.
ICP/~SD/OOI
(STD)
ORJG1NAL: "JitlGL'l8H " .. i
WORKSHOP AND TRAINING COURSE ON SEXUALLY TRANSMITTED DISEASES Sponsored by the
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Suva, Fiji 2-12 April 1979
REPORT
NOT FOR SALE PRINTED AND DISTRIBUTED BY THE REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, Philippines August 1979
NOTE
The view. expre •• ed in thi. report .re tho•• of the con.ultant. and part~cipant. in the work.hop .nd traininl cour.e .nd do not necft ••• rily reflect the policie. of the Ora.niz.tion.
Thi, report h" been prepared by the We.tern P.cific Reaion.l Office of the World He.lth Ora.nia.tion for Government, of the Member St.tel ;n the Region and for those who rarticipated in the Worhhop and Training Courle on Sexually Tran.mitted Dllea,es which was held in Suva, Fiji, {rom 2 to 12 April 1979. .
CONTENTS
1.
INTRODUCTION ••.. ,,. •.
t
••
t
••••••••••••••••
"
•••••••••••••••••
~
0
I
1.1 1 .2
Objectives .. , ......... , .......................... ~....... Gt;tner a1 ....... ,,. ..................................... I •
1 1
2.
WORKSHOP CONTENTS ...•....•.•.•.....•..........•............. 2.1 2.2 Clinical/control element ...................•..........• Teaching contents - laboratory........................ E~t~acurricu1ar activities •..........•...•.•....•.••...
2 2 13 14 14
2.3 3.
RlCOIIIINDATlONS ................... , . . . . . . . . • . . . . . . . . . . . . . • • .
A"NEXl - OPINING ADDRESS - REGIONAL WORKSHOP AND TRAINING COURSE ON SEXUALLY TRANSMITTED DISEASES BY WPC/SUVA •.••..••.. , ANNSX 2 - OPENING ADDRESS BY THE PERMANENT SECRETARY FOR HEALTH, FIJI •••..•....•..•.. , ...•........... , ...
19 '23
a..
ANNEX
~ ~
FINAL LIST OF PARTICIPANTS, TEMPORARY ADVISERS, CONSULTANTS. SECRETARIAT, OBSERVER •........••..•.••••••
27 33 35 43 47 49
ANN8X 4 - GROUPS FOR LABORATORY PRACTICALS ...........•..........• ANNEX 5 - PROGRAMME - WORKSHOP AND TRAINING COURSE ON SEXUALLY TRANSMITTED DISEASES •........... ,., •......• ,........... ANNEX 6 - BIBLIOGRAPHY .•.•...........................•.........•. ANNEX 7 - PRE-COURSE QUESTIONNAIRE SUMMARY Participants to the clinical/control element •••........ ANNEX 8 PRE-COUR~E QUESTIONNAIRE SUHHARY Participants to the laboratory-diagnostic element
ANNEX 9 - SUMMARY OF EVALUATION ON THE WORKSHOP AND TRAINING COURSE ON SEXUALLY TRANSMITTED DISEASES SUVA, FIJI. 2-12 APRIL 1979 ......•........••.........••
51
1.
INTRODUCTION
1.1
Objectives
Many health administrators have come to realize the need for more effective control programmes to stem the intrusion and spread of sexually transmitted diseases with their associated clinical and socioeconomic expenses. On request of concerned health administrators of the Pacific area the WHO Regional Office for the Western Paci fic decided to convene a practical workshop in Suva, Fiji (2-12 April 1979) with the following objectives: (a) (b) (c)
to strengthen the management of the control of sexually transmitted diseases; to promote the development of national control programmes on sexually transmitted diseases; to improve the competence of laboratory and clinical perRonnel in confirming the diagnosis of sexually transmitted diseases, . particularly of penicillin-resistant gonorrhoea.
1.2
General
The workshop was opened by Dr C.J. Ross-Smith, WHO Programme Coordinator, who read the message from the WHO Regional Director for the Western Pacific (see Annex I for text) and by Dr A. Penington, Principal Medical Officer on benalf of the Permanent Secretary, Ministry of Health, Fiji (see Annex 2 for text). Respect was paid to those who 90 tragically lost their lives in the disaster caused by cyclone "Meli" a few days prior to the workshop. The workshop was attended by 30 participants from 15 countries and areas of the Western Pacific Region (see Annex 3 for full list of participants and secretariat). Participants were divided into two groups according to their field of activity; 15 participants joinerl the laboratory diagnostic element (Annex 4) which was held at the Hoodless House near the Colonial War Memorial Hospital; another 15 participants attended the epidemiological-clinical element which took place at the Grand Pacific Hotel where interpreters were available. The epidemiological-clinical element lasted for seven working days (2-10 April) while the laboratory diagnostic element extended for two additional days (2-12 April). The programme (Annex 5) included joint sessions for both elements aimed at promoting the dialogue between the two services and members of the health team. Not less than 59 background and reference documents were distributed among various groups of participants in view of the limited availability of specialized literature in the area of participants (Bibliography: Annex 6).
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Pre-~ourse questionnaires were used to obtain information on participants' qualifications, activities and treatment practicel (Annexes.7 and 8). In post-cou~se que~tionnaires participants were given opp~rtunlty to evaluate the subjects dlscussed or introduced, regarding thelr usefulness, relevance and the time spent (Annexes 9 and 10).
2.
WORKSHOP CONTENTS
2.1 2.1.1
Clinical/control element Uncomplicated gonococcal infection.
Risk of acquisition of infection for a man expo.ed to an infected woman i. 25%, for a woman exposed to an infected man is 50%. The male developa .ymptoma of dysuria and/or discharge in 95+% of cal.a after an incubation period of 2-5 days, but occasionally as long as 10-14 daYI. The female may develop an abnormal vaginal discharge, dy.uria, mentruat abnormalities or lower abdominal pain, but most are nonsymptomatic or fail to notice symptoms. Infections spread to adjacent muco.al structurel if treatment ie delayed. Patients untreated eventually develop reeiatance with subsidence of symptoms and spontaneous resolution of symptoms but are liable to severe compl'ications. Diagnostic methods include: examination of men for urethral discharge; gram stain smear of urethral discharge or endocervical material; culture of urethral and endocervical material on selective media, and confirmatory tests of isolates. Specimen collection technique. were reviewed. The logistics involved in the extension of culture facilities to peripheral units and the transfer of specimens to centres capable of making a presumptive diagnosis raised considerable interest among participants. The transfer of gonococcal specimens in holding media (Stuart, Ames) at elevated ambient temperature is an unsuitable technique. Preliminary studies carried out in Singapore indicate that compared to immediate incubation (J6 0 C) of streaked plates, exposure of platea for not more than 24 hours to an ambient temperature of + JOoC (but not lea. than 24 0 C) in an C02 environment would result in-a 7% loss of gonococci only. However, the problem of specimen transport for extended periods at elevated ambient temperatures has not yet been solved satisfactorily. Trea~ment failures with penicillins, ampicillin (amoxicillin) and tetracycline are related to the in ~ susceptibility (MIC.) of the organisms. From the MICs of organisms, failure rates expected with various treatment regimens can be calculated. Penicillinase-producing gonococci (PPNG) are resistant to all forms of penicillin because the enzyme destroys the beta-lactamase ring.
II
II
II " " II
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l'h~ serum penicillin lpvels and their change over till1P vary J!rPllt ly with various penicillin preparations. Probenecid increasps the peak senlm levels by transiently blocking urinary excretion. Different dru~s hnv~ different advantages, including prevention of POlt-gonococcal urethritis and incubating syphili., and disadvantages, including side-effects and the patient's compliance.
References: 2.1.2
9, 9a, 10, 15, 2lb, 22, 23, 24, 25, 26, 27, 28a, 28b, 31
CODlplicated lonococcal infections
Pe\vic inflammatory disease (PID) occurs in 15% of women infected with gonorrhoea and is the most important complication of this infection becaul~ of hospicalization, infertil ity and ectopic pregnanciu. Factors other than gonococcal infection which predispose to PIn include: (1) prior PIn, (2) intrauterine devices, (3) surgi ca 1 .or obstetrical II18nipulat ion of the uterus. To minimize the severity of PIO, the diagnosis must be considered in w~n with lower abdominal pain or pain on cervical traction and adequate tr.atment for gonorrhoea given; a ten-day antibiotic regimen as a minimum. Sex partners .hould be identified, since male partners may be non.ymptomatic, and ~reated. Reduction in PID will occur with overall reduction in gonorrhoea and the reduction in the duration of infection in WotDeR by: U) proalptly locating olnd treating 's~eady' female partners of men with gonococcal urethritis and (2) promptly treating women with minor symptoms of gonorrhoea before PIO develops. Oi.seminated gonococcal infection should be suspected in youn~ patient. with acute, monoarticular arthritis. Cultures for ~. gonorrhoea .. lihou ld be obtained from mul ti pIe s i t('s. Trea tment can oft .. n be success fu] on an outpat ient basis. Gonococcal ophthalmia neona torum is a preventable cottdi t i on if all newborn are treated with silver nitrate (1%) eye drops or tetracycline or erythromycin ophthalmic ointment. References: 2.1.3 9, 9a, 10, 11, 12, 13, 14
Epidemiology of penicillinase-producing N. gonorrhoeae (PPNG)
The emergence of PPNG poses serious difficulties in gonorrhoea control, particularly in the Pacific, since these organisms havfl become estab] ished in many different countries. PPNG strains should be sought if the case (a) was acquired in Singapore, Thailand, the Philippines, to'alaysia, and perhaps C~ina (Province of Taiwan) and Bali, or (b) failed to respond to treatment with an effective penicillin regimen. Testing an unaeleeted .eries of gonococci from caaes which did not respond well to-penicillin tTPlltment for penicillinase production will determine the presence of PPNG strains. References: 9. 20, 21a, 2lb
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2.1.4
Syphilis
Primary syphilis lesions may be overlooked unless the examination is thorough, including the rectum and mouth of homosexuals. The rash of secondary syphilis may be difficult to differentiate from other skin conditions. Syphilis in pregnant women results in foetal death, neonatal death and congenital syphilis. Only 20% of pregnancies among syphilitic mothers will result in delivery of a normal, uninfected baby. Late consequences of congenital and acquired syphilis include central nervous system disease, cardiovascular disease and gumma~. Diagnosis of syphilis by clinical criteria is inaccurate except for the typical primary chancre, condylomata lata or palmar-plantar raah. Darkfield microscopy provides definitive evidence of syphilis when typical motile spirochetes are present. Serological tests become reactive early in the course of syphilis and persist in high titre for several years. After treatment of early syphilis, nontreponemal tests become nonreactive within 1-2 years; after treatment of longer-duration syphilis, nontreponemal teata may change little. Treponemal tests should only be used as confirmatory tests for patients where there is a diagnostic problem; often clinical evaluation and a quantitative nontreponemal test is sufficient for diagnostic purposes. Syphilis should be treated with long-acting penicillin preparations (benzathine penicillin or P.A.M.) to ensure completion of therapy. Other antibiotics should be avoided unless the patient is peniciilin-allergic. Screening pregnant women may prevent congenital syphilis, but should be done both in early and late pregnancy for maximum effect. Treatment of groups at high risk for syphilis without diagnosis was suggested, including sexual partners of a patient with early syphilis, was discouraged unless careful follow-up of these people could be ensured. Syphilis control efforts include diagnosis of symptomatic patients and screening, especially those at high risk; loc.ation of sexual partners of cases; repeated screening of selected groups, and antenatal screening to prevent congenital infections. References: 2.1.5 32, 34, 35, 36, 42, 43
Genital ulcerations
Genital ulcers caused by infectious diseases include herpes simplex virus types 1 and 2, syphilis, chancroid and donovanosis. Genital herpes may be recognized if typical grouped vesicles or tiny superficial ulcers are present. Infection of the female is most serious since women have more severe local disease and may transmit infection to her infant at delivery. No effective therapy exists. Donovanosis is common in Papua New Guinea but is otherwise rare. This disease causes distinctive lesions which may cause mutilation or disseminate. Therapy with streptomycin and tetracycline is ineffective in Papua New Guinea, but chloramphenical 2gm daily for 6-8 weeks is effective. Chancroid is an uncommon cause of ulcerative disease in Pacific countries. When it occurs, severely painful ulcers develop often with a unilateral bubo.
