Fiji 21

ICP/BVM/009

REPORT

~ERCOUNTRY TRAINING COURSE

ON LABORATORY ASPECTS OF DIARRHOEAL DISEASES I.'

Suva, Fiji 21 June - 2 July 1982

NOT FOR RESALE Printed and distributed

by the

Regional Office for the Western Pacific of the World Health Organization

Manila, Philippines December 1982

WHOIWPRO LIDRARY MANILA. PHfLTPPlNES

NOTE

The views expressed in this report are those of the participants and members of the faculty of the training course and do not necessarily reflect the policies of the Organization.

This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the participants of the tra~n~ng

course, which was held in Suva, Fiji from 21 June to 2 July 1982.

1.

2.

3.

4.

5.

CONTENTS

INTRODUCTION ... .. 1 PLANNING OF THE COURSE ... .. 2

CONDUCT OF THE COURSE •••••••••••••••••••••••••••••• , •••••• 2 CONCLUS IONS ... .. 3

RECOMMENDATIONS OF THE COURSE DIRECTOR 4

ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS,

GUEST LECTURERS AND SECRETARIAT ••••••••••••••••• 5 ANNEX 2 - TIMETABLE

...

ANNEX 3 - LIST OF HANDOUTS

...

ANNEX 4 - SUMMARY OF PROFORMA FOR EVALUATION OF THE INTERCOUNTRY TRAINING COURSE ON LABORATORY ASPECTS OF THE CONTROL OF DIARRHOEAL DISEASES,

9 13/16

SUVA, 21 JUNE TO 2 JULY 1982 •••••••••••••••••••• 17

1. INTRODUCTION

The Intercountry Training Course on Laboratory Aspects ,of :he Con:ro1 of Diarrhoeal Diseases, organized by the World Health Organ1zat10n Reg1ona1 Office for the Western Pacific in collaboration with the Ministry of Health

of Fiji, was conducted in Suva from 21 June to 2 July 1982.

This course was designed for countries of the South Pacific, the

governments of the region having indicated great interest in the laboratory aspects of diarrhoeal diseases. The objectives of this course were:

(1)

(3)

(5)

to impart practical laboratory skills for the diagnosis of diarrhoeal diseases. This will eventually lead to improved clinical management;

to train the participants 1n selected diagnostic procedures;

to enable the senior laboratory technicians, on their return to their countries, to train the staff under their supervision;

to impart knowledge of the epidemiology of diarrhoeal diseases;

to increase the sensitivity and reliability of the detection and monitoring of acute diarrhoeal disease outbreaks.

There were two participants from Fiji and one participant from each of seven other Pacific countries, making a total of nine participants from eight different countries.

The Director for the course was Dr N.U. Rao, WHO Microbiologist, based in Suva, and the Co-Director was Dr Karam Singh, the Consultant Pathologist at the Colonial War Memorial (CWM) Hospital in Suva. Mr Asphani Khan and Mr Rajendra Parmar, who are microbiologists in the Pathology Service of the Ministry of Health, Fiji, were temporary advisers. Dr I. Geizer, Regional Adviser, Health Laboratory Services, WHO, Manila acted as Operational Officer.

The course was opened by the Honourable Mohammed Ramzan, Minister for Health, Fiji.

Dr Y.T. Kuo, Acting WHO Representative and Programme Coordinator in Suva, representing the WHO Regional Director, Dr Hiroshi Nakajima,

delivered a message from the Regional Director, thanking the governments of the region for their strong support in the conduct of various training courses conducted by WHO for the diarrhoeal diseases control programme. In particular, he expressed his deep appreciation and thanks to the Ministry of Health of Fiji for having agreed to act as a host for this course and for making available the excellent training laboratory facilities at the Hoodless House in CWM Hospital. He stated that the course was designed more for bench work, where methods and techniques that had been tested and

recognized as accurate and precise would be taught. There would

accordingly be a limited number of lectures and plenty of bench work in the programme. In conclusion, he hoped that the participants, on completion of the course, would be able to impart appropriate training to the staff under their supervision in their respective countries.

