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Health Laboratory Facilities in Emergencies and Disaster Situations Table of Contents Health Laboratory Facilities in Emergencies and Disaster Situations.........................................................1 Foreword.................................................................................................................................................2 Preface...................................................................................................................................................2 Introduction.............................................................................................................................................3 Chapter 1 Diseases and medical conditions commonly associated with disasters................................4 Chapter 2 Situation analysis...................................................................................................................6 2.1 Planning and assessment of needs...........................................................................................6 2.2 Assessment of existing services................................................................................................8 2.3 Selection of laboratory staff........................................................................................................9 Chapter 3 Types of laboratory facility.....................................................................................................9 3.1 General......................................................................................................................................9 3.2 Existing laboratory facilities......................................................................................................10 3.3 Temporary stationary laboratory facilities................................................................................11 3.4 Mobile laboratories...................................................................................................................13 3.5 Portable laboratories................................................................................................................14 3.6 Referral of samples to reference laboratories..........................................................................16 Chapter 4 Selection of appropriate laboratory tests.............................................................................16 4.1 General....................................................................................................................................16 4.2 Direct diagnostic tests..............................................................................................................16 4.3 Indirect diagnostic tests............................................................................................................21 Chapter 5 Testing water supplies.........................................................................................................22 Chapter 6 Laboratory safety, disinfection and waste disposal..............................................................23 6.1 Laboratory safety.....................................................................................................................23 6.2 Disinfection...............................................................................................................................24 6.3 Decontamination and disposal of specimens and infectious material......................................27 Chapter 7 Laboratory kits and modules................................................................................................31 7.1 Introduction to the use of modules and kits..............................................................................31 7.2 Use of kits and modules...........................................................................................................31 7.3 Contents of modules................................................................................................................34 Chapter 8 Energy supply......................................................................................................................51 8.1 General....................................................................................................................................51 8.2 Combustion powered generators.............................................................................................51 8.3 Solar energy supply systems (photovoltaic systems)..............................................................52 8.4 Energy modules.......................................................................................................................55 8.5 Calculation of the energy requirements of an emergency laboratory.......................................55 Chapter 9 Laboratory equipment..........................................................................................................58 9.1 General....................................................................................................................................58 9.2 Microscopes.............................................................................................................................58 9.3 Centrifuges...............................................................................................................................59 9.4 Colorimeters and haemoglobinometers...................................................................................60 9.5 Portable incubators..................................................................................................................61 9.6 Refrigerators............................................................................................................................62 9.7 Water purification systems.......................................................................................................62 Chapter 10 Supply of blood for transfusion in emergencies.................................................................64 10.1 General..................................................................................................................................64 10.2 Situations involving patients with acute blood loss................................................................64 10.3 Blood transfusion in refugee camps.......................................................................................65 10.4 Bleeding donors on site..........................................................................................................66 10.5 Summary................................................................................................................................66 Chapter 11 Collection, storage and transport of specimens.................................................................66 11.1 General..................................................................................................................................67 11.2 Collection and storage...........................................................................................................68 11.3 Shipment of samples..............................................................................................................72 Chapter 12 Field laboratory record keeping and reports......................................................................75 12.1 General..................................................................................................................................75 12.2 The role of the laboratory in the investigation of disease outbreaks and epidemics..............75 12.3 Recording test