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The cause of genital ulcerations varies throughout the world. It was suggested that participants carefully evaluate a small series of patients to determine how much is due to syphilis. References: 2.1.6 6, 44, 45, 46
Chlamydial infections
Improved diagnostic methods have made feasible the recognition of the many problems caused by genital chlamydial infections. These include nongonococcal urethritis and epididymitis in males; cervicitis, salpingitis and Bartholin abscess in females, and finally neonatal inclusion conjuctivitis, pneumonitis and serous otitis media from infection of the newborn at delivery. Nongonococcal infections can be differentiated from gonococcal infections by gram stain smear, but diagnostic tests to identify ~hose due to chlamydia are not available for routine work. Tetracycline for at least seven days is effective therapy. References: 2.1.7 6, 29, 30, 31, 47, 48
Vaginitis
Successful management of patients will benefit STD control, since patients with one STD are more likely to have another. In addition, women will be encouraged to attend clinics promptly when symptoms occur, diminishing the chances of developing complications from gonorrhoea or syphilis. Trichomoniasis and moniliasis are the most common causes of vaginal infections. These can be diagnosed clinically in few cases but diagnosis is easier with saline suspensions of vaginal discharge, examined microscopically for the agent. Trich~moniasis can be treated with a single dose of 2gm metronidazole; moniliasis may be treated with vaginal pessaries or creams of gentian violet, nystatin or miconazole. References: 2.1.8 6
Homosexuals and STD
Homosexuals often have many sexual partners who are not known which puts them at large risk for STD. Both gonorrhoea and syphilis are unusually common among homosexuals since asymptomatic infection of the rectum or oropharynx may occur. Many enteric infections have been recognized as unusually common among homosexuals, including: hepatitis B, probably hepatitis A, amoebiasis, giardiasis, shigellosis and perhaps salmonellosis. These infections are probably spread by oro-anal sexual practices. Frequently homosexuals are not recognized as a high-risk group because they fail to utilize usual health services and if they do, clinicians fail to consider this possibility. (References: nil)
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2.1.9
STD diagnostic tests:
demonstrations
Demonstration of gram staining methods was done and gram stained smears were examined to show: typical smear of male gonorrhoea with many white blood cells containing gram negative diplococci; male NGU with only white blood cells; female gonorrhoea with only occasional white blood cells containing typical gram-negative diplococci; female endocervical smears without gonococci but many other organisms. The appearance of gonococci and the suppression of other organisms by selective media was shown as well as the oxidase reaction. Tests for PPNG were demonstrated as were confirmatory sugar fermentation tests. VDRL test performance was demonstrated including titres for a reactive serum. TPHA test results were also demonstrated. Re ferences:
15, 16, 18, 19, 20, 2la, 34, 35, 38
2.1.10
Assessment and importance of gonorrhoea control gonorrhoea must begin with an estimation of the occurring and the complications caused. This information persuade decision-makers to allocate appropriate resources and it will be used to plan the control effort, targeting on priority problems and locales.
Efforts to number of cases will be used to to this problem control efforts
Estimating the number of male cases is easier than female cases, since most men develop urethritis and will be easily recognized. Therefore, initial efforts should focus on estimating these cases. Reporting of cases is often incomplete; thus, sample surveys of cases occurring over a short period of time may give a better estimate of the total cases occurring. Such a survey must include: cases occurring in government facilities in central and peripheral areas, private practice, and others, including pharmacists in some countries. Complete demographic information about all such cases would be valuable for designing control efforts, but cannot be collected for most commencing programmes. Because clinical findings in women are nonspecific and gram stain smears are undersensitive, cultures may be the only feasible way to establish female cases of gonorrhoea. Culture surveys should focus on groups attending special VD clinics (if they exist), symptomatic women attending hospital facilities and other groups at high-risk, e.~. barmaids, masseuses, etc. The major complication of gonorrhoea is salpingitis. Cases of PID seen in hospital can be used as a first estimate of the magnitude of the problems. To establish the portion of PID due to gonorrhoea, endocervical cultures of ~ gonorrhoeae should be obtained from these women. This information can then be used to estimate the importance of this complication by calculating the costs for hospitalization, work loss, recurrent PID episode, surgical interventions needed and ectopic pregnancies. Reference: 13
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2.1.11
Assessment of importsnce of syphilis
The decision to implement a syphilis programme and how extensive that programme should be, must be predicated on counting cases of syphilis, and the direct outcome of undiscovered (and untreated) cases and congenital syphilis. Direct counting of cases may be difficult since the majority may not come to medical attention, and congenital syphilis may not be diagnosed. Results of syphilis treponemal serology appear to give the most accurate information, but there is still great difficulty in knowing how to interpret such data since other treponematoses may have been or are still present and results cannot be used to estimate the age when infection occurred. Serological data in infants are problematic because maternal antibody crossing the placenta and giving a (+)reaction in the infant cannot be interpreted as representing true infection in the baby. Some SOurces of syphilis data include: (1) (2) (3) (4) (5) (6) (7) (8) 2.1.12 clinic diagnosis/serology results special groups: prostitutes premaritals, blood donors, military, prisoners,
hospital admission serology antenatal screening programmes private sector physicians/physicians seeing male homosexuals special screening efforts perinatal death records abortion/stillbirths sero
(-»
(VB
normal birth, both by sero (+) or
Standard treatment programme
Standardized treatment practices for the entire country can ensure that treatments give optimal cure rates and minimize selection of resistant organisms. Recommended syphilis treatments for various stages of syphili, and gonorrhoea Were discussed. Selecting treatments for gonorrhoea were discussed in more detail, emphasizing the need to estimate efficacy of various regimens in the local situation on the basis of MICsand treatment trials; the effects of various treatments including failure rates, side-effects of drugs and drug effect on possible syphilis concurrently acquired; and the feasibility including cost, availability and chances to influence widespread use of the recommended schedules. Specific recommendations were discussed for the patient with uncomplicated disease, the patient failing to continue with therapy and the penicillin-allergic patient, both pregnant and non-pregnant. References: 22, 42, 53
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2.1.13
Clinical services and STD control
For clinical services to be an effective element of the disease control, team services must be accessible, both physically and psychologically, to infected patients. To ensure adequate evaluation at all health care facilities, guidelines should be developed for each provider. Standardized management suggestions include therapy, follow-up to identify failures or complications, and contact tracing. Contact tracing (Syn. Outreach to sexual partners) can be done by: (1) (2) (3) the patient notifying and motivating partner(s); using the patient to deliver an appointment slip (contact slip); eliciting names of sexual partners and health workers sending letters, phoning or visiting. All clinical services should be encouraged to report cases.
Specialty clinics for STD can perform some needs of the STD control programme including: (1) (2) (3) (4) operational research, training of health workers, collection of detailed data on disease patterns, etc., referral centre either by phone or patient referral for problem cases. 49, 50
References: 2.1.14
Prevention of STD
STD are greatly affected by behavioural changes in the society, so control efforts limited only to patients will be less effective than a broader, community-based approach. For example, urbanization removes many people from their societal constraints and exposes them to new behaviour patterns. Broadly-targeted educational efforts thus should be an important part of a control programme. Prophylaxis, including gonococcal vaccines, were discussed. Although they are useful, none are likely to be completely effective. Health legislation aspects were reviewed, including laboratory reporting laws, central seroreactor registry, minor treatment laws, antenatal screening, screening of other high-risk groups, and use of eyedrops for all newborns to prevent ophthalmia neonatorum. References: 51, 52
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2.1.15
A simplified approach to STD control:
Swaziland
The simplified approach to STD control when diagnostic laboratory tests are not available was reviewed. This example may be a feasible first step where facilities are limited. However, when possible, more accurate diagnostic tests should be used as the basis for control efforts. (References: 2.1.16 nil)
Laboratory services and STD control
Rational organization of laboratory services is essential when resources are extremely limited. Organization of laboratory serviee. should use laboratory resources available throughout the country. For example, culture facilities in hospitals c;ould begin gonorrhoea culturing or university facilities could do MIe testing. Also stressed was the need for communication between laboratory personnel and clinicians to ensure that patient care and STD control could be achieved. (Referenees: 2.1.17 nil) overview
STD control:
STD control should begin with an assessment of the magnitude of the problem. Then an evaluation of existing STD control efforts should be made, including government, practitioner and community groups. The feasibility of various control efforts should then be estimated and control priorities developed. Finally, strategies for implementing a control programme c.ould be devised which are consistent with the country health plans. 2.1.18 Individual plans toward STD control
At the end of the workshop participants were requested to di.cuss their short-te~ plans for the improvement of STD control activities in their area of work. American Samoa Syphilis has not yet been documented. American Samoans. (1) (2) (3) Increase of gonorrhoea among ~ecome
Genital lesions and pelvic inflammatory disease to
notifiable.
Implementation of an STD orientation programme for physicians.
!. lonorrhoeae.
Improvement of laboratory capability to
identify~-lactamase-producing
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Cook Islands One public health clinic sees STD cases. (1) (2) (3) (4) (5) (6) (7) Information to health workers on STD situation in the South Pacific. Evaluation of available statistical data. Consultation with physicians in preparation of standardized treatment prograDUl\e. Introduction of gonococcal culture technique. Introduction of contact slips. Establishment of a central syphilis serological reactor register. Expansion of health educatioq.
(1) (2)
Intensification of health education/information activities to public and physicians. Extension of VDRL screening programme to other parts of the islands.
French Polynesia Among 205 reported cases of syphilis about 25 had symptomatic early lesions. Widespread syphilis serological screening programme. Central laboratory tests about 10 000 sera annually. One-quarter of the popUlation live on 80 islands surrounding Tahiti and are difficult to reach. Of primary importance is to convince medical practitioners to pay more attention to STD. No infertility problem. Activities envisaged until September 1979. (1) (2) (3) Report on STD workshop will be given wide publicity, particularly stressing sequelae of gonococcal infections. Health information activities directed to local medical practitioners (seminars) and the public (mass media). Changes in syphilis treatment.
Gilbert Islands (1) (2) (3) (4) Introduction of gonorrhoea culturing in antenatals to provide data. Establishment of a central syphilis serological reactor register. Training on STD various levels of health providers (medical officers, medical assistants, village health aides). STD training to be incorporated into the nursing curriculum.