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The local arrangements were excellent. The cultures used in this course were supplied by the Nat~onal Health Institute, Wellington, New Zealand. The excellent asslstance and support received from

Mr R. Parmar and from Mr A. Khan deserve special mention in this report.

The list of participants is given in Annex 1.

2. PLANNING OF THE COURSE

In preparing the timetable for this course, due attention was given to:

(a) the stated objectives of the course;

(b) the content of similar courses held at the International Diarrhoeal Diseases Research Centre, Bangladesh (ICDDR, B)j

(c) the availability of resources in Suva; and

(d) the adaptability and use of the laboratory techniques taught in the course in the South Pacific countries.

Wherever necessary, emphasis was given to the basic principles underlying the techniques used. Each day's programme was designed to include a generous portion of bench work and group discussions. The timetable is given in Annex 2.

3. CONDUCT OF THE COURSE

After the lecture on the overview of the epidemiological situation of diarrhoeal diseases in South Pacific, practical demonstrations of some of

the laboratory techniques were given following discussions on laboratory diagnostic procedures. The participants were then given two unknown stool samples to be tested for Vibrio, Salmonella, Shigella and E. coli.

During the latter part of the first week, lectures were given on the practical application of the ELISA technique and on the characteristics and importance of rotaviruses in diarrhoeal disease.

After observing the standard of performance of the participants, some of the techniques were repeated with a different set of unknown specimens.

Unknown specimens containing especially Vibrio parahaemolyticus,

Yersinia enterocolitica and Campy10bacter jejuni were repeated till the participants felt confident about their skill to isolate and identify them. The duration of some of the lectures was curtailed in order to enable the trainees to work on more unknowns than originally planned. The list of handouts given to the participants is given in Annex 3.

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At the end of the course, each participant was given a package containing;

0)

(2) (3)

(4)

( 5) (6) (7) (8) (9) (10)

(11) ( 12) (3)

(14)

(5) (16) (7) (18) (19) (20)

TCBS agar

Moeller's Decarboxylase base Lysine

Ornithine Arginine

Vibrio cholerae poly 01 antiserum Salmonella 0 antiserum poly A to I Salmonella Vi antiserum

Salmonella group E antiserum Salmonella 0 antisera factor 2;

factors 4, 5; factor 7j factor 8;

factor 9

Salmonella H antiserum a-z

Salmonella H antisera a, b, c, d, ehj ij I-complex

Shigella antiserum, Group B

Shigella antiserum, Group C Shigella antiserum, Group D E. coli OK antiserum, poly A E. coli OK antiserum, poly B E. coli OK antiserum, poly C E. coli OK antiserum, poly D E. coli OK antiserum, poly E

1/4 lb 1/4 lb 5 ^gms 5 gms 10 gms

3 ml 3 ml 3 ml 3 ml

3 ml of each 3 ml

3 ml of each 3 ml

3 ml 3 ml 3 ml 3 ml 3 ml 3 ml 3 ml

The above antisera are in a lyophilized form with long shelf-life.

The availability of the above media and antisera will help the participants to continue or initiate the methods taught in this course in their

respective laboratories after they return to their countries.

4. CONCLUSIONS

With participants possessing different degrees of skills, it was rather ambitious to attempt to cover topics like the ELISA technique.

After a couple of days of working contact with the participants, some topics such as the isolation and identification of V. parahaemolyticus, Salmonella, Shigella, Y. enterocolitica and Campylobacter were more thoroughly covered and less emphasis was given to the didactic lectures.

Overall, the course appears to have been very successful. It was very heartening to read the comments of the part1c1pants on the evaluation

forms, completed by them at the end of the course.

- 4 -

The summary of answers given by the participants at the end of the course in the proforma for evaluation of the course is given in Annex 4.

5. RECOMMENDATIONS OF THE COURSE DIRECTOR

5.1 Consideration should be given to the holding of national courses, similar to this course, in order to extend the benefits of the intercountry course.