results............................................................................................................76 12.4 Laboratory procedure book....................................................................................................77 Annexes................................................................................................................................................78 Annex 1. Agencies providing health relief......................................................................................78 i Table of Contents Health Laboratory Facilities in Emergencies and Disaster Situations Annex 2. Reference laboratories for communicable diseases.......................................................81 Annex 3. Manufacturers of portable or mobile laboratories...........................................................82 Annex 4. Commercially available rapid diagnostic kits and reagents and their manufacturers......83 Annex 5. Reagents for urinalysis...................................................................................................96 Annex 6. Manufacturers of water testing kits.................................................................................99 Annex 7 Collecting water samples for microbiological examination.............................................100 Annex 8 Non−profit−making suppliers for tropical laboratories....................................................104 Annex 9 Manufactures of photovoltaic equipment.......................................................................104 Annex 10 Manufacturers of microscopes.....................................................................................105 Annex 11 Manufacturers of battery−driven and mechanical laboratory centrifuges....................105 Annex 12 Manufacturers of portable colorimeters and haemoglobinometers..............................106 Annex 13 Suppliers of portable incubators discussed in the guidelines......................................107 Annex 14 Cold chain equipment for blood storage and transport................................................107 Annex 15 Manufacturers of photovoltaic refrigerators.................................................................108 Annex 16 Manufacturers of water purification systems................................................................109 Annex 17 Filter paper technique for collection and transport of body fluid specimens................109 Recommended literature....................................................................................................................110 References.........................................................................................................................................111 Back cover..........................................................................................................................................112 ii Health Laboratory Facilities in Emergencies and Disaster Situations WHO REGIONAL PUBLICATIONS, EASTERN MEDITERRANEAN SERIES 6 Warren Johns Auckland New Zealand Warren Sanborn Solana Beach, California, USA Corinne Lacroix Médecins sans Frontières Paris, France Mohamed El−Nageh* World Health Organization Eastern Mediterranean Region Alexandria, Egypt Claus Heuck* World Health Organization Geneva, Switzerland Alfred Reich Manheim, Germany Paul Shears The University of Liverpool Liverpool, United Kingdom Patricia Corcorant World Health Organization Geneva, Switzerland *Editors World Health Organization Regional Office for the Eastern Mediterranean Alexandria, Egypt 1994 WHO Library Cataloguing in Publication Data Health Laboratory Facilities in Emergency and Disaster Situations/editors, El−Nageh, Mohamed M. and Heuck, Claus C. p.170 (WHO Regional Publications, Eastern Mediterranean Series; No. 6) 1. Health laboratories 2. Emergency medical services I. El−Nageh, Mohamed M. and Heuck, Claus C. II. WHO Eastern Mediterranean Regional Office ISBN 92−9021−182−2 (NLM Classification: WA 23) ISSN 1020−041 X First reprint 2000 copies, 1995 Second reprint 1500 copies, 1998 The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Manager, Health and Biomedical Information Programme, World Health Organization, Regional Office for the Eastern Mediterranean, P.O. Box 1517, Alexandria 21511, Egypt, who will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1994 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal 1 status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Printed in Alexandria, Egypt Bafra Graphics − 2500 Foreword Unfortunately, emergencies and disasters are widespread all over the world and many people suffer from famine, pain, injury, and infections. Therefore, there is a need for basic care and further support for emergency planning by national and international organizations. The World Association of Societies of Pathology (WASP) appreciates very much the publication of these very important guidelines by the Eastern Mediterranean Regional Office of the World Health Organization. According to these guidelines, the appropriate national organizations should plan, introduce and establish basic administrative and organizational structures to be able to respond immediately and adequately to an emergency or a disaster. The WASP supports all activities which promote the realization of a national contingency plan by local or international specialists in the field of laboratory medicine. These guidelines are an important contribution towards fulfilling the essential requirements of coping with emergencies and disasters. We strongly recommend that all relevant national organizations follow these guidelines. Prof. Dr. med. H. Reinauer Vice−President World Association of Societies of Pathology (Anatomic and Clinical) Preface Many countries are vulnerable to disasters and emergency situations and a number of countries in the Eastern Mediterranean Region have suffered from such situations in recent years. The Eastern Mediterranean Regional Office of the World Health Organization has identified the need for guidelines on health laboratory services and problems associated with disasters and emergency situations that fall within the scope of these services. This publication is intended to provide information on the provision of basic laboratory services in emergency situations. It is aimed at all health professionals, including physicians, nurses, laboratory technicians and other paramedical staff. The guidelines are also intended to assist international agencies, national authorities and other bodies involved in emergency and disaster relief in drawing up contingency plans for the provision of emergency laboratory services. These plans should enable those involved to respond rapidly and specifically to the needs of the situation. It should be emphasized, however, that the guidelines describe laboratory services that are intended for emergency situations and therefore may not necessarily represent what would be recommended for health laboratory services functioning under normal circumstances. Nevertheless, under any conditions, principles of quality assurance must always be applied and laboratory safety respected. Throughout the text it has been assumed that the laboratory staff involved are technically competent and well trained in good laboratory practice and quality assurance. For this reason, with a few exceptions, no technical details are given. This manual could not have appeared without the valuable support and encouragement of Dr Hussein A. 2 Gezairy, Regional Director for the Eastern Mediterranean, and Dr M. H. Khayat, Director, Programme Management, EMRO. Our thanks are also due to A. H. Moody, Hospital for Tropical Diseases, London, UK, Professor Dr H, J. Simon, University of California, San Diego, USA, G. Mortimer, Newcastle−upon−Tyne, UK, Professor Dr