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Guam 100 000 inhabitants. Notified cases {1979}: 15 latent syphilis, 258 gonorrhoea {estimated true incidence about double} from which 18~-lactamase producers could be isolated. Considerable number of short-term visitors and tourists. Thirty cases per month of salpingitis of unknown origin. (1) Extension of gonorrhoea and syphilis laboratory diagno.tic capabilities to the periphery in an attempt at least to assess the extent of the problem. In support of objective No. I, inservice training for nurses in specimen taking and culture techniques. E.tablishment of procedures for the manage.ent of anaphylactic and procaine reaction and .ubsequent training of health personnel. Review of the recommended treatment schedules in view of anaphylactic reactions and possible alternative treae.ent with tetracycline.
(2) (l) (4)
LoweI' priority
(5) (6) (7) (8)
Providing information to private physicians. Implementation of screening procedures on female. with salpingitis in the hospital emergency room. Development of health educational material for schoolchildren. Organization of national STD workshops for phy.icians for two years.
New Hebrides (I) (2) (3) (4) (5) (6) (7) (8) Adoption of a standard treatment regimen. Assessment of the extent of STD problem by data review including enquiry with pharmacists and herb doctors. Rallying the support of groups (politician •• clergy, etc) which had been opposed to the inclusion of STD in mass media advice. COBBencing a hospital-based STD control progr..-e which would eventually expand into a nationwide programme. Setting up educational programme on STD for various members of the health team and extension to general public and schoolchildren. As.essment of need for laboratory equipment and supplies. Establishment of central syphilis serological reactor register. Screening programme covering various high yield groups: Pelvic inflammatory disease, abortion and antenatal clinics.
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New Zealand (1) (2) (3) (4) (5) (6) Educational/information programme directed to private physicians and especially gynaecologists to obtain better cooperation. Promotion of dialogue between health department and hospital boards on closer link between clinical and epidemiological service •. Investigation into the problem of disseminated gonococcal infection. Intensification of surveillance forl'-lactamase-producing gonococcal stains. Establishment of a central syphilis serological reactor register. Research into sexually transmitted chlamydia problem and sequelae of perinatal transmission.
Papua New Guinea The plans for 1979 are still under discussion and consist of the following activities in the order of priority: (1) (2) (3) (4) (5) revision of national treatment schedules, particularly for gonorrhoea training and recycling of health personnel in STD management as integral part of their curriculum studies and research would include surveillance of t'-lactamase-producing!. gonorrhoeae and efficacy of treatment regimens coordination with the Division of Health Education and eventual transfer of health education for STD control to the programme unification of contact tracing methods and its extension to the periphery. Priority is given to areas with known STD prevalence.
There were 35 cases of gonorrhoea (including two females) and three cases of primary syphilis (1978). (1) (2) (3) VDRL screening of all contacts of the syphilis cases. VDRL screening of all prostitutes. Implementation of a standardized treatment programme.
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Trust Territory of the Pacific Islands Tourist trade is increasing and so is the foreign labour ~ich might import syphilis into the country. Among the antenatals a high gonococcal infection rate was found by culture. Urethral strictures have become JIOre frequent. (1)
'VDRL screening of prostitutes (six monthly) and foreiln labour (annually) . Teachina contents- laboTatory The method of choice for diagnosis of gORococcal urethritis in .. les is to examine microscopically a gram stain smear. As the method is 'hiahly specific and 98% sensitive there is no necessity to us.e the more costly method of culture. However. in certain circ~tances such as test of cure, asymptomatic patients (e.g. sex contacts>. research and detection of !: gonorrhoeae, from other sites •. culture is preferred. (References: 9, 15, 16, 29. 30, 31) In the best of hands, gram stain smear examination will detect not IIOre than 60% of gonococc'al infections in females. Because of lack of sensitivity, and the presence of other bacteria which may mimic N. lonorrhoeae. culture by the use of an enriched selective medium, 'uch as the modified Thayer Martin medium, is preferred for the diagnosis of gonorrhoea in females. The site of choice for specimenl is the endocervix. The addition of a culture from the rectum will increale the isolation rate by 10% but its practical application will depend on the prevalence of the disease in the population examined. The enrichment and inhibitors may be prepared by laboratories at low cost. (References: 9, 16, 18) The method of choice for the detection of beta-lactamase is the rapid iodometric method. It is fairly simple, cheap and results may be obtained in an hour. Using this method it is possible to screen large numbers of isolates in one session. The use of cephalosporin 87/312 ,is simpler but the antibiotic is at present not readily available in most countries. (References: 9, 2la, 2lb) The determination of HIC of drugs against N. ,onorrhoeae is valuable in evaluating the appropriate drug of choice 1n the treatmeut of gonorrhoea in a country. The technique is a sophisticated ODe. and laboratories regularly isolating !. gonouhoeae in selective medium should attempt to develop it. The recommended method i. the ODe used by Centre for Disease Control, United States of America, and control st~ains with known HIC values should always be used. (References: 9; NIC method from CDC) , It is advisable that laboratories should use only one non-treponemal and one trepone_l test for syphilis serology. Addition of more te.ts will not help but will further confuse the results. Besides, it is costly. Thli! non-treponemal test advocated is the VDRL .lide tesl: which is fairly simple to perform, and is used by moat countries. The treponemal test advocated is the MHA-TP test. It is simpler to perform than the FTA-ARS test and is le8s costly to set up. (References: 35, 36, 37, 38)
2.2 (1)
(2)
(~)
(4)
(5)
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(6)
To obtain reliable test results, stringent quality control measures should be observed by laboratories. Such internal quality control is designed to ensure reproducible results. However, to ensure that the different laboratories are producing results of equivalent standards national laboratories should participate in the CDC proficiency test' programme conducted through WHO auspices. This will help to standardize test performances among national laboratories. Such national laboratories should then undertake to conduct similar programmes among laboratories in their respective countries. It is desirable that laboratories should maintain a healthy working relationship with their clinical counterparts to ensure a minimum of wastage in resources. A continuing dialogue should be maintained to solve common problems so that limited laboratory resources can be utilized effectively. Extracurricular activities
(7)
2.3
A bilingual scientific session for interested participants was held on Sunday, 8 April, when members of the secretariat and participants r~ported on their recent research activities. Members of the secretariat participated in the first public forum on sexually transmitted diseases at the University of the South Pacific on Monday, 9 April. It was attended by over 120 persons. After a short introduction of the subject, the secretariat replied to written questions.
3.
RECOMMENDATIONS
The secretariat to the Regional workshop on sexually transmitted diseases (STD), held in Suva, Fiji, April 1979, recommends the following activities towards the development of more efficacious national STD programmes in the South Pacific. 3.1 Once the epidemiological component of the WHO intercountry epidemiological team (ESD 001) has become fully established, STD control should be incorporated into the team's activities. With this aim in mind, it is recommended that the team leader together with an 8TD epidemiologist and a consultant fully conversan.t with 8TD diagnostic technology, should visit island territories of the Pacific area, consult with the authorities on progress made in the assessment of the STD situation, evaluate proficiency in laboratory diagnostic techniques and draw up cooperative activities to further strengthen national control programmes. This would provide the team leader with valuable experience and would enable him to follow up the plans drawn up in consultation with health authorities. The holding of a one or two-day national seminar on 8TD case management and control at the time of the visit could further the aim of the mission.
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-------------~
- 15 -
3.2 It is IDOst important that participants in th.labor.tot'y.diagno.t~c, component of this workshop, after return to their home countrles,be ~lven the opportunity to apply .ome of the technique. they have learned dunn, the work.hop. Towards this end. laboratory workers were provided with gla.aware and reagent. to carry out'syphilis serologi~a~ teat~, The p~ovis~on of additional supplies (by the Western Paclflc Reglonal Offlce) lS nece.sary if the following minimal activities are to be carried out prior to the visits reco. .ended in the previous paragraph: <a) It is recommended that each territory be encouraged to eatablish a VORL .eroreactor profile on sera obtained from hospital admi.sions per attached table 1. The aim .hould be to te.t about SO sera per sex and group; if possible, weakly reactive and reactive sera should be checked by TPHA (MHA-TP). These data would help in the evaluation of yaws/syphilis transmission in the examined population and allow comparison with similar data obtained from other population groups, Likewise, the trained laboratory workers should aim to obtain about 100 N. onorrhoeae strains from male urethritis cases and te.t these straIns for -lactamase production. A comparison with direct smears would provide a measure to assess the proficiency achieved in the performance of the culture technique and to estimate the frequency of nonaonococcal urethritis. An optional activity would be the culture testing of male urethritis cases before and three days after treatment following the outline provided to participants to evaluate treatment efficacy.
(b)
J.J To keep the interest alive and to promote the exchange of idea. and experience between relatively isolated participants on implementation of , techniques discussed during the workshop, use may be made of the educational satellite telecommunication system. At these conferences the moderator would be able to respond to technical questions related by participants for the benefit of all listeners. 3.4 ~ -lactalaaae-producing strains of !:!. gonorrhoeae are being identified in a number of South Pacific laboratories and speed of identification of foci of infection with such strains may well enable their timely control and eradication. It is recommended that health authorities be encouraged to notify their counterpart authorities in other countries/areas promptly, providing them with as much detailed epidemiological information as possible (time, place of detection, source of infection, etc.) which would assist in locating foci in their area of jurisdiction. Any epidemiological information on cases from which these strains have been isolated should also be forwarded to the Western Pacific Regional Office of WHO (Attention CDS) to ensure dissemination of relevant data to other national health authorities.
- 16 -
3.5 The attention of health administrations should be drawn to training and referral facilities available at the WHO Collaborating Centre for Venereal Dheau Serology and Bacteriology (Director Dr E.H. Sng) , Department of Pathology, Outram Road Hospital, Singapore; also, problem sera may be sent to the WHO Collaborating Centre for Treponematoses Serology (Director Dr M. Garner), NSW Institute of Pathology and Clinical Research, Wes tmead , Sydney, Australia.
II 11
- 17/1' Table 1 Hospital ad.ission (for any cause) VD.~ s~rololical t~ts
Age (in yean)
0 M
-
2 F
3 M
-
S F
6 M
-
14 F
15 M
-
25 F
25 M
-
40
40 +
F
M
F
If R
WR
1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:64 i
TarAL
- 19 -
ANNEX 1
Official Openina Address by Dr C.J. Ros.-Smith WHO Programme Coordinator for the South Pacific
Ladie. and Gentlemen. A. you have heard from Dr Tin Maung Mauna and •• you can •••• Dr Senil.sakali i. unfortunately not with u. this aornins. The .-erl.ncy .ituation in the ea. tern and .outhern i.l.nd. of Fiji. wroulht by deva.tating cyclone Meli. h•• prevented hi. pr•• ence. Dr Senilalak.li left early this mornina with other health it.ff to vi. it i.land. in the Lau aroup - which were hit by the cyclone. 1 . . .ure you would all join with me in extend ina our d•• pe.t .,.pathy to the people of Fiji at thi •• ad tiae. Dr Penin,ton i. r.pre.entinl the Ministry of Health today and it would be auch .ppreciated, Dr Penington. if you' could pl ••• e p••• on this .....,. to the Fiji Government through the Minister of ".alth. Will you all please join with me in ob •• rvin, • short .ilence a. a .. rk of re.pect for tho.e who so tragically lost their live. in the cyclone disa.ter.
