (b) A training course in epidemiology, particularly directed to the establishment of community based research project. on diarrhoeal diseases, was held at the International Center for Diarrboeal Disease Researcb (ICDDR), B, Dacca, in October 1982. Participants from tb. China, Malaysia and tbe Philippines attended tbe course.
- 21 -
Annex 4 (4) The original priorLt1es of the Sub-Committee included the consideration of a number of environmental interventions as a means of reducing diarrhoeal diseases morbidity; more work is required in this area. The Sub-Committee therefore recommended thst, at its next meeting, an attempt should be made to develop specific protocols for studies on appropriate interventions to control diarrhoeal diseases with emphasis on food hygiene, safe water supplies, sanitation and nutrition (including studies of community participation and behavioural patterns). Considering the complexity and time required to prepare such protocols, the Sub-Committee further recommended that specialized expertise should be called upon to prepare praliminary working documents for the meeting. (5) The technical visit on the control of diarrhoeal diseases to the People's Republic of China in August 1980 further demonstrated the interest and potential for research in diarrhoeal diseases that exist in that country. The Sub-Committee recommended that WHO should explore the feasibility of organizing advanced training activities on diarrhoeal diseases research in China. (4) Considering the difficulty involved in preparing a protocol on environmental interventions and the need to standardize such a protocol aa far as possible at the global level, the Headquarters' CDD unit requested WPRO not to proceed with this activity until the feasibility and usefulness of such a protocol has been assesled. Recently a draft "minimum evaluation procedure" for evaluating water supply/sanitation programmes, in particular their impact on diarrhoeal diseases, has been produced by Headquarters and is currently under review. Although this procedure is more relevant to evaluation than to reaearch, it seems that it is a firat step towards identifying specific constraints in conducting evaluations, to which research could find a solution.
(5) A national workshop on the hygienic treatment of night soil conducted in Beijing in December 1981, focuaed on the evaluation and reaearch aapects of excreta disposal and use. The recommendations of this workshop are attached (Annex 1).
- 28 Annex 4 A number of activities directly related to reaearch on diarrhoeal diseases have been implemented, or are planned in China~ Activity Date 'iDiPIemented June 1982
Seminars on Research on Enterotoxin (Dr J. Craig, Dr Y. Takeda) Shanghai, Beijing Hational Workshop on Research Methodology Shanghai Workshop on Hygienic 1. Treatment of Hiaht 11. Soil Seminars on Diarrhoeal Diseases Research Reijing, Shanahai, Hangchow
25 Oct. to
5 Hov., 1982
December 1981 1983 (planned) Decellbel" 1982 (arrang_nts finalized)
In addition, participants from China were sent to training course. or study couraes in Ranglede.h (lCDDR, B), India, Japan and the United State. of America.
- 29 -
Annex 4 (6) The continued use of consultants and short-term training grants is desirable as a further step in improving research planning and management. The Sub-Committee recommended that a list of consultants available for work within the Region should be prepared.
(6) The list of potential consultants and temporary advisers was prepared. This list was used to provide consultants' and temporsry advisers' cooperation in planned or ongoing research projects as follows:
Country Visited China China (Hygienic Treatment of Night Soil) China
ConsultantL Tem~rar;(
Period
Adv1ser Dr J. Craig Dr Y. Takeda Dr P. Barua Dr
June 1982 Dec 1981
Dr Yao
Dr D. Maha1 anabis Dec 1982 Dr C. Kidsou Dr M. Merion Dr G. Morrie
Dr D. Sack Dr D. Tarantola
New Caledonia
Dr C. Kidson
Nov 1982 July 1982 April 1981 July 1982
Philippines Dr E. Gangarosa Korea Guam Dr Dr
R. Sutton E. Gangarosa
In addition, research projects were discussed during training courses and visits in which consultants and WHO staff participated. This applied, among other countries, to Fiji, Malaysia, Papua New Guinea, Vanuatu and Viet Ham.