J. Okuda, Meijo University, Tempaku−Ku, Nagoya, Japan, and I. Reid, Whangari, New Zealand, for reviewing the draft and for their constructive suggestions. Recommended steps in establishing a laboratory in an emergency Introduction For the purposes of this publication the following definitions of ‘emergency’ and ‘disaster’ are those used in the document WHO Action in Emergencies and Disasters [1]. emergency sudden occurrence demanding immediate action that may be due to epidemic, technological catastrophe, strife, or natural and man−made causes; disaster any occurrence that causes damage, ecological disruption, loss of human life, or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area. Emergencies and disasters demand prompt and adequate response, and the provision and monitoring of 3 relief will be required until normal services can be resumed. To meet these demands, contingency plans and preparedness are of fundamental importance. In order to be able to respond quickly and adequately to an emergency or a disaster, every country should formulate a national contingency plan and establish mechanisms for emergency preparedness and response in the health sector. The national plan should be based on coordinated multisectoral emergency activities and all aspects, including the plan for emergency health services, should fit into the established administrative structure. The provision of disaster relief may require the support of health laboratory services. Therefore a national programme of emergency health services should include provision for an emergency health laboratory service. When formulating a national plan for timely and appropriate response to emergencies and disasters a presumptive assessment of needs should be made. The assessment of needs depends upon many factors, some of which relate to the type of disaster (e.g. earthquake, destructive wind, flooding, epidemic, war, famine, refugees) and others which relate to local conditions (e.g. national economic situation; geographic conditions; state of transport and communication; availability of health facilities in the country as a whole and specifically in the affected area; number of people affected; availability of water, food, sanitation facilities, shelter and electricity). Those responsible for a national programme of emergency health services should have readily available a list of external health relief agencies to be contacted should external support be needed (see Annex 1 for a list of agencies providing health relief). In emergency situations and disasters, basic medical care is essential to limit morbidity and mortality due to infectious diseases and other medical conditions, such as trauma. Morbidity and mortality may result from an increase in the prevalence of existing endemic diseases, such as measles and infantile gastroenteritis, or from epidemic diseases, such as cholera and typhus. Disease surveillance is an essential component of disaster assessment and is also important for monitoring the effectiveness of relief interventions. Some diseases, such as measles, have a typical clinical picture which permits diagnosis without laboratory investigations. However, many infectious diseases require laboratory facilities to make or confirm diagnosis, or to enable valid epidemiological data to be collected. Emergency laboratory facilities operating in response to disaster face many constraints, including remoteness of location, lack of reagents, limited equipment and power supplies, and insufficient numbers of trained staff. Experience gained from disasters and famine relief areas over the last two decades has provided useful and important information on the optimal use of laboratory services with limited resources. The primary objectives of laboratory services in emergency situations are the prevention or control of infectious diseases and the management of conditions such as anaemia and trauma. The pages containing descriptions of contents of modules have been printed on separate pages for easy reproduction and inclusion with individual modules in warehouses and in the field. Chapter 1 Diseases and medical conditions commonly associated with disasters Different health problems are associated with different types of disaster. Box 1.1 lists various types of disaster. A list of the diseases and medical problems that may be encountered in disasters is shown in Table 1.1. Not all of these problems will occur in every disaster. For example some are dependent upon geography; e.g. a flood or tidal wave in a tropical area may create the conditions for an outbreak of malaria, but this is unlikely to happen in temperate climates. Other problems, such as outbreaks of dysentery and gastroenteritis, can occur anywhere. The conditions listed in Table 1.1 are frequently interrelated but may occur independently. Disasters which result in homelessness and population displacement may contribute to the spread of infectious diseases. The risk factors for potential outbreaks of disease should be assessed early on by a team of experienced health professionals and risk factors for infectious diseases must be taken into consideration when contingency plans for disasters are drawn up by national authorities. The relationship between the diseases that may be encountered and their modes of transmission are outlined in Table 1.2. Modes of transmission include inhalation, injection, induced trauma, and vectors. BOX 1.1 Types of disasters Natural 4 • epidemic • earthquakes • volcanic eruption • flood • cyclone • drought Man−made • war, including chemical and bacteriological warfare • environmental pollution including chemical and nuclear accidents and sewage pollution Natural or man−made disasters may result in the following: • population displacement and formation of camps for displaced people or refugees • famine • drought TABLE 1.1 Diseases and medical conditions encountered in disaster situations Disease/medical Population Epidemic Earthquake/volcanic Flood/tidal Drought War Environmenta condition displacement eruption wave pollution Aids/HIV 1 0 0 0 0 1 0 Anaemia 2 0 0 0 1 0 1 Anthrax 1 1 0 1 0 0 1 Cholera 2 2 0 2 1 1 1 Dehydration 1 0 1 0 1 1 0 Dengue* 1 1 0 1 0 0 0 Diphtheria 1 1 0 0 0 0 0 Dysentery/gastroenteritis 2 2 0 2 1 1 1 Enteric fevers 2 2 0 1 1 1 1 Haemorrhagic fever* 1 1 0 1 0 1 0 Hepatitis A 1 1 2 2 1 1 1* Intoxication 0 1 0 0 0 0 2 Leptospirosis 1 1 0 1 0 1 2 Leishmaniasis 1 1 0 0 1 Malaria 2 2 0 1 1 1 0 Malnutrition 2 0 0 0 1 1 0 Measles 2 1 1 1 2 1 0 Meningitis 1 2 0 0 0 1 0 Plague* 2 1 0 0 0 1 0 Poliomyelitis 1 1 0 1 0 0 1 Protozoan dysentery 1 1 0 1 1 1 1 Relapsing fever* 2 2 0 0 0 1 0 Streptococcal disease 0 1 2 0 0 0 0 Tetanus 1 0 2 1 0 2 0 Trauma 1 0 2 2 0 2 0 Tuberculosis 1 1 0 0 0 0 0 Typhus* 1 1 0 0 1 1 0 Viral encephalitis 1 0 0 1 0 0 0 Whooping cough 1 0 0 = Rare problem 5 1 = Potential problem (depends on area) 2 = Likely problem (depends on area) * Particularly in endemic areas TABLE 1.2 Modes of transmission of diseases encountered in disasters Disease AIDS/HIV Anthrax Bacterial dysentery/gastroenteritis Cholera Dengue Diphtheria Enteric fevers Hepatitis A Intestinal helminths and protozoa Leishmaniasis Leptospirosis Malaria Measles Meningitis Plague Pneumonia Poliomyelitis Protozoan dysentery Relapsing fever Streptococcal disease Tetanus Trench fever Tuberculosis Typhus Viral encephalitis Haemorrhagic fever1 Whooping cough MODE OF TRANSMISSION Food Water/sanitation Aerosol Vector Sexual Blood/needles Trauma/burns contamination droplet contact X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 1 The mode of transmission is usually a vector, but other modes occur depending on the particular virus involved. Chapter 2 Situation analysis 2.1 Planning and assessment of needs Poor water and sanitation, crowding and inadequate shelter are known to be risk factors common to most disasters and therefore likely to lead to outbreaks of communicable diseases which will require diagnostic laboratory services. Anticipation of these factors should enable the early establishment of essential laboratory facilities. 