- 20 -
Annex 1
MESSAGE OF THE REGIONAL DIRECTOR AT THE OPENING OF THE WORKSHOP AND TRAINING COURSE ON SEXUALLY TRANSMITTED DISEASES Suva, Fiji, 2-12 April 1979 Ladies and Gentlemen, It is my regret t~at I am not able to attend your meeting today but unfortunately this is due to a heavy work schedule and prior commitments in the Philippines. To carry my message to you at the coamencement of this important gathering, I am asking Dr Charles Ross-Smith, the WHO Programme Coordinator for the South Pacific, to represent me. I have become aware through many official and non-official communications from governments in the South Pacific of the fact that sexually transmitted diseases are becoming an increasingly serious problem in the area. In particular, syphilis and gonorrhoea are on the increase, giving rise to seve,re malformations and infertility, as well as other tragic social consequences. In fact, the situation at present createa a public health problem of considerable magnitude. All of you will know that' throughout the world where statistics are readily available, the prevalence of sexually transmitted diseases was quite low after penicillin became widely available in the late 1940s. An upsurge then has been 'explained mostly by higher transmission rate owing to increased permissiveness, greater mobility of population facilitated by an increase in travel and growth of tourism. At the same time, traditional control measures could not cope with the dramatically increasing numbers in sexually transmitted diseases. Recently, with the streamlining of epidemiological control measures, some of the more developed countries have been able to stem and reverse the tide and a reduction of cases from STD has been documented in those countries. This hopeful development, however, has been countered by the emergence of beta-Iactamase producing strains of the gonococcus which are penicillin-resistant. All countries are subject to this threat. While the more developed countries with strong control services may be able to deal with this new problem, the developing countries face a double handicap. Not having yet developed satisfactory control mechanisms for the classical srn they are now confronted by the new face of STD which makes the problem even much harder to control.
2/ ...
- 21/22 -
Annrx I It can be predicted that the problem of .exually transmittell di.ea.e. in countries of the South Pacific will get wor.e before It will get better. Ca.es will tend to increase until better control mechani.ms are developed. Thi. muat include adequate provisions to detect and deal with penicillin-resl.tant gonorrhoea. Your pre.ence here today make. it clear the South Pacific area have taken cOlnisance health problem pOled by IexuaUy tranlmitted countriel are planning to do lomething about that the governm.nt. of of the I.rioul public diu .. e. and that yotlr it.
I appreciate the kind ge.ture of the Government of Fiji for alreeing to ho.t this important work.hop and training courle .nd I would like to thank them in particular for making available the facilities which are to be uaed for the practical training activity. I am confident that the consultants and the member. of the .ecretariat who have come from many countriea abroad will do their very be.t to provide you with all the necessary information 80 as to enable you to develop and improve programme. in your countriea on the SrD control. To all participants, I trust that this meeting will prove a most fruitful and rewarding learning experience. Finally, I am pleased to note that Dr Jona Senilagakali, the Permanent Secretary for Health of Fiji, will be with you today and that he has kindly consented to deliver the opening address.
- 23 -
ANNEX 2
OPENING ADDRESS BY THE PERMANENT SECRETARY FOR HEALTH, FIJI (DELIVERED BY DR A. PENINGTON ON BEHALF OF THE FIJI The Workshop Director, Dr Antal, The Consultants, Dr S. Thompson C.D.C. Atlanta, U.S.A., and Dr Sng from Singapore, Distinguished Guests, Delegates from the Regional Countries, Colleagues, Dr Charles Ross-Smith, Ladies and Gentlemen, In the absence of Dr Senilagakali, who has been called away because of the emergency situation following hurricane Meli, it is my honour and privilege to be here with you this morning to perform the official opening of this Workshop and Training Course in Sexually Transmitted Diseases, and to deliver Dr Senilagakali's address. May I welcome, on behalf of the Minister of Health, and the staff of the Ministry, all colleagues and friends who are visiting Fiji for the first time. I hope you'll find our weather and hospitality agreeable. Likewise, I would like to extend a warm welcome to all delegates, from American Samoa, Australia, Cook Islands, Gilberts, Guam, New Caledonia, New Hebrides, New Zealand, Papua New Guinea, Solomons, Tonga, Trust Territories and Samoa. At its twenty-eighth meeting in May, 1975, the World Health Assembly had as its subject for Technical Discussions the "Sexually Transmitted Diseases". This subject had been chosen because of the increasing world incidence of this group of infectious diseases and their effect in infant mortality and morbidity and the loss of economic productivity and costs to the community of these diseases in both males and females, particularly, in the younger age groups. Among these infections, gonorrhoea had become the most commonly notified infectious disease in the United States of America, and the number of cases being reported in other countries was increasing proportionately to the populations. Not only was there an increase in the number of cases of gonorrhoea, but also others of these diseases were apparently on the increase, with an increase in morbidity and often prolonged ill health or infertility in younger females. An increase in the number of syphilitic infections was also reported and the Assembly discussed some of the factors which were apparently contributing to this worldwide epidemic. GOVER~!NT)
- 24 -
Annex 2 Opening address delivered by Dr A. Penington (cont') During the course of the discussions it was pointed out that comparison of statistical data between countries were difficult owi.ng to variations in the criteria and standards of diagnosis and reporting, the facilities available, and the extent to which treatment was given by private practitioners, pharmacists and others, including the patients themselves, who may have resorted to traditional local remedies for treatment. Even in developed countries, the official statistics may indicate only a fraction of the total extent of the problem as underreporting of these diseases is usually very high. The increase in the number of cases of syphilis reported was a cause for concern, as syphilis, through its complications, could be associatpd with significant morbidity and cost to the community involving death, cardiac invalidism, mental deterioration, blindness and deafness. It was also considered that in regions where yaws had been eradicated and new susceptibles have arisen, syphilis may appear as a new disease. The hopes for control of sexually transmitted diseases through the demonstrated effectiveness of penicillin in treatment had not been realized, and in the case of gonorrhoe'a, the development of penicillin-resistant gonorrhoea with beta-Iactamase producing organisms has been demonstrated in many countries, and appears to be an increasing problem, and while there has been an increase in the numbers of sexually transmitted diseases in all age groups, there is a disturbing trend towards higher rates of increase in females in the age group 15-19 years. It was concluded that the existing methods of control as then applied, had only limited success, and this limited success now appears to be even less apparent. It was recognized that the varlOUS factors leading to the present increase in the number of cases of all types of sexually transmitted diseases were demographic, medical, socioeconomic, technical and behavioural in origin. These factors still apply in all communities, and exist on a worldwide scale. It is not surprising, therefore, that th.ere has been an increased recognition of many forms of sexuslly transmitted diseases which had previously been regarded as non-sexual in character. These include chlamydia which has been found in about 40% of males affected by non-gonococcal urethritis and may represent a genital focus for trachoma. About 1.0% of patients with non-gonococcal urethritis develop the classic Reiter's syndrome with associated rheumatic, ocular and sometimes cardiac complications. Genital infection with herpes type II virus may be responsible for systemic infection in the newborn which is usually fatal, but is also suspect in the causation of carcinoma of the cervix. Granuloma inguinale and chancroid are found more commonly in certain countries than in others, while genital warts are seen in most c'ountries, but have not hitherto been reported uniformly nor have they been included in the list of notifiable infectious diseases.
- 25/26 -
Annex 2 Opening address delivered by Dr A. Penington (contI) While the worldwide epidemic of these diseases has been well recognized, it is only within recent years that these conditions have become more commonly recognized in Fiji. The incidence of gonorrhoea in Fiji showed a dramatic increase during the 1960s, and the maximum number of 1506 cases occurred in 1971. The number of reported cases remained in the vicinity of 900 per year except for 1918, when 1073 cases were reported. An even more dramatic and disturbing situation applies to syphilis, which has now be.come a major cause for concern. Others of the sexually transmitted diseases are less common in Fiji, and our major problems lie with gonorrhoea and syphilis, although non-gonococcal urethritis and herpes infections are being seen, even if not reported under our Notifiable Disease Ordinance. The same factors leading to the increase in these infections apply in Fiji as in other more developed countries. Fiji has, during the past fifteen years, undergone rapid changes in the social and economic areas, and population movements have been accelerated through improved transport systems. Similar changes are taking place in most countries in the South Pacific area, and it is possible that. the same increase in sexually transmitted diseases could occur in other countries of this area. It is for this reason this workshop and training of those engaged in public sincere wish that all will being provided for you and which you are attending. that the World Health Organization has organized course, which will meet one of the "felt needs" health in the various territories. It is my benefit from the course of training which is that all countries will benefit from the course
Last, but certainly not least, may I extend our appreciation to the World Health Organization for its collaboration in this workshop. I now have great pleasure in declaring this Regional Workshop and Training Course in Sexually Transmitted Diseases, open.
- 27 -
ANNEX 3
FIRAL LIST OF PARTICIPANTS, TEMPORARY ADVISERS, CONSULTANTS, SECRETARIAT, OBSERVER 1.
PARTICIPANTS Or Tofiga Liaiga Associate Public Health Officer L.B.J. Tropical Medical Center Pago-pago Tutuila Mr Sile P. Koria Bacteriologist L.B.J. Tropical Medical Center Pago-pago Tutuila
AUSTRAl.IA
Dr Darcy Kelly Health Officer Queensland Department of Health Corner George and Elizabeth Streets BriBbane 4000 Dr Teariki Tamarua Acting Director of Public Health c/o Ministry of Health P.O. Box 109 Rarotonga Mr Louis Maraters Senior Laboratory Technician c/o Ministry of Health P.O. Box 109 Rarotonga
COOl. ISLAIIDS
FIJI
Dr Samuela T. Baravi1ala Senior Health Officer (VD Clinic) Health Office P.O. Box 30 Suva Dr W.T. Malani C.W.M. Hospital Waimanu Road Suva
- 28 -
Annex 3 FIJI (continued) Hs Stella Driu Laboratory Technician Lautoka Hospital Lautoka Hr Vinod Lal Laboratory Technician Pathological Laboratory C.W.H. Hospital Suva FRENCH POLYNESIA Dr Jacques Louis Epidemiologiste Institut Recherches Louis Malarde Papeete Hademoiselle Jeanne Lecaill Technicienne Laboratoire, Hopital Hamao Papeete GILBEILT ISLANDS Dr T. Beriki Princ"ipal Medical Officer (Heal th) c/o Hinistry of Health 6 Community Affairs P.O. Box 268 Bikenibeu Tarawa Hr Tebebeku Teia Laboratory Technician c/o Hinistry of Health 6 Community Affairs P.o. Box 268 Bikenibeu Tarawa GUAM Hr Charles Crisostomo COllllllUnicable Disea.e Programme Coordinator Department of Public Health and Social Service. Government of Gua. P.o. Box 2816 Agana
- 29 -
Annex 3 GUAM (continued) Mi8s Teresita Bolano . Microbiologist Department of Public Health and Social Service8 Government of Guam P.O. Box 2816 Agana Guam 96910 Dr Hubert Schill, Biologi8te Pa8teur In8titut B.P. 61 Noumea Dr Le Gonidec Directeur Pa8teur In8titute B.P. 61 Houmea liEW HEBIIPES
NEW CALlI)ONIA
Dr Peter M. Bull District Medical Officer Vila Base Hospital Box 55 Port Vila Mr Kalfabun Eaau Laboratory Technician Hopital Georges Pompidou B.P. 207 Port Vila
NEW ZEALAND
Dr Timothy Johnston Deputy Medical Officer of Health District Health Office Bledisloe State Building Auckland Ms Margaret Joy Green Scientist National Health In8titute Wellington
PAPUA MEW GUINEA
Dr Tompkin Tabus Senior Medical Officer Veneral Disea8e8 Department of Health P.O. Box 2084 Konedobu
- 30 -
Annex 3 PAPUA NEW GUINEA (continued) Dr Joseph D. Igo Assistant Secretary National Health Laboratory Services Port Moresby General Hospital PMB Boroko Mr Augustine B. Dunstan Health Extension Officer <STD) Department of Health P.O. Box 457 '
!:!! Mr Arua 19ua Laboratory Technician Port Moresby General HOlpital Boroko 8OLOIIOII IIUMDI
Dr Nathan Kere Senior Medical Officer Giza Hoapital Western Province Mr Nicholas Kikini Laboratory Technician Ministry of Health' Medical Servicel Honiara
TORGA.
