RRPORT OF VISIT n, PAKISTAN~EA`Nl CHOLERA RESEARCH LABORA`iORT BY #IE CROLIPRA ADVISORY CrnITTRB, JAWUART, 1962 I IHTRDDlETIo# 21 PROPOSED PLANS FOR MugDIATR DRVEUIPMBJT III BROAD POLICY RRCOBtME?4DATIOHS Iv 8umfART TM Paklstan~EAnl Cholera Research Laboratory (CRL) ln Dacm haa 3 develaped cxmwidambly dwingCth&kmtyear, hothas re@mia fta ntaif and its m&mtlfla euacmplishnmt~. recsstlyrrtlrcrd fzutheDireatcBmhfp afthePanAmwlc%nSanltary Bureau,asawnedth6 Dlrectcnvhip oftheCholera Resear~hLahoratarlpln February, 186X* Tbmughhirr effem%s, tbeadainietrat%nsprucedw and th6 admlnicdratlve rtaff hava ken put on a working bwi8. lourimg the y4mr a revbed agrmm6n tbotwwn tbsOavernwntofPaklst.an~ and the UnltedShtea haa bmnnegotiatmd iaorderto facfltate tha neaearch effort. hcmg other things, thie prov%dm greater auto for the CRL arid cofves it a Mreating Couwilandr %ehnlealAd~leoryCmit~. A new Section un Clinical Remarch ~SAS been establi&ed with W. Robert 8, o)ordaa, om ef the s lnvwtlgators of the WE, lo chaxw. / ksltiting hh 1s another tBPlE3 ofW3er, Dr. 0. Rum MeIntyr6. Th6a6twehave6l!6atedaree6amh laboratory for blocrhemicwl and phymfalogicgl inve8fS@Wnrs and are in the final=of establishing a 2Obed ward law&l& they will study uholera amw lnthuaaute pham of the dlimme. A ftmetianfngwateranalysisla~Wwatory, wlthequipmentandtrained hkistQaite~hnidann,ur added totheCIlLthroughthe gwd offlam of th6 Age?XQr for International bv6lupmant (AID) Miuicm to Pakicrtaa when theParmmaCmpany oompleteditsmrvwyofwaterxwe~ In Rant -2- Faklatan for AID. This laboratory has already proved to be a consfderable asmat in the field studio6 on cholera. Dr. Ic. A, T4onmr, the CUei of the Bacteriolw Section of the CIQI, has developedimprtmdtechniqusrr for the dSa&?mmtioimlatian of&d& oholm, the umme of the disease. of greatest interest Is his maintenanccl,medSa used intra%apcwtir@@peciwms. Theumally fragile vibrio survWea In this awdia, even when held for uwka. %B availability of euehansrtoalhaa enabled Dr,SoperandCiRLto forWLatoaplan for the aunt$nuSng stwveillanseof 8holera in Bbst Pal&tan. Thw, 8ampla8 ofthamdia,andmbe forobtainingrectalwpeolum8aill besantto Rural HealthCentera andtovillam; in the lattertheymay beplaued in the ear0 of the oehcml teacher, Whenany disrrheal disease appears in the populatiane under obeervation, specimen8 will be obtained teacher and sent by ord.Qa~mailtotheCRL for Inmteriologi~l studicwr. diagnostic Ibureastn$ interest fnC& inIkecm haa beendemonetrated by other Bownnarsnts. For lnstanae, the haa ~trlklted to the , / A / CRL Laboratory equipment in the amount af UO,OOO. We funda w6re utilised for the pumhase of laboratory equipment for the physiology The proaeedlngs of tM lnternati aqgX held In Deaamber, 1960, in Dama, 1s mw at tb printer. Thla lSO=page momograph ail1 make available to ooientlats throu@ou t the world the most current infbrmkttcm on ebobma. II PROPOSIGDPLAWS FOR ZMbIRDIATRDRVEaMpMapf ib outlimd abeve, notable progrseu hae been mde in eexpleting th0 agr60i56ntjhiehd0fin06th6at6tu6 ofCRL66 anaut~uctmw unit and in / / 