- 30 -
Annex 4 (7) Exchange of information regarding diarrhoeal diaeases activities between regions (especially between the Western Pacific and the South-East Asian Regions) is desirable. The Sub-Committee believed that the current level of interregional cooperation in the area of the diarrhoeal disease research was sub-optimal and recommended that increased efforts should be made in this regard. - SEARO represented at a meeting of WPACMR, April 1982 - Chairman of WPACMR Sub-Committee on the Control of Diarrhoeal Diseases attended global meeting - Exchange of reports and documents - Use of ICDDR, B as interregional institution. (8) The Sub-Committee felt that considerable progress had been achieved during the year in implementing the recommendations made at its April 1980 meeting and felt that the activities of this Sub-Committee were important and should continue within the present terms of reference. The Sub-Committee recommended that it should meet again next year. (8) The third meeting of the Sub-Committee will be held in Manila from 1S to 16 November 1982. (7) A number of steps were taken in order to increase the interragional exchange of information. In particular: - SEARO wa. represented at the meetings of WPACMR in April 1981 and April 1982; - the Chairman and the Secretary of the Sub-Committee on Diarrhoeal Diseaaes of WPACMR attended a meeting on operational research, which was held in Geneva in April 1982, and which involved Headquarters staff and participants from all the regions; and - reports and document. were periodically exchanged between reaions.
- 31 ANNEX 5
RECOMMENDATIONS OF THE NATIONAL WORKSHOP ON HYGIENIC TREATMENT OF NIGHT SOIL BEIJING, PEOPLE'S REPUBLIC OF CHINA, DECEMBER 1981
The following research priorities were proposed based on the results of a critical assessment of present practice in night soil treatment and use in China and the technologies existing in their countries by the consultants and participants; (1) microbiological studies of the effluent from biogas digesters as collected for use as fertilizer after different retention period. should be carried out to determine the value of MPH method for faecal coliform (F.C.) and Ascaris egg count as indicator for adequate treatment. The study will have to be done in different seasons and different parts of the country on a relatively large number of digesters and should include, in addition to the MPN for F.C. and Ascaris egg count, search for pathogenic enteric bacteria (at least Salmonella), one of the enteroviruses or coliphage., cysts of !. histolytica and £. lamblia and eggs of other hel.inths (hookworm, trichoris, etc.). The idea is to see whether there i. a correlation between a coli-titre and Ascaris egg count and the pre.ence of pathogenic bacteria, other helminths and enteroviruses in the . .terial, which may help to decide on a IJIOst practical and reliable indicator. (2) similar studies should be undertaken for sludge reaoval from biogas digesters at 6, 9 and 12-month intervals; compoat material after different time intervals of composting; and effluent and sludge from multiple-compartment septic tanks in order to develop a simple test as an indicator to monitor these processes of treatment on a routine ba.is. -(3) the studies mentioned above should be Combined with studies on survival of the microbes found in the effluent/sludge/compost when applied in the field, on the soil and on the crop. (4) if possible, it would be ideal to undertake en epidemiological study at the same time, on tbe incidence of diarrboea with deteraination of etiological agents, among the consumers of these crops. Such studies should be multidisplinary and involve epidemiologists, .icrobiologiats and sanitary engineers. If a coabined study is not possible, epidemiological studies should be carried out independently in different parts of the country to evaluate the public healtb risks of the current night soil utilization practice. (5) though the current practices ·of night soil treatment by biogas and composting processes in China are helping to reduce enteric infectionl, there is still room for improvement. Therefore, there i. an urgent need
- 32 -
Annex 5