Dr S.T. Puloka Senior Medical Officer, Public Health Ministry of Health Nuku'alofa Mr Taniela Moala Assistant Laboratory Technician Vaiola Hospital Nuku'alofa
TRUST TERRITORY OF THE PACIFIC ISLANDS
Dr Burton Jano District Director of Public Health Servicel Trust Territory of the Pacific Ialanda Ponape, B.C.L. Mariana Islands 96941 Mr Sebio Shoniber Laboratory Supervilor Ishoda Memorial Hospital Majuro Marshall Islands
- 31 -
Annex 3 SAHQ4
Dr Falenia Asaua Consultant Pathololist National Health Laboratory P.O. Box 1077 Apia 2.
SECRETARIAT Dr G. M. Antal (Workshop Director> Bacterial and Venereal Infection Unit WHO Headquarters Geneva, Switzerland Dr Stuart T. Brown Bacterial and Venereal Iafection Unit WHO Headquarters Geneva, Switzerland Dr Chin Wen Tao Short-term Consultant Communicable Diseases Unit WHO Regional Office for the Western Pacific Manila, Philippines Dr Guiseppe Cuboni WHO Epidemiologist Epidemiological Surveillance Project P.O. Box 5896 Port Moresby Papua New Guinea Ms R. Haessig WHO Technical Officer c/o Ministry of Health & Coa.unity Affairs P.O. Box 268 Bikenibeu Tarawa Gilbert Islands Dr C.S. Lee WHO Medical Officer P.O. Box 113 ~, Fiji Dr R. Lindner Regional Adviser on Coaaunicable Diseases WHO Regional Office for the Western Pacific Manila Phil ippines
- 32 Annex 3 SECRETARIAT (continued) Te.porary Advi.er Dr A. Penington Principal Medical Officer Ministry of Health ~, Fiji Dr N.U. Rao WHO Microbiologist P.O. Box 7330 Boroko Papua New Guinea Short-tera Coa.ult.nt Dr E.H. Sng Department of Pathology Outram Road Singapore 3 Republic of Singapore Dr Sumner E. Thompaon Chief, Clinical Re.e.reh Section Venereal Dise.ae. Control Diviaion Center for Dise.se Control Atlanta, Georgi. 30333 United States of America Dr Tin Maung Maung WHO Medical Officer P.O. Box 113 ~, Fiji Dr P.N. Wang WHO Medical Officer c/o Ministry of Health Nuku'alofa . Tonga 3. OBSERVER Dr Tim Kuberski South Pacific Commi.aion Noumea New Caledonia
Short-term Con.ult.nt
- 33/34 -
ANNEX 4
GROUPS FOR LABORATORY PRACTICALS (Venue: Pathology Laboratory, Fiji School of Medicine, at Hoodless HOule) Team 1
CROUP A
Hr Sile Koria (American Samoa) Hs Stella Driu (Fiji) Hr Vinod Lal (Fiji) Mr Louis Marsters (Cook Islands) Mr Tebebeku Teia (Gilbert Islands) Hs Terelita Bolano (Cuam) Hr Taniela Hoala (Tonga) Mr Sebio Shoniber (TTPI) Ms Hargaret Joy Green (New Zealand) D.r Asaua Faleniu (Samoa) Hr Arua Igua (Papua New Guinea) Hr Nicholas Kikini (Solomon Islands) M8 Jeanne Lecaill (French Polynesia> Dr Hubert Schill (New Caledonia) Mr Kalfabun Eaau (New Hebrides) M8 R. Haessig
T"a. 2 GROUP B (Dr P.M. Wang) Team 4 CROUP C (Dr N.U. Rao) Team 6 GROUP D (Ms R. "aeuig) Team 8 Team 7 Team 5 Team 3
REMARKS: 1. 2. 3, 4. Put protective gown on before you start laboratory work. Take every precaution againat laboratory infection with pathogenic microorganisms. Clean your bench-top and tidy your bench after finishing your work. No smoking in the laboratory.
- 35 -
ANNEX 5 PROGRAMME WORKSHOP AND TRAINING COURSE ON SEXUALJ.Y TRANSMITTED DISEASES SUVA, FIJI, 2-12 APRIL 1979 ".<1 : MONDAY, 2 APRIL . . ., Joint Session at GPH Hibiscus Room ~
.
~.
09.30
Official Opening Me .. age from Regional Director WHO/WPRO' Global STD situation Fiji.STD situation Coffee Official photograph Introduction of faculty and p.r~icipants .Organi2ation and orientation of workshop Precourse questionnaire Lunch "UncQlllplicated gonococcal 'infection" Clinical spectrum Diagnostic methods Discussion Antibiotic 'resistance and therapy Discussion Close TUESDAY, 3 APRIL
10.15
10.30 10.45 , '"
12.00
14.00
15.00 16.00
Clinical and epidemiological at GPH Hibiscus Room 08.30 Treatment of uncQlllplicated gonorrhoea
Laboratory at Moodless House 08.30 - Exercise - Preparat ion of 12.00 modified Thayer-Martin medium - tiaemoillobin solution - GC agal' base - Autoclave above solutions
.09.30 "Complicated gonococcal infection" Salpingitis Discussion
- 36 -
Annf>x 5
TUESDAY. 3 APRIL (continued) Clinical and epide.iolo,ical at CPH Hibiscus ROGa . 09.15 Coffee 09.30 Disseminated aonococcal infection (001) Gonococcal ophthal.ia 11.00 "Epid••ioIQIY of penicillin.s. producing!. ,onorrho••e" DhcuBiion Lecture ~
Laboratory at Hoodless House Laboratory _thod for the isolation and identification !. .onorrhoea.
Ixercis. - Preparation of enrichment and inhibitors .. pour platea and label Di.cuI.ion - _dia types
12.00 1.unch
U.OO
Lunch
Afternoon - Joint Session at CPH 14.00
"Syphilis" Clinical aspect. and differential diaanosil Congenital Iyphilil and other lequela. Dilcu.. ion Coffee Diaano.tic .. thod. Diacusaion Clos.
15.00 15.15 16.00
- 37 -
Annex 5 WEDNESDAY, 4 APRIL Clinical and epidemioloaica1 at CPU Hibiscus Room 08.30 - Lecture -
Laboratory at Hoodles. House "Presumptive testing of gonococci"
Diacullion 09.30 Control
12.00
Discuaaion
Exercise - perform presumptive test. on previously inoculated MTM - subplate to instructor's eA
10.lS Coffee
10.30 "Syphilis epidemiology in Fiji" Diacullion 12.00 Lunch
Lecture -
Quality control of CG culture medium" Exercise - Perform quality control testing on participants' MTH. comparing it with instructor's HTM
14.00 "Genital ulcer disease"
Donoyanosis (granuloma inguinale) Discussion 15.00 Coffee 12.00
- test unknown swabs using MTM and CA Leetu!'e - "".intenance of stock cultures"
Lunch
- 38 -
I\nn"x , --~-.--
WEDNESDAY, 4 APRIL (continued) Clinic.' .nd epid..iololic.l at CPR Hibiacul Roo. 15.1' Genit.l herpea 14.00
Labor. tory at Hoodleaa Hou.e 16.00
Diacuaai.on
-Lectu!'e - "Laboratory identific.tion of penicc'ilin.aeproducinl ·Ionococc i" Ixereiae - Penicillin .uaceptibility teat by diec diffuaion o..on.tration - Confir..to!'Y te.t by carbohydrate utiliution
Diaeua.ion
16.00 CLOSE
16.00
CLOSE
THURSDAY, 5 APRIL 08.30 "V.ainith"
08.30 12.00
Lectu!'e - "Di.ano.is by Gr•• atain .... 1''' Exerei •• - perform Gr ••. atain on ....1'. and ex..ine
Oiacu.. ion
Diacullion
- read quality control plate. and evaluate - read unknown .trains and perform preaumptive teata - read disc diffusion plate De.onstration - C.rbohydr.te utiliaation
10.45 Coffee 11.00 "Unuaual STD aIOnl hOllOa~xuah"
Diacu.. ion 12.00 Lunch
- 39 -
Annex 5 THURSDAY. 5 April (continued) At Hoodless House 14.00 STD diaano.tic te.t. Laboratory demon.tration. 15.00 Coffee 1S.15 Laboratory deaon.tration (continued) 12.00
Lecture
- "Specimen collection. handling and quality control at peripheral level" - "Review GC laboratory .ervice." - Antibiotic susceptibility testing - "Laboratory diaanosh of syphilis"
LUNCH Lecture
14.00 16.00 16.00 CLOSE
Di.cu•• ion
Lecture 16.00 FRIDAY. 6 APRIL 08.30 "A.aea •• nt of importance of gonorrhoea" 08.30 12.00 CLOSE
l.eeture
"VDRL slide test"
Di,cullion 1O.1S Coffee
Exercise - VDRL teat - prepare test needles - check rotator speed - prepare VDRL., antigen - prepare VORL antigen with control sera - test unknown sers
10.30 "A •• e ••Mnt of importance of syphilil"
Di,cu8.ion
- 40 -
FRIDAY, 6 APRIL (continued) Clinical and epidemiological at CPH Hibiacus Room 12.00 LUNCH 12.00
Laboratory at Hoodless House LUNCH Exercise - test unknown sera (cont'd) - review results Lecture - "Glassware cleaning, reagents prepation, handling and transportation of specimens"
14.00 "Standal'd Tl'eatment Pl'ogl'aJlll1ll!" 15 .15 Coffee 15.30 Diacuuion
16.00 CLOSE 16.00
CLOSE
MONDAY, 9 APRIL
8.30
"Clinical services and STD control" Acce88ibility Evaluation (proficiency testing) Hanagement (follow-up, contact) tracing) Discussion
08.30 12.00
Lecture
"Quality proficiency testing for peripheral laboratories"
Exercise - test unknown specimens by VDRL - review results and discussion Visit Central Pathology Laboratory 12.00 14.00 16.00
LO.lS Coffee 10.30 "Pl'evention of STD"
LUNCH Lecture - Introduction to Rapid Plasma Reagin test"
Prophylaxis Comaunity participation Health education Legislation Discussion 12.00 Lunch
Demonstration - RPR card test - darkfield microscopy fol' T. pallidum. 16.00
CLOSE
- 41 -
Annex S MONDAY, 9 APRIL (continued) 14.00 "A sblplified appraoch to STD
control: Swaziland" Diuu.. ion 15.00 Coffee
15.15 "STD control, an overview" Dhcu .. ion l6.00 CLOSE
TUESDAY, 10 APRIL Joint Session AT GPH Hibiscul 100. 08.30 - 10.15 "STD Control - Laboratory Servicel" discussion (continued - in leparate sessions) Clinical and epidemiological at GPH Hibiscu. Room 10.45 Individual short and medium
Laboratory at Hoodlel' Hou.e 10.15 12.00
Lecture
plans Discule10n
.,. "Treponema I telt."