6 Preliminary assessment of the overall health situation and needs should be made by an experienced health team, using check lists and other means of collecting data. When medical services are required, an experienced laboratory technician should be part of the operational team. Where risk factors are not apparent or the situation is more complex, for example where trauma is involved, such data may be used to determine laboratory needs. Figure 2.1 Laboratory referral/support hierarchy During the early stages of a disaster, laboratory services are more useful for identifying the major health problems than for diagnosing individual patients. This information, when combined with the available data on prevalent causes of morbidity and mortality (such as measles, diarrhoea and dysentery, respiratory infections and malaria), can provide a useful basis for planning and evaluation of control measure efficiency. Laboratory results, together with data on disease prevalence enable ongoing surveillance to determine changes in disease patterns and to give early warning of epidemics. During epidemiological investigations, laboratory services can provide a definitive confirmation of a suspected disease. For a population dispersed over a large area or several locations, one laboratory may serve all or part of the affected population. In such situations it is more appropriate to collect and transport samples to a central field laboratory than to set up a laboratory in each location. The field laboratory will not always be able to undertake all the necessary investigations such as the proper testing for viral infections or the culture of mycobacteria. Therefore, it is important that the laboratory be part of a laboratory network as illustrated in Figure 2.1. Support to district and regional laboratories in the form of materials, equipment, or personnel may be an important component of disaster response. National and international reference laboratories should be involved in supporting field laboratories (a list of international reference laboratories is given in Annex 2). 7 2.2 Assessment of existing services 2.2.1 General Central and local laboratory services, where they exist, should be assessed by the laboratory technician during the first visit of the assessment and/or operational team(s). Capabilities should be recorded. Strengths and weakness of available health laboratory services should be reported. 2.2.2 Supplies The laboratory technician should also visit a number of local suppliers of laboratory equipment, chemicals and reagents. A telephone call is not sufficient. A personal visit enables the technician to check: • availability of equipment and supplies; • storerooms for stock levels; • the possibilities for local purchase of basic items such as microscope slides, methanol, Field’s stain and Giemsa’s stain, together with their prices. 2.2.3 Reference laboratories The laboratory technician should also visit local reference laboratories and check the following: • standard of work, professional capability and willingness of laboratory staff to test referred samples; • availability and quality of media and other consumables such as Cary−Blair, Amies transport medium, alkaline peptone water, TCBS medium, and Group O1 polyvalent antiserum; • expiration dates of materials; • source of supplies. 2.2.4 Blood transfusion services Finally the technician should visit the local blood transfusion services to check the following: • adequacy of blood stocks; • contingency plans for provision of extra blood supplies from other centres and other countries; • stocks of in−date grouping antisera; • availability and routine use of HIV and HBV testing kits; • cold chain equipment and vehicles for blood transport. 2.2.5 Logistics of sample referral and transport of blood The laboratory team should check the following: • state of all transportation (road, rail, river, sea and air); • timetables for buses, trains, ships, river ferries and aircraft flights; • other agencies, e.g. United Nations or Red Cross/Red Crescent, to determine if specimens can be sent on chartered aircraft. 2.2.6 Contacts with existing laboratory services and suppliers The team should also register the following: • names, addresses and telephone numbers (work and private) of contact persons and store−room key holders; 8 • opening hours of services; • availability and call−up signs of high frequency radio, for base office of UN, Red Cross/Red Crescent, Médecins sans Frontières, and other organizations; • fax and telex numbers of services, including the above organizations. 2.3 Selection of laboratory staff Staff for emergency laboratories may be locally trained or expatriate. Criteria for selection should include the following: a) Essential • internationally or nationally recognized qualification in medical laboratory technology. The laboratory technologist must be familiar with: − microscopical techniques for the identification of parasites and bacteria; − basic haematological investigations; − water testing for thermotolerant (faecal) coliforms; − blood grouping, crossmatching, and HIV, HBV, and syphilis testing, using rapid or simple tests; − use of other rapid or simple diagnostic tests; • flexible approach to tasks and problems encountered in field and emergency laboratories; • willingness to work long, unsocial hours; • ability to work and take decisions without direct supervision. b) Desirable • experience in logistics and purchase of equipment; • experience in general laboratory management; • experience of working overseas (if expatriate); • working knowledge of language of the country (if expatriate), whenever possible. The employment of bilingual local staff or an interpreter may also help. Chapter 3 Types of laboratory facility 3.1 General There are five types of laboratory facility: • existing laboratory facilities • temporary stationary laboratory facilities • mobile laboratories 9 • portable laboratories • reference laboratories. Figure 3.1 Transportable rigid structures 3.2 Existing laboratory facilities Existing laboratory facilities should be prepared to provide emergency services wherever possible, particularly in situations such as epidemics not associated with disaster. Review of central and local laboratory facilities must be included in the preliminary assessment of the situation. It may be necessary to provide supplementary support to local laboratories in the management of specific diseases. 10 Figure 3.2 A temporary laboratory (A) Figure 3.2 A temporary laboratory (B) 3.3 Temporary stationary laboratory facilities Where there are no existing laboratory services, laboratories may be established in temporary facilities. There are three types of temporary laboratory: a) existing building; b) transportable rigid structure, e.g. caravan, truck (Figure 3.1); c) tent or shelter constructed with available material, e.g. bamboo, straw mats, plastic, poles and canvas (Figure 3.2). A temporary laboratory can be set up in an existing room, a tent, or a specially constructed shelter using locally available materials. The long axis of the laboratory should run from east to west so that the laboratory faces south and obtains maximum sunlight (for microscope use). It should be near the health centre. A storeroom should be situated on the cooler, shady side of the laboratory (see Figure 3.3). A system for safe disposal of specimens should be prepared (see Chapter 6). If possible, there should be a separate room for collecting samples. Basic items of furniture and equipment that may be purchased locally are listed in Table 3.1. 