5.2 Some countries may wish to send their laboratory staff for attachment to the microbiology laboratory at the CWM Hospital in Suva. This type of tra1n1ng would be more beneficial, particularly for the laboratory workers who have not had any formal training in medical technology.

II

II

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LIST OF PARTICIPANTS, TEMPORARY ADVISERS, GUEST LECTURERS AND SECRETARIAT

1. PARTICIPANTS

COOK ISLANDS Mr Aitama Rakoia

Laboratory Technician Ministry of Health P.O. Box 109

Rarotonga FIJI

KIRIBATI

MARSHALL ISLANDS (TTPI)

SAMOA

Mrs Ansuiya D. Singh Technician

Lautoka Hospital Lautoka

Ms Saras W. Prasad Technician

C.W.M. Hospital Suva

Mr Tekaibeti Tarataake Laboratory Technician Ministry of Health and

Community Affairs P.O. Box 268

Bikenibeu Tarawa

Mr Harrington Nenam Laboratory Technician

Armer Ishoda Memorial Hospital Majuro

Mr Maka Sapolu

ANNEX 1

National Health Laboratory Hospital Apia

SOLOMON ISLANDS Mr Andrew Wag ira

Assistant Laboratory Officer c/o Ministry of Health and

Medical Services P.O. Box 349

Honiara

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Annex 1

TONGA Mr Sitino Maka

Assistant Laboratory Technician c/o Ministry of Health

Nuku'alofa

VANUATU Mr Simeon Banga

Laboratory Technician c/o Ministry of Health P.O. Box 102

Vila

2. GUEST LECTURERS

Dr D. Collins

Koronivia Research Station Koronovia

Nausori

Dr T.U. Bavadra

c/o Ministry of Health Government Buildings Suva

Mr Uraia Lesu

Senior Health Inspector Ministry of Health Government Buildings Suva

Dr J.U. Mataika

Wellcome Virus Laboratory

Tamavus, ~

Mr Mohammed Salim

Senior Health Inspector Ministry of Health Government Buildings Suva

3.

4.

- 7/8 -

TEMPORARY ADVISERS

Dr K. Singh (Co-Director) Consultant Pathologist C.W.M. Hospital

Suva

Mr A. Khan

Lautoka Hospital Lautoka

Fiji

Mr R. Parmar C.W.M. Hospital Suva

SECRETARIAT

Dr Y.T. Kuo

Acting WHO Representative World Health Organization P.O. Box 113

Suva

Annex 1

Dr I. Geizer (Operational Officer) Regional Adviser

Health Laboratory Services World Health Organization P.O. Box 2932

Manila

Dr N.U. Rao (Course Director) Microbiologist

World Health Organization P.O. Box 113

Suva

Dr A.C. Adiao Medical Officer

World Health Organization P.O. Box 113

Suva

Dr M. Gunaratne Medical Officer

WHO Intercountry Team on Epidemiological Surveillance in the Pacific

P.O. Box 113 Suva

Day 1 (21 June) 08.30 a.m.

09.30 a.m.

10.15 a.m.

1. 30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

"-

Day 2 (22 June)

8.00 - 9.30 a.m.

9.30 - 10.00 a.m.

10.00 - 12.00 p.m.

1.30 - 3.00 p.m.

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ANNEX 2

TIMETABLE

Registration

Opening ceremony - at the Grand Pacific Hotel

Tour of pathology laboratories at C.W.M.

Hospital, Suva

Overview of the epidemiological situation with respect to diarrhoeal diseases in South Pacific -

Dr M. Gunaratne Coffee break

Enteropathogenic organisms and diseases caused by them - Dr I. Geizer

Pathophysiology of diarrhoeal diseases - Dr K. Singh

Coffee break

(1) Laboratory diagnosis of salmonellosis and shigellosis - Dr N.U. Rao

(2) Demonstration of different laboratory procedures:

(a) 0 & H agglutination (b) Slide agglutination (c) Biochemical reactions

Laboratory methods for the isolation and identification of

v.

v.

All the practica1s were held at the training laboratory 1n Hoodless House of Fiji School of Medicine.

Annex 2

Day 2 (cont.)