Exercise - TPSA telt - prepare TPSA reaaents - perform tests on unknown sera 12.00 14.00 16.00
12.00 Lunch 14.00 Individual plans, continued
lS.OO Coffee !S.IS Discullion
Lunch Lecture -"ProU.ncy telting: lera preparation, di.tribution and interpretation"
Cour.e lu.... ry CLOSING CEREMONY
ay
WPC 16.00
CLOSE MEDICAL OFFICER PROGRAMME
CLOSE
- 42 Annex 5 ----WEDNESDAY, 11 APRIL 08.30 12.00 Exercise - read TPHA test results Exercise - test IS unknown sera by VDRL and TPHA tests Lecture - "Interpretation of syphilis serologic reactions"
12.00 14.00 16.00
Lunch Lecture/ Demonstration - Laboratory services for other STD including LGV, chancroid, Donovanosis, trichomoniasis, herpes" CLOSE
16.00 THURSDAY, 12 APRIL 08.30 12.00
Exercise - read TPHA tests Discussion Lecture - "Respons ib it it ies of central laboratory and relationship to other countries" Discussion
12.00 14.00
Lunch Course summary and discussion Course questionnaire and critique CLOSE
16.00
- 43 -
ANNEX 6
BIBLIOGRAPHY
ADMINISTRATIVE MATTERS 1. 2. 3. 4. Information Bulletin No.1 Information Bulletin No.2 Information Bulletin No.3 Programme
REVIEWS 5. 6. 7. 8. The World Situation on Sexually Transmitted Diseases and its New Aspects - G.M. Antal Sexually Transmissible Conditions other than Gonorrhoea and Syphilis by Willim M. McCormack Sexually Transmitted Diseases - by Gavin Hart Revue generale - Methodes de laboratoire utilisables PQur Ie depistage et la surveillance des maladies a transmission aexuelle - by C.M. Antal and G.Y. Causse GONOCOCCAL INFECTION Review: 9. 9a. Neisseria Gonorrhoeae and Gonococcal Infections - WHO Technical Report Series No.6 Gonococcal Infection - S.T. Brown Epidemiology 10. Simplified Cycle of Gonorrhoea Transmission, ElF Clinical aspects 11. 12. 13. Disseminated Gonococcal Infection - by K.K. Holmes, C.W. Count. H.N. Beaty Complications of Gonococcal Infection - by Ronsld K. St. John Economic Consequences of Gonorrhoea in Women: Experience from an Urban Hospital by R.C. Rendtorff, J.W. Curran, Chandler, W.L. Wiser and H. Robinson
•
I
- 44 -
Annex (,
Diagnosis 14. Gonorrhoeal Conjunctivitis - by R.W. Thatcher and T.H. Pettit Criteria and Techniques for the Diagnosis of Gonorrhoea Procedures for Use by the Laboratory in the Isolation and Identification of Neisseria Gonorrhoea Preparation of Nephelometer (McFarland) Si.plified Media for Isolating Neiaseria Gonorrhoeae - by E.H. Sng, V.S. Rajan and A.L. Lim Identification of Neisseria Conorrhoeae by Carbohydrate Disc Reactions on a Modified Fermentation of Medium - T.O. Odugbemi and S. Hafiz "-lactamale producing 20. 21. 21b.
15. 16.
17. 18.
19.
!.
gonorrhoeae
Detection of Penicillinase-producing Neisseria gonorrhoeae by Starch Paper Technique (modified) Rapid Laboratory Tests for)f-Iactamase Production by Bacteria -lactamase-producing N. gonorrhoeae- Weekly Epidemiological Record No. 45 p. 357 Treatment
22. 23.
Gonorrhoea Treatment Schedules, 1979 - MMWR Morbidity and Mortali,ty Weekly Report National Gonorrhoea Therapy Monitoring Study - by Jaffe, Biddle, Thornsberry, Johnson, Kaufman, Reynolds, Wiesner and the Cooperative Stu4y Group Therapy for Incubating Syphilis - Effectiveness of Gonorrhoea Treat.ent by Schroeter, Turner, Lucas and Brown Adverse Reactions to Drugs Used in the Treatment of Venereal Diseases - by Harold W. Jaffe Clinical Survey. ANAPHYLAXIS - Course, Mechanisms and Treatment - by J.F. Kelly and R. Patterson Comparison of Aqueou8 Sodium Penicillin G in Lidocaine and Aqueous Procaine Penicillin G for Treatment of Gonorrhoea - by M.G. Adams, H. Turck and K.K. Holmes Use of Probenecid and Cause of Treatment Failure - by K.K. Holmes. W.W. Karney. J.P. Harnisch. P.J. Wiesner, H. Turck. and A.H.B. Pedersen
24. 25. 26. 2,7.
28a. Single D08e Aqueous Procaine Penicillin G. Theraphy for Gonorrhoea:
- 4S -
Annex" , 28b. Nature et importance des reactions secondaire. a la penicilline, compte tenu notamment de. case mortel. par choc anaphylactique - by O. Idsoe, T. Guthe, R.R. Willcox and A.L. de Week NON-GONOCOCCAL URETHRITIS 29. 30. 31. Diagnosis of Non-gonococcal Urethriti. - by Stephen L. Swart. Gonococcal and Non-gonococcal Urethriti. in Men - by N.'. Jacob. and S.J. Kraua Prompt Pointers to the Aetiology of Male Urethriti. - by P.S. Nathan, M. Jeg.the.an and S. Ra.alin,am SYPHILIS Review: 32. 33. Syphilis - by S.T. Brown Epidemiological'Aspects of Syphili. in Fiji - by A. PeninRton Dialno.i.: 34. 35. 36. Spirochete Differentiation Criteria and Technique. for the Diagno.i. of Early Syphilis The Laboratory Diagno.i. of Syphilis - New Concept. - by Harold W. Jaffe
37a. Micro-haemagglutination AlSay for Treponema Pdlidum 37b. L'epreuve d'hemagglutination - WHO/VDT 76.410 38. 39. 40. 41. d~
treponeme (MBA-TP) por Ride et D'Co.ter
Manual of Te.ts for Syphilis - 1969 Materiel et Verrerie Reaction VORL sur La.. Preparation des serumS de controle et de. enchantillon. pour Ie. epreuves d'efficacite Treatment
42. 43.
Recommended Treatment Schedules for Syphilis, 1976 Section: Syphilis in Pregnancy and Congenital Syphili. - The Value of Penicillin Alone in the Prevention and Treatment of Congenital Syphilis - by N.R. Ingraham
- 46 -
Annex 6 CHANCROID, DONOVANOSIS, LYMPHOGRANULOMA VENEREUM 44. 45. Chancroid, Donovanosis, Lymphogranuloma venereum Donovanosis in Papua New Guinea - by I. Maddocks, E.M. Anders and E. Dennis HERPES 46. Treatment of Genital Infections with Herpesvirus Hominis - Editorial CHLAHYDIAL INFECTION 47. 48. Chlamydiae as Agents of Sexually Transmitted Diseases - by J. Schachter, G. Causse, M.L. Tarrizo Chlamydia Infections - S.T. Brown CLINICAL SERVICES 49. 50. The Establishment of a University-Based Venereal Disease Clinic I: Description of the Clinic and its Population - by Peter E. Dans The Need for Problem-Oriented Venereal Diseases Clinics by J.H. Armstrong, P.J. Wiesner CONTROL ELEMENTS 51. 52. 53. The Prophylaxis of Gonorrhoea - by E. Barrett-Connor Antenatal Screening for Gonorrhoeae in Christchurch - by A.B. Maclean, S. Paltridge, W.K. Platts Outline for Comparison of Drug Regimens in Uncomplicaterl Gonococcal Infection RESOLUTIONS BY WORLD HEALTH ASSEMBLY 54. 55. Resolution 58 - Control of Sexually Transmitted Diseases (1975), ElF Resolution 59 - Control of Sexually Transmitted Diseases (1978), ElF
- 47/48 -
ANNEX 7 PRE-COURSE QUESTIONNAIRE SUMMARY Participants to the clinical/control element (n- 13 of 14 attenders) Prior education 11 Physicians, many from Fiji Medicsl School 2 non-physicians - I health extent ion officer for 7 years 1 BS, environmental health
Advanced degrees (MD'.)
4 Public or community health degrees 3 Specialty boards: Ob-gyn pediatric., general practice 2 Diplomat. Venereology 1 EPI I, II, III
12 Full or parttime government - some physicians also in priv.ate practice 1 Researcher (leprosy, filaria,il, dengue, ST~) 2 al.o unver.ity post. Job duration 4 4 4 1 10+ years (3 Directors of Public Health) ) 2-4 years ) variety of po. it ions Ie .. than 2 years ) No answer
Gonorrhoea therapy 5 adequate 1 or 2 may be adequate 4 or 5 probably inadequate: PAM, benzathine, APP6 1.2 au qd x 6, Pen (?) 2 mu + .5g qd x 2d 2 no answer (no patient care) Syphili. therapy 4 No .yphilis (TTPI, Cooks, American Samoa, New Hebrides) 4 Adequate therapy 3 Excessive therapy PAM daily x lO-15d; Pen (?) 25 mu, APP6 (?PAM) 1.2 qd x 30 d 2 No answer (no patient care)
- 49/50 -
ANNEX 8 PRE-COURSE OF QUESTIONNAIRE SUMMARY Participant. to the laboratory-dialno'tie e.e.ent Laboratory No. of participant. No. of countrie. No. doing MBA-TP No. FTA - ABS No. CDC proficiency -
- 15 - 14 (Fiji - 2 participant.)
3 (Suva, Lautoka, Papua New Cuinea) . 3 (Gua., New Caledonia, French Polyne.i.)
6 (Suva, Cua., Aaerican 5..0., New Caledonia, ·Sa.oa, Tru.t Territory ~f the Pacific hland.)