11 Figure 3.3 Plan for a temporary laboratory TABLE 3.1 Items to be purchased or prepared locally Quantity1 Item Tables2 Chairs2 Matches Soap powder, medium sized Hand−washing soap Adhesive tape Cupboard, wood or metal, length 150 cm, width 40 cm, height 120 cm, fitted with shelves (for storage of laboratory equipment and chemicals) Padlocks and keys, for cupboard and laboratory doors Padlock catch for cupboard and doors Basic first aid kit (for cuts and burns) Bucket for use in case of fire (12 L) Strong glue Quicklime (for burial of waste material) 1 2 2 4 1 packet of six boxes 1 packet/bag 1 cake 1 roll 1 3 sets 3 1 1 1 tube 1 sack Quantities required may vary according to the situation. Alternatively, sufficient wood, nails and screws. The following tools should be available: − pair of long nose pliers − small hacksaw and spare blades − screwdriver with interchangeable pieces − adjustable 20 cm spanner wrench − file − set of vicegrip pliers − saw − hammer 12 − small spirit−level − ruler − tape measure (8 metres) 3.4 Mobile laboratories A mobile laboratory is a laboratory mounted on or built into some form of transport. The transport might be a truck or van, a trailer, a railway carriage, a boat, or a large self−supporting container−like unit that can be conveyed by truck, boat, plane, or helicopter. All of these formats exist and have been used very successfully. Planning authorities should give serious consideration to including mobile laboratories in their emergency contingency plans. A mobile laboratory has three advantages: • It can go almost anywhere, depending on the type of laboratory and the location of the disaster. • It is self−contained, usually with its own sources of electrical power and utilities, such as water and gas. • It is designed to be operable immediately upon arrival. The disadvantages are: • cost; and • the fact that it may not be able to reach the emergency areas in some situations. Mobile laboratories can be configured for almost any type of investigation, including, for example, medical diagnostic tests and environmental investigations. Mobile laboratories should be chosen according to the anticipated conditions e.g. ship, boat or canoe−transported systems for rivers and seas (Figure 3.4); vehicle or rail−mounted systems on land. Preplanning is necessary to take advantage of the capabilities of mobile laboratories. They must be procured before the emergency situation has happened. This requires planning to decide and, perhaps, design what is needed for the area projected as a target. A list of manufacturers of mobile laboratories is given in Annex 3. Once the laboratory has been obtained, the personnel that are to use it should receive periodic hands−on training, working together so that they have the opportunity to form an efficiently functioning team. Actual work in the field is essential for solving potential problems in the system. 13 Figure 3.4 A boat− mounted laboratory 3.5 Portable laboratories Portable laboratories are self−contained diagnostic systems that can be carried by hand. They are compact and relatively lightweight. Portable cases or plastic boxes containing laboratory materials may be used in combination with existing temporary or mobile laboratory facilities. They are particularly useful for epidemiological surveys in the field. However, there should be a critical evaluation of portable systems available, as some are extremely expensive and not well compiled. A list of manufacturers of portable systems is provided in Annex 3. A heavy duty plastic box 60 cm x 40 cm x 30 cm can be used to transport laboratory materials (Figure 3.5). Rubber may be used for hinges and carrying straps. Diagnostic equipment and supplies can be put into another box or case for taking to the field. However, it is advisable to use a well−sealed case that will withstand environmental conditions such as rain, immersion in water, and dust. The case should also be sturdy enough to withstand the rigours of transport. Conditions in the field will not be known prior to the emergency situation, therefore a carrying case appropriate to any eventuality must be chosen. The inside of the case should be designed so that the equipment and supplies are arranged for ease of use. Provision should be made to protect delicate equipment, either by securing it in position or by using shock−protective padding. A portable laboratory should be modular, so that users can pick and choose the components needed for the particular emergency situation being addressed. At the same time, a portable laboratory should also be able to meet unexpected diagnostic requirements. Most of the diagnostic tests described in Chapter 6 can be carried in a portable laboratory. The amounts of reagents available for some tests will be limited by space, but a portable laboratory can carry sufficient supplies to obtain a good picture of disease prevalence in an emergency situation. By using micro−methods, a portable laboratory can provide a large number of certain diagnostic tests. Technical instructions must be included in a portable laboratory system, and the parts should be identified by name, illustration, and function. 14 Figure 3.5 Portable laboratories in rural health care a) Plastic box b) Portable laboratory system An important component of a portable laboratory is specimen collection and transport. A sampling of appropriate specimens can be returned with the investigation team to their base for analysis. Test results from these specimens and from on−site tests, especially in the event of high endemicity or even an epidemic of disease, will help significantly in identifying the appropriate modules for a laboratory kit (described in Chapter 7). After its use in the preliminary investigation, a portable laboratory can remain on site to provide continuing support until a more comprehensive laboratory system can be set up and to expand investigations into satellite areas. A portable laboratory is shown in Figure 3.6. Military casualties resulting from war or armed conflict are usually the responsibility of military medical services, but there may also be civilian causalities and mobile or portable laboratories may be particularly useful in such circumstances. The modules of a portable laboratory should include equipment and reagents to perform: • specimen collection and transport • basic haematology • urinalysis • blood and urine chemistry tests • microscopic microbiology • rapid serodiagnostic tests. 15 3.6 Referral of samples to reference laboratories Where it is not possible or feasible to establish any kind of laboratory or where investigations are required that are beyond the scope of the local laboratory, samples may be collected and transported to reference laboratories. Figure 3.6 Applications of portable medical laboratories in rural health care and epidemic investigations Chapter 4 Selection of appropriate laboratory tests 4.1 General Many medical laboratory diagnostic tests are suitable for use in the emergency laboratory. Most of these are the same as those used in conventional established laboratories, but some tests have to be modified for use in the field. Diagnostic laboratory tests can be classified as either direct or indirect. Direct tests are intended to specify the exact cause of the disease. Indirect tests examine the host’s reaction to the infection or medical condition, as in haematology or urinalysis tests. Both types of diagnostic tests are appropriate for emergency laboratories. Since infectious diseases are the primary concern in most disaster situations, direct tests are often the most important. 