for development of reliable, simple and appropriate chemical engineering and microbiological technologies to ensure the sanitary control of the.e processes for application allover the country. (6) studies should be undertaken to determine the incidence and nature of enteric infection and chlonorchiasis among consumers of fi.h and other aquatic products from fish ponds receiving night soil for promoting pisciculture (though most of the products may be difficult to trace after being sold, there may be a large number of local con.umers who eat these products regularly). Such studies are to be limited to areas where such utilization of night soil exists. (7) an epidemiological study is needed to determine the incidence of acute enteric infections among workers and their f . .ilies engaged in handling, treatment, and use of night soil. The incidence will have to be compared with that in a control group of different profes.ions but otherwise similar. (8) fundamental research for elucidating the nature of chemical processes and the types of bacteria and enzymes involved in the composting and biogas systems should be encouraged in order to improve the rate of pathogen kill in these processes. (9) a pilot plant scale study on thermophilic anaerobic dige.tion for urban night soil treatment baaed on the Qingdao experience .hould be undertaken for the determination of the optimum design and operational conditions in terms of elimination of surviving parasitic egg. and pathogenic bacteria, heat balance, maximum ges production, maximum BOD reduction and minimization of capital, operating and maintenance costs. In conducting the study, consideration should be given to different conditione in different cities in the country with particular eaphaai. on the thickening of raw night soil to achieve favourable net energy production in the process. (10) studies should be undertaken to develop standard laboratory methods of parasitic and bacteriological examination for use througbout the country. (11) a research centre to study hygienic treatment and use of night soil should be established to coordinate research on development of engineering methodologies, to improve sanitary control of biogas, composting and other processes used for night soil treatment, to innovate technologiea for night soil treatment and to develop epidemiological and microbiological methodologies for monitoring.
I
J
- 33 -
SUMMARY OF COLLABORATIVE RESEARCH PROJECTS RECEIVING SUPPORT FROM WORLD HEALTH ORGANIZATION, OR UNDER REVIEW AS OF 31 OCTOBER 1982 1
Ilssued as a working paper, number WPR/RPD/CDD/82.11 and distributed to those who participated in the Third Meeting of the Sub-Committee on the Control of Diarrhoeal Diseases of the Western Pacific Advisory Committee on Medical Research held in Manila, Philippines from 15-16 November 198Z.
- 34 -
Annex 6 County (Humber!
Title Etiological structure of diarrhoeal diseasea with special reference to young aga: groups.
Investigator(s) Prof. Dang Due Tracb
Institution(s) National Institute of Hygiene and Epidemiology
Summag
Date started and status Proposal received in wpao on 3 April 1981. Project in Progress. Second year funding is under consideration
Viet Nam. (WP/8100S)
The specific Objectives of the study are;
(a) Btudy of the distribution, morbidity and mortality patterns of diarrhoeal diseases; (b) identification of environmental factors contributing to the prevalence of diarrhoeal diseasesi (c) identification of behavioural and nutritional factors COntributing to the prevalence of diarrhoeal diseasesi (d) determination of causative pathogens, especially among children aged below four years, i.e. tbe group where diarrhoea is most prevalent. The study findings will be analy•• d in order to establisb more effective method. of control aod prevention ..
This will contribute to increaBed understanding of the epidemiology of diarrhoeal disea8e. iu Viet Has and the region. Philippioes (WP/81003)
A study of the epidemiology of diarrhoeal diseases
Dr M.S. Claudio-Saniel Dr Thelma E. Tupasi
The leaearcb Institute
for Tropical Medici.e
Received ill WPRO tbe epide.iology of diarrhoeal on 3 July 1981. diseases with .pecial reference Project ia procre... Second to bacterial pathogens. year fundiug under Th. stu.dy protocol is designed to puraue ~ltiple factors such consideratioD. aa .icrObiological, environmeutal, nutritional, behavioural, factors ¥bieb influence the .pideaiololY of diarrhoeal dise •• es La the Philippine •• The objective is to study
- 35 Annex. 6
Couaty (Number)
!ll!! A atudy of iDfectioo8 amoDg preachool children in • p£'i.JUry he.,l tb care .attiae in • Pacific village ca..DDity.
tnv•• tiaatorCs) Dr Ian Gu.t Dr Richard J. Taylor Dr Prank Spooner
ID8titQtioa.(.) - P.irfield Hospital, 1fa1_ - South Pacific ec-i •• ion - Vaauatu IIIB
8_7
Date 8 tarted aad status Proposal received in WPIO 00 28 Dec. 1981.