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

Day 3 (23 June)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

1.30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

Day 4 (24 June)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

1.30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

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Coffee break

The participants are divided into groups of two. Each group will receive two stool specimens to be tested for Vibrio,

Salmonella, Shigella, Yersinia and E. coli

Continuation of laboratory work on the specimens received yesterday

Coffee break

Discussion on diagnostic methods - Mr Rajendra Parmar, Mr A. Khan Dr N.U. Rao, Dr I. Geizer

Isolation and characterization of Entero- pathogenic E. coli (EPEC): Enterotoxigenic E. coli (ETEC) and Enteroinvasive E. coli

(EIEC) - Dr N.U. Rao Coffee break

Epidemiological investigation of diarrhoeal diseases and the role of laboratory

services - Dr I. Geizer and Dr M. Gunaratne

Discussion - Laboratory safety in microbiology laboratories - Mr A. Khan, Dr N.U. Rao, Dr I. Geizer

Coffee break

Continue laboratory work on samples received on Day 2.

Introduction to ELISA technique - Mr R. Parmar

Coffee break

Current methods for the isolation and identification of Campylobacter foetus ss jejuni and Yersinia enterocolitica -

Mr A. Khan

Day 5 (25 June)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

1.30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

Day 6 (28 June)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

1.30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

Day 7 (29 June)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

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Annex 2

Practical application of ELISA technique ~n

the laboratory aspects of diarrhoeal diseases - Mr Parmar

Coffee break

Clinical aspects and management of cases of diarrhoea in children - Dr A. Adiao

Rotaviruses and their characteristics and their relative importance as etiological agents for diarrhoeal diseases - Dr Mataika Coffee break

Visit to the Wellcome Virus Laboratory

Water analysis for the detection of Vibrio, Salmonella and for the enumeration of

faecal coliforms - Dr N.U. Rao Coffee break

Demonstration of M.F. technique for water analysis

Each participant will receive one stool sample for the detection of Vibrio,

Salmonella, Shigella and Y. enterocolitica and Campylobacter

Coffee break

Discussion: Methods for the isolation and identification of different intestinal

pathogens - Dr K. Singh, Mr Rajendra Parmar, Mr A. Khan, Dr N.U. Rao

Continue laboratory work on stool specimen received yesterday

Coffee break

Practical: each group will receive one water sample. Test for the detection of

(a) Vibrio, (b) Salmonella and enumerate faecal coliforms by MPN technique

Annex 2

Day 7 (cont.)

1.30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

~ (30 June)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

1.30 - 3.00 p.m.

3.00 - 3.30 p.m.

3.30 - 4.30 p.m.

~ (1 July)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

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Laboratory aspects of food sanitation - Dr N.U. Rao

Coffee break

Inoculation of food samples for

Staphylococcus, Salmonella and Clostridium perfringens

Continue laboratory work on the:

(a) stool sample received on Monday (b) water analysis

(c) food sample Coffee break

Discussion: Simple bacteriological methods to be used in a small laboratory -

Dr N.U. Rao, Mr A. Khan & Mr R. Parmar Diarrhoeal diseases control programmes - Dr T.U. Bavadra

Coffee break

Antibiotic sensitivity testing - different methods - Mr A. Khan

I. Continue laboratory work on:

(a) stool specimen received on Monday and report the result

(b) water analysis

(c) final test, if any, on food sample II. Inoculate given cultures into broth for

antibiotic sensitivity testing 'in the afternoon

Coffee break

Lecture: Rabbit ileal loop assay for

V. cholerae and E. coli toxins - Mr A. Khan

Day 9 (cont.)

1.30 - 3.00 p.m.

j

3.30 - 4.30 p.m.

Day 10 (2 July)

8.30 - 10.00 a.m.

10.00 - 10.30 a.m.

10.30 - 12.00 p.m.

1.30 - 2.00 p.m.

2.00 - 3.00 p.m.

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Laboratory aspects of zoonosis - Dr Desmond Collins

Coffee break

Annex 2

Antibiotic sensitivity testing using tube dilution and agar diffusion techniques.