4.2 Direct diagnostic tests 4.2.1 Rapid diagnostic tests for infectious diseases Rapid diagnostic tests are defined as laboratory tests that can yield a specific diagnosis within 24 hours, preferably within 10 minutes. Rapid diagnostic tests that are appropriate for use in emergency situations must be simple, easy to read, and clear to interpret. 16 Standard brightfield light microscopy provides direct, rapid diagnosis for many diseases, for example, malaria, bacterial meningitis, and intestinal parasites. Since microscopic examinations provide rapid diagnosis for many other infections, microscopy is considered a first−line rapid diagnostic technique. Rapid diagnosis can also be made by serodiagnostic or immunodiagnostic tests. Serodiagnostic tests can be done rapidly by a variety of methods. Since these tests are very specific, pre−existing knowledge of potential disease problems in any geographical area is required to choose appropriate serodiagnostic reagents. The most suitable serodiagnostic tests for field diagnostic testing in disasters are: • serological immobilization • inert particle aggregation (passive agglutination) • enzyme−linked immunosorbent assay • fluorescent antibody (immunofluorescence). Serological immobilization is the interruption of bacterial mobility by treatment of the specimen with specific antiserum. It is most commonly used for rapid diagnosis of cholera. This test can often be done directly on liquid stool specimens. Inert particle aggregation tests are very simple and useful. The two most commonly used are latex agglutination (LA) and coagglutination (COAG). Latex reagents are tiny styrene spheres covered with latex to which a specific antibody or antigen has been attached. COAG reagents are made from killed and stabilized cells of certain strains of Staphylococcus aureus that are rich in a substance called ‘protein A’. Specific antibodies are attached to these cells through a natural affinity of the immunoglobulin−G of certain species for protein A. The resulting antibody−coated staphylococcal cells, tiny spheres themselves, are COAG reagents. When either LA or COAG reagents react with a homologous antigen such as bacteria in the spinal fluid of meningitis patients, a serological reaction occurs that causes clumping of the LA or COAG particles. This reaction can be observed easily with the naked eye, providing a very rapid and specific diagnosis. LA and COAG reagents are about equal in sensitivity. Some of the important infectious diseases that can be diagnosed rapidly with these reagents are: • cholera • bacterial meningitis • bacterial pneumonia • salmonella gastroenteritis • typhoid and paratyphoid fevers. The difference between LA and COAG reagents lies in the ease of reagent preparation. The latex particles must be purchased. The COAG reagents can be easily prepared in almost any laboratory. Commercially available LA and COAG reagents are listed in Annex 4. Enzyme−linked immunosorbent assay (ELISA) is becoming widely used for rapid diagnosis of infectious diseases, autoimmune diseases and normal conditions such as pregnancy. It can identify both antigens (microorganisms or their by−products) and antibodies. ELISA tests are very sensitive and easy to use. Many are commercially available (see Annex 2). Fluorescent antibody (FA) tests are used to detect and identify both antigens and antibodies. The reagents are antibodies to which a fluorescent dye, a ‘conjugate’, has been attached chemically. There are two types of FA test, direct and indirect. In direct FA test the specific fluorescent reagent is made to react with a specimen that may contain the target microorganism. If the target microorganism is present, for example, the meningococcus in spinal fluid, the individual (meningococcus) cells will glow brightly against a dark background when viewed with a fluorescence microscope. For indirect FA tests, an antibody is first made to react with the specimen, and then a fluorescent antibody specific for the protein of that antibody or species serum is made to react with it. The latter process yields great versatility to the indirect method. Only one fluorescent conjugate is needed, and many antisera (polyclonal and monoclonal) are available for detecting a wide variety of infectious disease agents. The primary disadvantage of performing FA tests in the field is the need for a fluorescence microscope. Recent technical developments in fluorescence microscopy equipment, however, have made it quite practical to do FA tests and fluorescent acid−fast stains in the emergency laboratory. This technological advance is due to the development of fluorescence objectives which can turn any standard microscope into a 17 fluorescence microscope, at very reasonable cost. 4.2.2 Communicable diseases: bacteria, parasites, rickettsia and viruses General The principal tests required for diagnosis of communicable diseases that may occur in disasters are listed in Table 4.1. The tests are divided into those that give presumptive diagnoses and those that are confirmatory. Presumptive tests for some diseases are sufficiently sensitive and/or specific that further confirmatory tests are not appropriate or needed. Presumptive tests for other diseases are only a guide, having low sensitivity and/or specificity, and confirmatory tests should be done if at all possible. TABLE 4.1 Diagnosis of communicable diseases in disasters Disease Specimen examined AIDS/HIV Serum Anthrax Lesion Sputum Faeces Bacterial dysentery/gastro−enteritis Cholera Faeces Dengue Diphtheria Enteric fevers Serum Throat swab Blood Faeces Urine Urine Faeces Hepatitis Intestinal helminths and protozoae Leishmaniasis Leptospirosis Malaria Measles Meningitis Serum Blood Serum Blood Serum Cerebrospinal fluid Plague Pneumonia Bubo aspirate Sputum Serum Sputum Presumptive diagnostic Done Confirmatory Done test on test on site site ELISA Yes Serology No Fluorescent antibody Yes Latex agglutination Yes Gram stain Yes Culture No Serology No Culture/coagglutination Yes Culture Yes1 Microscopy, polymorphic and red cells Serum immobilization Coagglutination Latex agglutination None Microscopy, Gram stain Culture/coagglutination Yes Yes Yes Yes No Yes Yes Culture Yes1 Serology Culture Culture No No Yes1 Test strip Microscopy Yes Yes Serology NA No No DAT ELISA Fluorescent antibody Culture Darkfield Microscopy ELISA Coagglutination ELISA Latex agglutination Microscopy Gram stain Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Culture Serology No No Culture Serology NA NA Culture No No Culture No Coagglutination ELISA Fluorescent antibody Latex agglutination Yes Yes Yes Yes Culture No No 18 Poliomyelitis Serum None No Protozoan dysentery Relapsing fever Faeces Blood Yes Yes Tetanus Trench fever Trypanosomiasis Microscopy Field’s stain/Giemsa’s stain Microscopy Wet mount (brightfield or darkfield) Throat swab Coagglutination Latex agglutination Microscopy, Gram stain None None None None Serum or plasma CATT Tuberculosis Sputum Yes No Streptococcal disease Viral diarrhoeas Viral encephalitis Faeces Serum Microscopy, acid−fast stain Fluorescent acid−fast stain Indirect fluorescent antibody Weil Felix stained antigens Latex agglutination None Viral haemorrhagic fever Serum None Whooping cough Naso−pharyngeal Fluorescent antibody swab Typhus Serum Culture, Serology NA Animal inoculation No Culture No NA Serology ELISA Giemsa’s stain Culture and sensitivity No No No Serology No Culture Culture, serology Culture, serology Culture No No No No Yes Yes Yes Yes Yes No No Yes No Yes Yes1 Yes Yes No Yes No No 1 Dependent on the level of sophistication of the emergency laboratory. For example, many mobile laboratories can do this. CATT Card agglutination test DAT Direct serum agglutination test NA Not applicable Notes to Table 4.1 1. A presumptive test involving bacterial immobilization with anti−V. cholerae O1 antiserum solution can be used in the field. If O1 antiserum containing preservatives is used, it must be diluted 1:10 with saline solution. Interpretation of the test is subjective, and prior experience is important. COAG and LA agglutination tests have been developed, and these have been field tested but not in disaster situations. 