4' \\ 6p8aifylngthtB~f6lua far 526 finauOi616IlppOrt. %-wqm6mtdOfinO6 crrearly tha flrummrk in which the work of the lamtory can pl-ogrese and pmvld8uthe basis for its suwdul6@emtion in the tuture. Great I eralit is dur, to Dr. B0p6r for hie 6lclll and patiemoo in briaging theso nsgotiatlanu to eueh i h6ppy eonelu6i0n. it io now possible to a0v6 \* foswimd to l%mdy the d6f5Oi6nOml $n Organis6tiOn, rt6ffing 6ml program 1. &mlacmment prrrd sulaneabrfloa a seientifla etaif, %e be$rmntdepartumofDr.Fred L.Ropa, toaammm reeponelble dutien e'bmwbere, net only will crmto a tnsGuKaJl diffioult to 1511 but also will imp066 a n66d for restruutur~ Mb0 senior staffing >c pattern of CRL, It is vftalfar th6 ecmtinu6dd0vmlOpan6ntofCRL that a 80aior sohntlst Or public htsalth exp6rt oPith tmcmd eqerlence in admini6tmtWu and fn international affairs be reerulted praslptly t0 60cpo aa Dirmtor of CRL. that th6 poeiticm of SOlrntifLa Di2wtor o by Om6t6dpawptlyinCRL, The Wdividual who ocouples th36 paoitian iI wn12d k r66pOmlb~e to ths Dire&or of C%L for all the ecdentlfia aetivlti66 09 th6 labor6too)r. k mruld prcroida, gmmral aeientdfic dircsetion to th6 A lef*j the Se&loas cfT Clfnltwl fnveatigatiolrus, B$iberio_Bgy, Baat6riolOgy b 6nd the Sectlonq $#Water and Smitatlon. At the present stage of devolopent of CRL, one of the Section Chiefs could also 6erwD a6 Sefentifitr Dfrector. ft i693~tbeLthr.5-kb6l-t oordan, fX=WdlJt Chief of the Se&ion in Clinical Inveaitigations be given the addItiona r86pOn6ibil,ity' of dlerviag as Scdentiffc Director of CF. Tha, posltiom of Deputy Dlreator should be retained with redlponslbilltios limited to those of 6erving for the Director in his absence 6nd of 6saumfng uertaim admfnietrative activiti66 which ar6 specifioafly 666Sgn6d to him by the Dir6otor. Dr. Joe stoekard shutid continue to 6erve as Deputy Director but this re6pomibillty should not b6 permitted to interfere with h&o primary duty as Chief of the Sectiom m ~idemi~logy. 2. The need &gs senior barcterioloais~* -- Recanse of the dekpaam ofDr.K.A.MOn6ur from the laboratory to beeamo dire&or of the Institute of Public Health, a 6eriou6 chfielenayhas beencr66t6d. If is fraperatb?OthataVigOrOUS Seam#bb6 lately to find a 6lMN3e66oo:tb~,~t!l', ~tht# EOlm Of this march hSngea the 6ntir6 futWt6 of CRL. kcmme of his krarl6dg66bl6IW66 in th6 field of cholera and b6e6use the work of CRL and the Institute of Publie Realtb are oompbaent4wy,~~m~~thst Dr.lsanattrberetai~acra oon6u&t6nttoCRLwith6pproprfate -aYlttioII. While this $8 hkportstrt iOr fholo6gr6&36 proglrar&CRL it 36 tr68iItisl that hi6 Ser~iQgll be 0btaismipendSng the6+ointmentofa fulltiPw 6enior bacteriologist. 3, oolmlng~ rard faoilitfewt ThepFWWt6&8tktifi6 Shff Oft- &&OlWt~ 36 6OWl6~ mainly afth the clinical ampoeta of tha dfeaamo, eluefdation of the phynfolcmg&aal abnanraltlw and tbC#irtIWaWt. Itirr 6asmt%althat OpPatiOSl Of th6 W&l!