Use the inoculum prepared in the morning

(1) Reading of the results of antibiotic sensitivity testing done yesterday (2) Complete, if any, unfinished work on

the unknown stool sample and on the water sample

Coffee break

Discussion: Importance of surveillance of water, sewage and food samples - all staff and Mr Uraia Lesu and Mr Mohammed Salim Evaluation of the course by the participants Concluding session followed by refreshments

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ANNEX 3

LIST OF HANDOUTS

1. Global Diarrhoeal Disease Control Programme 2. pathophysiology of Diarrhoea

3. Laboratory Diagnosis of Salmonellosis and Shigellosis

4. Laboratory Methods for Isolation and Identification of V. cholerae, V. parahaemolyticus and NCV

5. Characteristics of EPEC, EIEC and ETEC

6. Epidemiological Investigation of Diarrhoeal Diseases and the Role of Laboratory Services

7. Laboratory Safety in Microbiology Laboratories 8. Enzyme Linked Lmmunosorbent Assays

9. Rotaviruses: A Brief Outline 10. Bacteriological Analysis of Water 11. Laboratory Aspects of Food Sanitation

12. Current Methods for the Isolation and Identification of Campylobacter fetus ss jejuni and Yersinia enterocolitica

13. Microbial Susceptibility Testing

In addition to the above handouts, several flow charts for the

isolation and identification of different microorganisms were given to the participants:

(a) Flow chart: Guidance for Identification of Important Enteric Bacteria

(b) A table listing selective and differentiating plating media and the descriptions of the characteristics of colonies of different organisms

(c) Inoculation Scheme for the Isolation of Pathogenic Bacteria from Stools

(d) Isolation and Identification Flow Chart of Vibrios

(e) Biochemical Reactions of Salmonella, Shigella and E. coli (f) Abbreviated Antigenic Scheme for Salmonellae

Note:

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ANNEX 4

SUMMARY OF PROFORMA FOR EVALUATION

OF THE INTERCOUNTRY TRAINING COURSE ON LABORATORY ASPECTS OF THE CONTROL OF DIARRHOEAL DISEASES

SUVA, 21 JUNE TO 2 JULY 1982

All the participants are requested to complete this form. Please circle or underline your opinion. It is not necessary to sign your name. Thank you.

1. Did you find the length of the course?

too short / adequate / too long

34% 66%

2. The relative proportion of time devoted to lectures, practicals and discussions was?

poor / acceptable I good I very good

44% 44% 12%

3. How confident are you in laboratory diagnosis of?

3.1 Salmonellosis

3.2 Shigellosis

3.3 Cholera

3.4 V. parahaemolyticus

3.5 E. coli diarrhoea

3.6 Food poisoning

3.7 S. aureus

3.8 Campylobacterial diarrhoea

3.9 Yersinia diarrhoea

3.10 In testing of water for salmonella and vibrios

not confident / confident / very confident

66% 34%

not confident / confident / very confident

56% 44%

not confident / confident / very confident

12% 44% 44%

not confident / confident I very confident

12% 44% 44%

not confident / confident / very confident

12% 56% 32%

not confident / confident / very confident

12% 76% 12%

not confident I confident I very confident

44% 44%

not confident / confident / very confident

88% 12%

not confident / confident I very confident

88% 12%

not confident / confident / very confident

12% 44% 44%

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Annex 4

4. If not confident on any of the above areas, what is your suggestion for improving the training? Only one comment

5. Did you find the theoretical and practical exercises on micbrobial susceptibility testing of practical value?

6.

not much / helpful / very helpful

34% 66%

Do you expect to train others in skills learned in this course. If yes, whom? Workers in your laboratory / other laboratories

how?

44% 24%

formal course 32%

/ informal discussions 50%

7. Do you consider that the teaching materials provided have been adequate?

8.

9.

Yes / No 100% -

Considering the level of instructions, do you too low / adequate

88%

The arrangements for accommodation were?

poor / satisfactory

12% 32%

10. Other comments:

think the level was?

/ too high 12%

/ good / excellent 44% 12%

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