Vaauatu (WP/81008)
The Objecti•• of this .tudy i. to defia. the iecidea.ce aDd etiolol1 of eataric infectious amaas ehildreo in a 'a.i£ic village c~Dit,. by • 10001itadlael .lady. 'l'h. iu£onoaliou collected will ....bl.
eo..ittea
preveative measure. to be fonmlatad.
baa agreed to recommend the propo•• l for !undine. BoVever. cba1l8e in the uae of the PI v •• proposed. Propo•• l ~eceived in IIPIO aD 27 July 1981. Be.iled propo •• l received all 3 Sept. 1982. Subaitted to peer
au-
Salmonallosi. Ie
Quaa
Dr Iobart L. IIad40ck
Deper_t of _lie H.alth .ad Soci.l Servi...
'l'he stad)' aiM at iuft.ttptina the .ade of traaa.i•• ioD of ••laoaello.i. iu Guam. Kierobiolosical. epideaiololical aDd arir~tal factor. will b. e_ldarad. Spacial ~.l.. will be plac.d OD s. vaycr08 •• Study OIl tile etiolou of i"fantU. diarrhoea .... PI troateriti. OD the b •• i. of
reviewer ••
Hew CelMODie (liP /80004)
Bpide.ioloaical .tudy on
ittfaDti1. 4iarrho.. a04 . . <r_teritia ill _ Ca1e40llia.
Dr George. La Ganidec Dr J.8O Joseph Ploch
In.titut 'asteur de_
laceived in WPI.O 00 26 September 1980.
para.ltolo,leal, baeterioloalcal Project iD .... wirololi••l ..... proar.... 8aarcb for • li1lk with epi-
dooILololical ODd ••rologic.l ..ca. Doe fiuel .iII of tbe 'Cady ia to proyU. a .e iqtUie bale for control a . p~.... tioD
Sacolkl ,.ear fuDdiu, wader coa.li.der.tion.
of ....ure. of
Chi....
• .... teriologic.l .....,. GO
Dr lII1il&ll 8i11a
iur••til. 4iartbeeo
.pU.ic
eftae
. . . . . Ifti-....,...,iaiI
iIIfatil. diarrbDaa • 'l'he .la of ebb ruaarcb propont b to obtai" bett.r
Proposal received. ill IIPIO all 14 July
CoitCI'.:8 _ -
uadultaadiq of the caua. 1981. of 4iarrboul di...... doe Project ia to .... idec.lou of ~lO bace. .i!.i!!!!, '1erlbeDtera- proare.. . pat"-1c --~j ~a
"eGa-
a lead, .... i.
..acted for eoa.icieratiOD by DOC.
_icipatit,.
- 36 -
Annex & County (Number) Republic of Korea (WP/8l004)
.lli.!.! Study on pathogens for acute diarrhoea and its aotibiotic susceptibility
lavestisator(s) Professor Seung Kahm. Park
Institution(.) Hanyans University
SulllllJ.&ry The study aLaa at deteraining the etiology of diarrhoea in bospitalized ea.es. It also ai~ at defining the antibiotic susceptibility of pathogenic bacteriae isolated.
Date started and status Proposal received ia WPRO on 7 July 1981.
Progre8s report received on 2 Sept. 1982.