No. G.C. culture No. u.ing .elective mediull No. HIC
- 13 (except Cook I.land., Papua New Guinea) 7 (Su.va, Lautoka, AlMrican Samoa,N.w Zealand,
Gua., New Caledonia, French Polyne.ia) 1
(New Zealand)
- 51 Al~NEX
9
StJt.1MARY OF
EVALUATIO~ f)~ O~
TIfE '~f)Rf(SHOP AWl T~A PHW; SF:1(UAttY TRANSMITTED OT"lEASES SUVA, FUT, ::>_12 APRIL 197'1
CO!JRSF:
A., eva l.u""t io., q'l'·~t io.,n~ i rl! .W'lS '1; st .. i "utl!C +:'0 eacl'l of' the seventeen Me!'ltcal of'fice"s I.lno1 ftfteen l~.,o,,~to"v PI.l"ti.ct"l.lnt~. F:leven mer:lic~l Of'1'i.CE!I"S (1;4. 7~ "e~ponse rate) a!'1d nftee'l '.",,!)orl.ltl)ry I"esponr:lents (1 OO'C response rl.lte) co~pleter:l tl'le postcourse questionnaires and info ..~tion furnis~ed was user:! to assess tl'le usefulness and cI)nduct of t~e wo"kshop.
The objectives of the wo"kshop were: (a) 'to stren!then the manl.lgement of the control of sexualty transmitted diseases; (b) to promote the development of national control program~es on
sexually transmitted diseases; (c) to improve the co~petence of laboratory/clinical personnel to confirm the diagnosis of sexually transmitted diseases, particularly of penicllttn:"resl.stant gonorrhoea.
I.
Medical Officers
The responses of the eleven ~edical officers to the questions on the usefutness of the workshop were tabulated in Annex 1. In the questionnaire assess~.ng the u~efulness of the ,.,orkshop, two "eolies were reqll1.rer:l for each topic cove"p.d, t~e relev~nce/usefulness of tl'le ir:leas anr:! t~e apol"oD1"iateness of the time o1evoted to eac~ topic. Partictn~nt~ we"e "equesteo1 to lI~e t"e f'0110l-li.'l1!; rat1.t1g ~cale~: (a)
Uti'i.+.v
~ca'e
Ij
(F.xt"'e\'llplv Ilseful to me), 4 (~ode"ately use"ul ), ~ (C;ome use), ~ Plot 'Duch ul'\e) , , (I .. ~eleva"t "or me);
(h) Time !'!O",nt
Ij (~uc" too lot1~), 4 (Slt~"tly too ll)n~), 3 (Time Just rig~t), 2 (St ig"Uy too .'J"ort,), 1 (Inadequate ti.me).
A column on "no answer" was 'ldded in Annex l. The mean 0'" average of t'1e ratings/scores for each topic was computed. The mel.ln ratings/scores for the topics were ranked i.n descending order (highest - 5, lowest - 1) separately for the utility or relevance scale and for the time spent scale (Annex la). It is noted in Annex la that the medical respondents considered the following topics: Epidemiology of penicillinase-producin~ N. gonorrhoeae; Complicated gonocoocal infection; Chlamydial infections; Prevention of STO; STn control: labol"atory services; Syphilis; Standard treatment programme; Clinical ~ervices and STO control, as extremely useful (with mean 'Jcores of 4.5-5.0) and the foltowin~: Assessment of importance of ~onorr"oel.l;
- 52 -
Annex 9 Uncomplicated gonoccocal infection; Individual plans and discussions; Genital ulcer disease; Assessment of importance of syphilis; Laboratory d~monstrations; STO control, an overview; Vaginitis; A simplified approaoh to STO oontrol; and STO among homosexuals, as moderately useful (with mean scores of 3.5-4.4). Please refer to Annex la for the ran~ing of the mean soores of the topios. In addition, the Medical officers commented (Annex la) that the time spent for the discussions of most of the following topios: Assessment of importanee of gonorrhoea; Standar1 treatment programme; Uncomplicated gonoccocal infection; Assessment of importance of syphilis, STn control, an overview; !pidemiology of penicillinase-producing N. gonorrhoeae; STO among homosexuals; Lahoratorv demonstrations; A simplified approac~ to STOcontrol; Clinical services and STO control; Genital ulcer disease; Prevention of STD, syphilis; va~initis; STn control: l~~or~tory services; and r.omplieated gon"ccoca 1 . i.nfection I'tnd c"lamydial infeetions were .1ust ri~"t U~.C;-3.4' !lnr! time SP~"t on thq Individual plaM ant1 cUscussions were sli~"tly too short (l.~-2.~).
11.
Laboratory Participants
The responses of t~e firte~n 1abo~atory particip!lnts to the queries in the postcourse questionnaire were tabulated in Annex 2. P~rticipants were requested to use the followin~ ratln~ sC'ile: 1 (strongly positive), 2 (slightly positive), 3 (neutral), II (slightly negative) and 5 (strongly negative). A column on "no answer" was added i.n Annex 2. The mea:n or average of the ratings/scores for each query was computed. The mean ratings/scores were ranked in descending order (highest - 1, lowest - 5) separately for the practical workshop, for practicals on gonorrhoea, and practicals on syphilis serology (Annax 2a). The reactions of the laboratory participants (Annex 2a) towards the statements related to the practical workshop, practicals on gonorrhoea and the practicals on syphilis serology were as follows: (Statements) Strongly Dositlve - PartiCipants could follow the lectures. - Pr~cticals on Gonorrhoea were relevant to their worK and would be useful to them in their future wo"'k. - t>~'!\~ticals on Syp'I1.1 i.!,! Serologv would be useful to the~ in thei'" future work. - PrClctica1.s in Sypl1y1 is to thai'" 'lfork. Neutral Serolo~y
we"e relevl'tnt
- The or''\ctical workg1-Jop was too lon~; there were too few lectu"es; the lectures were ~eliver'~d too fast. - Practica1.s on Gonorrhoea were too simple - P"'acticals on Syphilis Serology were too si!llple
- 53 Annex 9
Slightly negative
- There were too many leotures; the praotical workshop was too short - Praotioals on Gonorrhoea were too diffioult. - Praoticals on Syphilis Serology were too difficult. - None
Strongly negative
Inasmuoh as the answers of laboratory participants to the last 3 questions are quite varied, a listing of the responses are in Annex 3.' The ~espondents stated the subjects which they teel should be omitted as well ~s the subjects to be included in future courses; the general impressions of the respondents were also inoluded in Annex 3. In summary, the Medical Officers considered 8 of the 18 topiCS covered to be extremely useful to them and the rest of the topics as moderately useful (Annex la). With the exoeption of the time allotted/spent for individual plans and discussions, the Medical Offioers stated that the time spent for the 17 topios covered were just right (Annex la). The laboratory partioipants had positive reaotions towards the following statements: Participants oould follow the lectures. Practicals on Gonorrhoea were relevant to their work and would be useful to them in their future work. Practicals on Syphilis Serology were relevant to their work and would be useful to them in their future work. The negative reactions of the laboratory participants to the .tatements 1n the questionnaire should be taken into account in planning fvture courses of this nature.
- 54 -
Annex 9 REP!.!!!:S 01' THE "f!I)ICAl. OI'FtCF.RS TO Tll'- QUERIES HI THE POSTr.OURS! QUESTIONtlAtRE WORl(:'lHOP API!) TIIAtNl'I'l r.OUIISE O~ SF,XUAl.lY TRAI/SMITTEn DISEASES Suva • ?-l? Aprll lq7q I1tn ttv Sa"l" (Relev .. n",,) Tooic Exuej Modely use- r.rely fut tone useful
T'''''' Sent Mean Much t('O
Some
Nor mm:h Ult'
lrrcit'valli for mt!
No
SlIghrIy too
11me just
SlIghr,), Inadl·· !oo ~Uarl.·
No J\ us .... d
l\ ll'.ll1
use
An' ....·er
r; l.
II
, 2
2
,
long
1011": ~
ri),dlt
'i
, 5
,hllU ~
liml'
, 3.0
UncOlllpl.tll,te<l ~enooooo"l
tnr"otton 2. CompUoated
5
I,
~.3
3
3
genocooaal infection
9
1
1
4.7
, 2
6
3
1
2.6
3. Eptdemloloay
of penlct HInase N. lonorrh.,... Syplll\ tI dtaeese
10
1
4.S 'I. 5
7
, , 1 2 I
?.9
0;, QenUal uloe"
-.
6 r;
4 3 1 4 4 I)
1 3
9
?.7 ?8 2.0;
4.;> ~.
;> 1 1 1
~
,
6. CII1.IIIV"h\
t.,recU"",.
" ~
, b C;
7
I,
'i
, 1
7.
Va~'.n't'.,.
'." ,.7
"i
4
2.7
CI. :'lTD aIIIIlnll; """,",(",(""\11
?
1 2
7 ~
, 0;
'.q ?'l
".
\.I\h,,"stol"'f d....on!lt ... tlonll
3
1
,
3." 4.4
1
10. Asses8",..nt of llll!)"rtana.. "t gonorrho.." 11,
0;
C;
I
'5
r;
, 1 I
3.11
Assessment of illlportano" of Syphilis
3
6
2
4.1
3
6
3.0
12. Standard tr,,"t'llent progr._ 13. Cltnio .. l servic"s Ilnd STD control 14. Pr"v .. nHon or STO 1c; •
7 Ii <;
3 4 ~
I
4.5 4.0; 1 4.~
1
2
7 0;
, ~
3·3
1
?
2.8 1
II
2
2.8
A.tmDltr1ed
""1'''0110'' t.o 'lTD o".,t;..o~ 1~.
3
STll cont.rol: "" ov".. vi .... STO contrnl: . l"horatory . serviaes Ynd! vidual plans and discussion
17.
" 0;
.,
" 4
•
1
'.R 3.Q 3
10
1
2.0
,
1
0;
3
3.0
2
4.6
.;
3
?
?7
,r. ,v.
5
3
2
1
4.3
2
3
2
3
1
2.4
- 55 -
Ann!!!! 9 REPLIES ('4KAN OR AYERAGJ:;) 01" 'fHE '4EDICAL OFFICERS TO THE QUERIES IN THE POSTGOURSE QUESTIONNAIRE
(MEANS RANKED
l~ UESCE~DING
ORDER) ~-'-~-~--1fl'!1"
UtHlty Stlale il!pt"8'II.~"lOO;Y of p"ntol\lna",,-' ~~o~u~tno;!. ~onorr~~~e
Spf!'nt
$I)~\"
'!opt.
""ean 3. 11
"n~e
't. ~ 11.7
" ExtremJ:·
~8, .. s~~n~ of t'!lPort~"e~ ~r ~~"o~r~oea '
Time jUlt
,
~o~~lle~t~~ ~O"~~~oo~l
Iy .,.(ul
~t.~~~"~ t~~t~-.~t.
right
""'II;~"'""'" ~.7 ~ ,"~~,'I~~t~1 ~~~n~eo~~t
"'",,c". ttn\ I~ 1'\l'S"~~""p'.,t.
to>f' <;
"YII~'
1.'"
n'
of
:"'I.!U., .. tll"\CP.
:.0
~T" eo,!t.r"l, • .,
OV'l"vt .. ·~
",
O:l't<!"~totn~Y or p"ntell11 '1ase"prl)'1u()~,M
~. gono",."l1oe'1" 7 ~tandard treatment pro~r~~~e 8 lel tntolill servtMs and STD 100ntrOl ~ ~ssellll~ent or l~port_~ee of ~ono~r~ol!"