@ b6 o bWt6d at an early date 60 the&t advan- QIlr be taken of the 8olentifSc oppotiunltiea that ail1 ocaur wit& the Imglnnlng of the epidmnia that dan be expected in the spring. In addition to tbs xi pr$me selentlflo rouwo for an early opening of tha, clinical faollity, therram Other WaSON rfriC?hIO6k6thfsmOV6 irnpOrtan't SUChaS the folbmlngr provi8lon of a dernonetration uuit for instruction of PakIstani phyalcianm In ahmtifia therapy of eholorag reeruitmmt of young cliniclam into the program8 duvelopsent of a bmfs for e public relations with Pakistani physfeians and health workers; putt* into u8e neeaed elinieal faeilitiea whiuh are standing fdlo. Porthew reason6 itie Stqtbti tnb q.MWd ssrly )ddl in the spr$ng of &068 ewzb though expMirn(;lr must lm d6vi66d for feed axtd laundry se~fas. 4. wlati0848~*CIlfi& mi8hborlqg santifl~ ~=tifut~ofm Purther devmlopmentof aolldoamtlan?aetwmmCIIL,Ra~ WxIicpl /d Call@@ and Mitf8rd -ital lllpg 6666diaX fOS' the e&rntifi@ grorth Of - laboratorrg. Tj,iS is Of pl&Z'tfUUhr h#h+U- in order to provide effe&We training faryopmgpaki6tarm~.inthrspldasalol~ 6ndtresWt of aholera am -11 as for the xwruitmut of alinleal and seimtifie pomo611iLor. Thr, t31~4b 4k86ahktl0n, mwinstqndlxa and wll8boratiw n- e~st~ng ktweem CT& and the Institute of Publia Health shmld b6 foeferad ati dmlopadfurtba~. T%is uan be aqlisbmbd by Joint sppointment6 6nd czonmrltaatshlps, `trg thQ prcwirion of facflltles and eptipmmt to be umd in ammom, and by aawying cut joint saientlfia programs. 5. CollabomtSoqgf Cl& withJnstftuticnr3 u amncles $g other countries: The assoeiettions and aollaborative effarte of CRL should be e%tendd bQyOI&j its aelghbori~ oxgzmfzpltions. Thc)r should aEibFac9 other interested groups ln distant reg2om including tbo%e in the NXH, Jeffex-666 ItI% ~ritmoe&uriagthepasttwolasmonths orithaholera iamainland nwd for intonsificmtions of work on all aapecta of this diSe66e by indlvldual 6uientist6 and by national and intwmatbnal gpoupa. PurtbermOr@, the rollbg front of aholera in the Wesztern Pacfficr dwands that cm4 awume some of tha obligaktioms iarplied under its SEATO banner. Wlith the latter poitnt In m&nd It is ~edtbt666-66the fir8tBMiMDtingl of the Directing Counall of CR& $8 completed both Dr. loper and m. Stockard v&nit a number of the affeatsd rtn$ potentially threatened areas* Dr. Soper could pwfitabZy spend the interval kfarcb aompletlng his duties rith CRL in diilmssions with offfclals of SEA?po Nationm regamilng partialpation in international anpwte of taholera contml. It lm also re caamsndsd that Dr. Stoakard spend a month or 60 in the PhSlQplnea 6tudyUg the eplde@logy of cholera, partieulsrlythemde of epmad in thle lbowendwia arwe 0, &#darioloq&& and Vauela Studleq Epidmiblo@(3aletudiea of tro @meral kind6 ehould be atartad a6 soon a8 pumlblet (a) %&msio, 6tUdy should b6 undB of a populatlcm in a defined am with tha prirrary aim of defsrradrrfag the effectlwmea* of cholera vm3oiws fmd wmdary aim sucrb da the rstlatlonmhip of nutritional St6tU6 t0 @bO@W6i6. -1s study should be set up in an a-ible alYbb such aa the liadth Matriet at Ma~inpur where a Fiealth Center baa just been eefrblishsd, 'f0 be fully effec3tive stud166 of cholera should be amwdinatadwlthotheretudles or