2. If shigellosis is suspected, stool specimens should be transported in Cary−Blair medium or on filter paper for culture and susceptibility testing at a regional bacteriology laboratory. 3. Experience with COAG and LA tests on selective enrichment broth cultures is limited, and confirmatory culture tests may be helpful. 4. LA and COAG tests on clinical specimens have been used under field conditions, particularly in endemic meningitis areas. They may be considered an acceptable alternative to microscopy with comparable sensitivity. 19 5. The CATT is a useful screening test for trypanosomiasis. DAT is a useful screening test for visceral leishmaniasis. Representative serum samples should be sent to a reference laboratory for more sensitive and specific serology. Marrow or splenic aspirates should only be done by suitably experienced medical personnel. 6. Where specific viral fevers are endemic, and may become epidemic in disasters, on site serological tests should be considered (e.g. dengue). Cholera Diagnosis of cholera is, in most cases, essentially clinical. Presumptive laboratory diagnosis is important for epidemiological and outbreak investigations. Culture confirmation is essential for public health notification and to determine antimicrobial susceptibility. V. cholerae isolates or stool specimens should be sent to a reference laboratory for biotyping and serotyping. Stools may be tested directly on site with simple COAG or LA slide agglutination tests. Use of alkaline peptone water for enrichment culture incubation followed by LA or COAG tests gives more sensitive diagnostic results. Enteric fever/salmonellosis Typhoid/paratyphoid fever outbreaks are relatively uncommon in disasters, but all types of Salmonella infection are increasingly common in HIV endemic areas. No satisfactory non−culture diagnosis test for salmonellae exists for field use, with the possible exception of FA. Widal serological tests are of no value in tropical areas. Rapid COAG tests on stool and blood selective enrichment broth cultures have been reported. Confirmatory tests require culture of blood or faeces followed by biochemical and serological identification of suspect isolates. Shigellosis A presumptive diagnosis of shigellosis can be made by the presence of blood and polymorphonuclear leucocyte cells demonstrated by direct microscopy of the stool specimen. However, in the absence of amoebic trophozoites, this is rarely necessary and is of low specificity for epidemiological purposes. Culture confirmation and serotyping is necessary for epidemic investigation. Antibiotic susceptibility testing should be done in an extensive outbreak. Amoebic dysentery (amoebiasis) Stool microscopy demonstration of amoebic trophozoites is sufficiently sensitive and specific for diagnosis. Faecal specimens for this test must be very fresh. Other diarrhoeal diseases Investigations additional to those for shigellosis and amoebic dysentery are rarely indicated in disasters. In a diarrhoeal disease outbreak in which the above investigations are negative, a sampling of faecal specimens can be sent to a reference centre. Stool microscopy for other enteric pathogens Intestinal helminths and protozoan infections are common in communities where water and sanitation facilities are deficient. Their diagnosis may be important in individual patient management, but they are rarely implicated in disease outbreaks. Therefore, examinations for intestinal helminths should take low priority. Although they are easy to do and hold interest for those inclined towards parasitology, these examinations will have little impact on the health of the community at risk. Bacterial meningitis In an outbreak of suspected meningitis, lumbar puncture should be performed on a representative number of cases using aseptic technique. It should only be done by an experienced health worker. Stained cerebrospinal fluid (CSF) specimens should be examined with a microscope. Antigen detection, using COAG or LA tests has proved to be a useful field diagnostic technique. Culture confirmation will define the causative agent and allow serotyping and antimicrobial susceptibilities to be determined. Tuberculosis 20 Presumptive diagnosis of tuberculosis can be made by microscopic examination of sputum smears stained by either the Ziehl Neelsen or Kinyoun methods. Fluorescent acid−fast staining provides very sensitive diagnosis. Mycobacterial culture facilities are often limited at regional or national levels. If tuberculosis is a major health problem, dispatch of a limited number of sputum specimens to a reference centre for culture and antimicrobial susceptibility testing may be considered. Microscopy is an essential component of tuberculosis control programmes. The idea is to detect active cases so that they can be treated and immediate contacts can be immunized with BCG vaccine. Blood parasites Microscopic examination of Giemsa−stained, Wright−Giemsa−stained, or Field−stained blood films for malaria, relapsing fever, and trypanosomiasis should be done. A card agglutination test (CATT) is available for serological screening, but microscopy remains the first line of diagnosis. Rickettsial and viral fevers For investigation of presumed viral or rickettsial fevers, filter paper blood specimens should be sent to an appropriate reference centre. Such specimens should be taken by a special investigation team, and adequate safety precautions must be taken for shipment (see the special shipping precautions described in Chapter 11). Leishmaniasis The direct serum agglutination test (DAT) can be used in the field as a screening test for visceral leishmaniasis. Serum specimens should also be sent to a reference centre for more specific serological tests. Viral diseases Increasingly, rapid diagnostic tests for viral diseases are becoming commercially available (see Annex 4). They are designed for detection and identification of either antigens or antibodies, but the most rapid and specific serodiagnostic tests detect and identify virus antigens. These simple rapid diagnostic tests are particularly significant because conventional tests for detecting and identifying viruses are time−consuming, difficult, cumbersome and expensive. Rapid diagnostic test systems for viruses are available in a variety of formats including filters, micro−wells, slides and dipsticks. Testing methods include LA, COAG, ELISA, DNA probe−antigen immobilization, immunoperoxidase staining, and FA. Some of these methods are very suited to use in the field. The equipment required for some tests is more elaborate than that required for others. For example, FA tests require a fluorescence microscope. As indicated above, some of these microscopes are field instruments and require very little electrical power. However, other methods require no electricity at all. Among these, the most simple are COAG or LA tests that can detect antigens or antibodies, for example the antibodies to HIV or infectious mononucleosis. The tests are simple, producing a reaction on a slide that can be read by the naked eye. Dipstick methods have been produced for multiple testing at one step using one dipstick. They can be operated by hand, and reactions are read by eye. The technologies in these dipstick tests are ELISA and DNA probes that yield colour reaction endpoints. Dipstick technology is available to test for rubella, rubeola, HBs antigen and antibody, and HIV antibody. This technology can be easily adapted to other viral diseases. 