4.'>
7
~TD
'\""''1,;0:
1l0'!l0"eXU"'~9
2.1) 2,,)
9 Moder'le" Iy
~:s t'!I:> 1\ rt .. rt IlPP"ORC'J ~.o
'0 ~ncnmpltc .. t-.~ ~onoeoooat tnt'eotl"n
u,.-
(ul
S'l'D oOJ\~l 10 ' I-:u n'."'1 t "-.rv{ee,, F"'1Vol
~'1" .STD
II. ~
,~
A~~~~s~~~~ o~ t~~~pt~~~~ !lvn~Pt
nr II • 1 1~
..
kI",~. ~, t I ~
10; 16
~TD e"ntrol: l~~~r~to~v iservtoe .. C~Rplle~te1 ~"no()e"c~l
Yao:!ntth A st~pltrled control approac~
IS to STD 3.7 18 .-.. "'.--- -..........
tn!'eetlon _ • • e • • • • • • ___ . _ . _ .
17
2.5
Slightl"~lvldual
19. STD
amon~ homose~ua\s
plans
a~"
ly 100
disoussions
2.4
shorr
Range Rattn!! lIoale: Extremely u .. eful to mA ~ode~t"lv use'ul ~.." us .. Not ltIUo~ us .. Irrelev""t ror .... 5 4 3 2 ~.5-0;.O ~. 5-4.4
2.'5-3.4 1.~_2.4 (l. I
Ratln5 ,ealer quch too lon~ ~ Slt~~tlY too lo~~ ~ Th., just "t~!lt 3 Sll~~tlv too ..~oPt 2 t"~d~~UAt" tl~
ij.S.S.O 3.5-'1.~
• 'I
1
'-.5.3.4 1.5.2.4 11.1.4
- 56 -
Annex 9
OF TIJI': !..A!30~ATORY PARTICIPA1~TS TO TIfE QUERIES IN THE POSTCOURSE QUESTIONNAI~~ WORKSHOP AND TRAINnm COURSE ON SEXUALLY TRANSMITTED DISEASES, Suva, 2-12 April 1978 qEPLIE~ Stron~ly Slightly Positi.ve Positive
Neutra
Stro"~ly
Sltghtly Negatlv~
Negative
No Answer
M~.'l"l
I
2
3
It
5
~. (a)
Was tn~ practical workshop too long? Was it too short? t4e!"e tl1e!"e too Iftllnv l.l!ctures? "Ie!"'! tlte!""! too few? l':ou1-1 vou rollow the lqctu""'s" We!"e the t"!o+:u"'!'1 -1p.ltv,,"erl too ""st? "Ie!"e the p"actioats on~o"orrhot'!a
2
10
2
1
7
3 ~
It
1
3.2 3.B 1.">
(I))
~
8 ., :> I)
'-
., ". :I 1
"3.? 1 1. 1
(0'
11
;>
1
1
II
1
3 .11
e.
('l)
r",lev'lnt to your ·..,ork? (b)
lit 1
1
1.1
We"e they too Simple? Were they too difficult? Would they be useful to you tn your future work? '4el"e the practicals on syphilis serology relevant to vour work? Were tl-t'"v too 1'!1.",.,1e1 He"", •• h"lY t;o" rit rrl.ou1 1;1
3 1
1
2
, (,
1
2.9 1t.1
(c) (d)
3
It
1
n
1
1
1.3
~.
(a)
Q
'3 ?
1
1
1
1 .13 1 3. 1 II. n
(I»)
., '5
2
3 '5
1
(ol
II
,
(<1)
t"tev be u!!Ip.rul to you 11'1 VOU" futUl"e wo ..l(? :~ollld
12
2
1
1 1. 1
- 57 -
Annex 9
REPLIES (MEAN OR AVERAGE) OF THE LABORATORY PARTICIPANTS TO THE QUERIES IN THE POSTCOURS! QUESTIONNAIRE (MEANS RANKSD IN DESCENDING ORDER)
Rank
Query
Mean
Rating Scale Range
A. 1 2
Pl"aotiolll IIIo,,\(sh22 Coult! vou rollow VIOl) leot:.u,.es? Was it too lon~? rlllW
r--.-"--~~-- ----------~.--------. 1.4 Stronlly postttVOl)
~----~---3.~
.. --------------------"Ieut,.at
3
We ..e thea too
leotures?
3.2 3.4
4
"Iel"e tl'l. lecturOl)s "",Uve,.ed too fast? Were there too many -lectures? Was it too short?
5 6
~---------3.6 3.8 ~--
-.-------------~-----
B, 1 2
Practicals on ei°norrhoea Were they relevant to your work? Would they be useful to you in your future work? Were they too sl111ple? Wer" they too dtrf1cult?
. ------- --------------------------~-------------. Strongly positive
S11shtly negattve
~---------1.1 1.3 t-----.. ----2.9
3 4
~---------11.1 t---.. --- ...... -
-----------------.--Neutral -------------- .. ---- .. Sl1~"tly
nesative
C. 1
Praeti.cals on SII!~i lis Serol0!5v
------------------------------------ .. ---Stro,,~ly
Woult! t""'y bill useful to you 1." you.. rutu"~ wo .. k? We,.", they ,.elp-vant to you!" '"ork? We,.. t"ey too simple? Were they too diffioult?
~---------1 • II
2
-------_ .. -- -------. -------- .. Slightly positive 1 .8 ... --------.,. 3.4 ~----------
posiHve
---~
3
4
------.... - ------------.------.4.0 Slightly "eS'ltive --.. ~---- .. ----.------1 1. 1
--------~-----------Neutral
R~ting
Soale:
Strongly Slightly Neutral Slightly Strongly
positive positive negative negative
Score --,2 4 5
o-
Range
1.5 - 2.4
3
2.5 - 3.11 3.5 - 4.11 4.5 - 5.0
- 58 ,\nnex 9
tAqOftATORY PARTIt:IPANTS TO T"I:::': QUl<;q"[;;;~ THF. POST~OURSE OUESTtO~NAt~F. WORKSHOP AN!) T~AINING COURSE O~ SEXUALLY TRANSMITTED DISEASES, Suva, 2-12 Apl"11 11')79 TJ{~ "[~
RF.PLII';S OF
D. (a).
T~e
followin$ subjects should have been omitted: I think th~ practtcal work on VORL w~s too much; could have been sllQrtened and TPHA lIIore emphasized.
1.
2. ~.
None so fa!", I unllerstllnd that all the subjeots th'lt we had oOYe!"ed It.-a ver'y use!'ul !'01" the futur'e upgradl.ng of eaol-J Ind1vlt1u'll. tllboratol"1..,s, 'ftostly in the Pacino hiantis.
c;. fl •
., 1\.
q. 10.
"'a 'St !! , "'\loh 'IS 'l'PHA tP.!'It, whtch shoulrt be o~ltt"!rl.
SO'De
1.l'Iborl'lto.. tes os"mot affo!"d.
11. 12.
14.
~el~hing
of 2 g of heamoglobin (1-1/2 ~ou!"s); Leoture on the mak!n~ of a dropper releasing ~O d1"oplI per '111.
15.
- 59 -
AnDex 9
1.
FTA-ABS tect11"e, "t 1M3t th~ princi.ole in value ll"lrl 1"'A.tion'llp. ~nd if possible, a demonstrlltlon or the technique.
2.
3.
Atl the other serological blood testj exa.ple - RA, Febrile Alg., etc •. One or two lectures on treatment and results obtained lifter treatment would have been interesting. The (illegible) of the reactive serum oontrol tor VORL should have been included.
4. 5.
7. 8. A vhlt to a VO olinlo to many participants. 3M
t"e Sflt up would t,e of ''''!In to
10.
12.
One or two lectures on t"elitment a.,d response.
13. 14. FTA-absorption test and M!C - Joint demonstrations with thp. epide~1.ologists. Joint meeting wit" the epidemiologists on t"P. problems of case-fin~ing and routine exam~nations.
15.
I think that an ~IC test could have been organized for the practioalwork oniJonorrhoea.
- 60 Annex 9
D. (c)
General impression: 1. Excellent workshop; well presented; the lectures are verv knowledgeable in their own field. I'm glad I came and I hope Guam will be invited to the next workshop. The two week course WAS well done, couldn't be any better. fine set-up and all in an, !,:ood inst"uctor-s. I w1.sh t'1at the WHO will put up more wo"l<l!hop~ like tl1is for labor-atory personnel, two or t~"ee times a year. r.on~"atulations to all the staff who took part in this wo~kshop. You have done a goo~ job. Thank you again. I feel there should l1ave been mor-e joint discussions and ~I"OUp discussions with different countries asked to give their views and everyone taking part. I personally feel that some participants kept silent throughout. Otherwise the workshop has been successful. The course itself was quite an experience as it made participants to share the problems they have in their own countries and we hope there will be a kind of dialogue created by some means. Satisfactory. - Good irtea to go back to basics to standardize and update methods. - Good practical infol"mation given on control of methods and materials. - Adequate inrormation gj.ven to allow partiCipants to evaluate methods and materials and choose the most appropriate one fo" their own ~ituations. - Art<'!quate time allowed fOl" participants to hAve qu'!!stion:'l I!nswere~ rull V. Joint sessions ~lIve g;ood clinical QAcl<",rounr:l and helped to emphasize that r:liag;nosis of STD'! is very muc~ a team erfo~t. SOl"ry tl1ere WIIS no Austr!lli1'ln laborator-y participant. I h~ve ~aine~ knowled~e of lahoratory pl"ocedures well. Th~ l~st .1otnt session was a bit too late, not much di.5cussion. I think participants were tired. The Joint session would have much discussion if it was placed mid course. Participants have learnt something already and have not been tired. I was really impressed about the workshop but there was really nothing concluded about the standard method. There has been a very friendly cooperation between the lecturers and the participants and I fell very happy to be one among those taking part in this WHO intercountry workshop on STD. A
2. 3.
~.
5.
6. 7.
A.
q.
10.
- 61 -
Annex 9 D. (c) General tmpresston: (cont'd)
11. I strongly feel that courses as such, tf conducted at this frequency (whatever subject it is) ~nd this manner would undoubtedly promote self-oonfidenoe to both the administrator (DR) and the lab ·worker. Far better than poorly organlzed scholarships and fellowships. 12. It was a successful seminar. We learned a lot of new ideas and techniques. Also the participants were oooperative.
13. This is the first time I participated in such a course; helped me a lot. new. In any case I am very happy to learn
it som~thtng
1_. The technioal competence of Dr Sing has been un~erused. Very hlRh level of the epidemiolo~y part of the meeting; too low level of th ... laboratory part. There has been no rAil! contact betwet'ln laboratories Ilnd phvstcians ooncernin~ the practical conduct of lIlbo..atorv tests required by phystctans. A laboratory t~ not solely staffed with 11Hter3te la!)oratorv techntctans who "l~e not interested in eptdemlolo~iMl prohlems. ·.,.,i Ie the epidemtolo~i!'lts were able to review the whole question, the lll"orato\"y part of the meeting remalnef'! ra .. below tts potentialities. The time wasted explAintn~ the direction of rotations and the number of revolutions required for stIrring as well as for cofree breaks might have been used otherwise •• 1S. I think that this workshop is positive since I have learned new techniques which I can demonstrate 1n the laboratory where I work. I have found the workshop rather long, for instance \t took us 1-112 hours to weigh Ilnd dilute 2 gr!l:nmes of lIIel11u1ll (which is too long) and we performed VDRL tests during three consecutive days. We could have devoted that time to other topics. However, on the whole, the workshop has been very interesting.