survey6 tobe carrlsa outbyth6Palkletan Cbvwnmwt a&the bp ibelt or in eoSS.aboratfm w%th offlclal agmolw 6U6h I8 AID cw private agm8i68 SUCh 66 the Population Coumil, These studi should lnolude an dntensivm auttitlonul sulv6y in a populatim group of a~prmdmek~y 50,000 pimmns a6 -3% Iu a 8anltary o mmy. Of fundewntal lmportanatotb suaawb of811 of these stUdie6 lsanro6umk an6u6 and domgmphicr analymls of the population of the Bealth DiStri#Y%. fb) Study of the perrl@xmoe of cholera vlbs4o in a highly iaaIgmrentlnfwtiom or ewriem and&the presence of the vihvio in the onvirwwnt. Ita purpaas aould lzll to detemln6 hOW the VibX'iO 16 maintained in apepulatiaeabetmenepidemicm. Ramuse of the eactelllritn effort6 lnvolv6d in aaawmlat* n~~tmmmy daformatiem on a pgrulation group before rtudies of the type uwmttomed in (a) can be undertahen pmfltably, It fs reooarBDIMbd that inlti&l epidem*oIegiaal offarts be wnantratod in the intmnsiva summy. Pracnr the naahamlw for thPs are opemtive, then attention uan Ee concentrated GXB t&O am and pqwlatlom which c3an be studied for persletenee of oibrio xtiSth6 aollcILuItllbl QhOlUrar,. of the vl8ltlng grmp that the same site will not b6 suitabl6 for both typea of 6pid6siologfo study. III BROAD POLICY -ATIONS The etmmlttae has conwtemd itself prlum~ily with technical and administrative matter6 that bear dirsatly oa CRL and am pertinent forth6 lmediat6 futura. At thi6 point, hou&mr, it feels oowtrained to catwont on lmg rasq@ ob$stirrrs that should b6 brought to th6 attentiom of the MreetingComell, the Staff of theLabbntoryaadth6Supp0rting Group6,and ~hrlly~llbrwcaaein~~tedintathe pailo6qhyof a. 1. It i6 t~Upinl~Of thecomlttee that the problemof eholem ie of auclh broad slgnlflcmuee to mrld health that any activiw short of ame which bring6 the tschnlqurn of raicwse to bear directly and importantly onthranyps@obXrrae of the dl6ea66ls ahort6ightedand inad6ewat6. 2, @!I, hea aImady established i-elf as 6 key fae$ar in the apparatw thatwlllbrb rmqulrod to eradlaatethedfaease. Support for CRL is lmperatlva in obtalnigec fu%Wh, pkgalarl faallltlw end the high 1~81 rclentlflc staff it require0 to aontribute it6 dare to th6 aaocqlishwmt of the @.mrmow tadu ahe6d. 3. Commpamtip, it $8 F that th6 staff of CRL aontinue their plsaalng rith1666 xegwdtoth6 fund6 whichhweImenav6ilableup toth6pr666ntthantotb6 importanc6ofth6 brarktfacsyaddr666t~lV66 to. lw SUIWUCV 1. CRL has made solid p-s durlnr$ the past yww eupscial3y in tbs adxfni~af;nrtfve aTea. This hag remlted in an am t WhMh d6flne6 its Matus as an au+smmmw unit, wh%ah outlines its program and z-espclnsibllftloo in broad term and which cspeclfi~ the mechanic for its euppOrt, 2. W'lth its status alearly defined CRL shauld praaeed forthwlth ta replace the scientific staff it bas 1-t ancl to augment it as fndicated above; totW@n its dliniaaland epidmnAoW&alpr~~; and to develop in detail its lw range pFagmIuo This report if0 hised on a vlait to Ruma, Jsmary 21 to 26, 1902 by+s.K-th-, Colin&W, Joseph%.Snw?el s.ndTheedare Collin M, nlaaeod Robert A. Phillips JomphB.Sm~del