Tongatapu, Tonga (WP/82002)
Coaprebensive .tudy of the epidemiology of rotavirus diarrboea in the Kingdom of T011&8
Dr Tupou Dr A. Divan
Tonga Ministry of Health
Tbe overall objective of thi. research is to elucidate the epidemiology of rotavirus diarrhoea in tonga. The specific objective. ar.~ (1) to determine the role of rotaviruses as etiological alents of diarrhoeal disease in infants and young children; (2) to determine the prevalance, distribution aDO relative importance of the two known rotaviru •• erotypes; (3) to elucidate the epidemiological characteristic. and Laportant clinical features of rotavirus diarrhoea; (4) to deteraioe the pattern and the extent to ¥bicb crosstrana.ia.ioo, of human and pig rot.viru. oecur under natural couditiou8; (5) to evaluate the role of d~8ti c.ated piss a. po.sible reservoirs of rotaviru. infection io buaaas; (6) to iotelrate all the fiDdia&. from tbe three survey•• and with respect to tbe objectives of the WHO diarrhoeal di.eaae. control proSr..... to provide a coapreheasive .tudy of tbe epideaio\ogy of rotavirus diarrboea in Tooga; (7) to provide accurate aad pertineat data for the purpose of supportiol studies aiaial at tbe developmeut of a rotavirus vaccine for use in -an ao4 d.sisoia, a stratest for ~oprophylaxi8 aaaiaat di.rrhoeal 4i.ea ••• ia tong ••
Propo8al received on l5 Karch 1982.
Propo8al supported, bowever t revi.ion of the protocol i. rec.ouaettded; to reach WPI.O 'DOt later thaD 15 Bov. 1982.
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AIm"" 6 c-..ty
<_er) Papua )lev Guinea (IIP/82001)
!!E.!!. BYaluation of oral rehydratioD proar...e for t't'eataent of diarrhoea
lave.tia_tor(a) Dr' Deborah LebaaDn
Iutltutioub)
au-&ry
.Date started. and Itat~
tari .....rcb Dnit
in Soutbern Bi8blaada ProviDce. Papua x . Guinea
The objectives of tbi. study .re~ (1) to determine the aortality rate fro. diarrhoea in children and Whether oral rehydration tberapy (OIT) may have contributed to • fall in .art.lity fro. diarrhoea in cbildreaj (2) to a.seaa the extent of IDOrbidity fro. diarrhoea in childreni (3) to a8.e88 health workera akills in the treatment of diarrhoea; (4) to dete~iDe the availability of neces.ary ORr equipaent at different level. of health care; and (5) to determdDe comaunity kDowledge. attitude. and practice in relatioD to diarrhoeal diseaa.8. Thia field atudy in d..olrapby and . .die.l anthropology on diarrhoe.l aDd asaociated diaea8e8 in aome provincea of the Philippine. ai.a. (1) to .atiaate -arbidity and sortality ratea due to diarrhoeal di.ea8e8 in childreni (2) t~ better co.prebead aod uoderatand the factors of the ecosyst. . , physical aDd cultural. responaible for the levela of theae disea8e8 ia the conditions as.ociated with theR; (3) to attempt to reduce the affecta of diarrhoeal diaeaaes upon children l • health. particularly by aeasures aieed at improvement of environmental and parental behaviour; and most importantly; (4) to involve parent. in imple.eutinl the project (with medical staff a. catalyst and adviser).
Ileceived in WPRD aD 15 April 1982. Original iropo •• l revhed b, the PI along ~e line• auggeated by the extenal reviewera. Project funded; now at it. initial .tase~
Pbiii,pinea (IIP/82004)
Toward the eatabli.b8ent aDd . . iuten.nce of .,re
Dr PraDei. Co. Madigan
effective primary healtb care service focusing upon diarrhoeal, paraaitical. malnutritive. and other common diseases among aboriginal and underprivileged lowland culture groups of the Southern
Re.earch Inltitute for Hind.nao Culture Xavier University
Propo.al received., Reviewers have indicated the need for a revision of tbe protocol. A consultantls .ervices . .y be required for this purpose.
Philippines.
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Annex.
6 County (Humber>
!!fu. Study of bacterial pathogens associated with acute diarrhoea in infancy and childhood in Beijing
Investigator(s) Dr Xu
Inatitution(s) Beijing Children's Ho.pital
Summary The aim of the study is to define the etiology of diarrhoea of bacterial origin in a paediatric population in Beijing.
Date started and statu. Origioal proposal received in January 1982. Two WHO consultants cooperated with the Priocipal lovestigator in revising the proposal, DOW under conlideration for fundina:.
China (WP/81003)
Zhao Yu