4.3 Indirect diagnostic tests 4.3.1 Haematology Haematology tests for the emergency laboratory situation are much the same as in any medical laboratory. They are used to define the blood picture to give physicians and other medical care providers clues to the nature of the patient’s disease. The tests include: • total white cell (WBC) count • differential WBC count • abnormal red blood cells (RBC) 21 • platelet count • reticulocyte count • anaemia tests. Total RBC counts are not normally done because they tend to be inaccurate. Better, easier methods exist to examine RBC content of the blood and the haemoglobin level. All of the above tests can be easily done in the field. Microtechniques are available for certain tests, like staining blood films and haematocrit. These permit limiting the quantities of certain stains and solutions required. 4.3.2 Rapid urine chemistry tests Investigation techniques for common urine analytes are simple enough to be included in a portable or mobile laboratory. The reagents can be purchased from scientific suppliers, or they can be prepared locally. Convenient dry chemistry tests are commonly used, either by means of a test strip or with a powder mixture of chemicals. The stability of these dry reagents is greater than that of reagents in solution. Urine tests for use in emergency laboratories are available for the following analytes: • haemoglobin • protein • glucose • nitrite. While other urine analytes can also be measured easily, they are less important for diagnosis and monitoring of diseases in emergency situations. Test strips are produced by a number of companies. Test strips with more than these four tests on them are considerably more expensive. Urine haemoglobin, glucose, protein, and nitrite can also be investigated by means of locally prepared mixtures of powdered chemicals. These tests are just as sensitive as the commercially available test strips but powdered chemical tests are far less expensive. Preparation of the reagent mixtures is described in Annex 5. Chapter 5 Testing water supplies In most emergency situations, following a natural disaster or in population dislocations, water supplies should be assumed to be contaminated. Drinking water should be boiled or treated with commercial bleach or iodine before use. As the situation stabilizes, water supply systems return to normal. At that time, the emergency laboratory should begin to monitor drinking water supplies to ensure that the water delivery system is functioning properly. Priority must be given to minimizing the risk of faecal contamination of water supplies. This may range from preventing defaecation in close proximity to the water source to construction of simple protected wells. When improvements in water supplies have been achieved by cleaning wells or system chlorination, water testing should be undertaken to monitor and ensure adequate sanitary water quality. In addition, water should be tested during investigation of enteric disease outbreaks. The principal water quality test to assess the risk of enteric infection is the faecal coliform count. It is rarely appropriate to test water supplies for specific enteric pathogens because faecal coliform counts will detect faecal pollution. This test is more sensitive and specific than culture for enteric pathogens. There are several test methods available. Either a selective lactose broth method or a membrane filter method can be used (see Annex 6 for manufacturers of water testing kits). The membrane filter method is rapid, provides a confirmed test, and contaminating bacteria in the water can be counted easily. The selective lactose broth method uses the production of gas by coliform bacteria in the water. It is less expensive than the filter method, but the investigator is left with a concentrated culture of bacteria requiring sterilization and disposal whereas membrane filters can be incinerated. If the broth method is chosen, one of the selective lactose broth culture media, e.g. lauryl sulfate tryptose broth, should be used. Presumptive positive results can be accepted in an emergency situation without doing confirmatory tests. 22 The preferred method for bacteriological monitoring of drinking water is the membrane filter method. Testing is easy and confirmed results are available in 18−24 hours. Exact numbers of coliform bacteria in a water sample can be determined. Compact portable laboratories for membrane filter water testing are available. They are very effective, but rather expensive. If an inexpensive field incubator is included in the emergency laboratory, an inexpensive plastic suction device can be used to sample the water, and the cost of membrane filter water testing equipment is considerably reduced. The monitors are disposable plastic, and the culture medium comes in a pre−packaged form, perfect for emergencies. More details on collecting water samples for microbiological examinations and field tests for bacteriological analysis are given in Annex 7. Chapter 6 Laboratory safety, disinfection and waste disposal 6.1 Laboratory safety 6.1.1 Safe practices The key to laboratory safety is good, careful technique. The practised skills of a qualified laboratory technician working in an emergency situation will promote efficient laboratory testing, good management, and personal laboratory safety. The most frequent laboratory−acquired infections are: • hepatitis B • tuberculosis (very infectious by aerosol) • salmonellosis • shigellosis • brucellosis (very infectious by aerosol) • histoplasmosis (very infectious by aerosol) • coccidiomycosis (very infectious by aerosol). Less frequently reported laboratory infections are: • anthrax • plague • tularaemia (very infectious by aerosol) • leptospirosis • relapsing fever • melioidosis • meningitis • filoviruses • arenaviruses. Personal hygiene and good practices are important to ensure personal safety. The following rules apply. 1. Make sure that vaccinations for hepatitis B, tuberculosis, tetanus and typhoid fever are up to date before working in the emergency laboratory. In certain areas anthrax, plague, pneumococcal pneumonia, yellow fever, tularaemia meningococcal A and Japanese encephalitis vaccinations are also needed. 2. Do not eat or drink in the laboratory. 3. Wear a laboratory gown or coat in the laboratory, and leave it in the laboratory when going out. 4. Wear disposable gloves when handling hazardous material. 5. Wash hands before, during, and after laboratory work. 23 Safe laboratory practice includes the following. • Specimen spillage can be reduced by using tube holding racks. If specimens must be left standing on a workbench, they should be placed in a pan or on a disinfectant−soaked towel or cloth. Spills should be disinfected. After disinfection, the area should be washed with soap or detergent. • Mouth pipetting must never be done. Safety pipetting devices should be included in the basic module. • Infection can occur by inhaling aerosols containing pathogenic microorganisms. Aerosols are formed when containers break in centrifuges, when samples are opened, when cultures or specimens are spilled, during pipetting, and when flaming bacteriological loops. To minimize aerosol infection, liquid specimens should always be kept covered, with the cap on the container, and opened carefully. When handling a sample suspected to be hazardous, a protective microbiological safety mask should be worn. • Used needles and lancets should be discarded into a metal or sturdy plastic container, not paper or plastic bags. Lancets may be sterilized by boiling or autoclaving. • The laboratory must be cleaned and decontaminated each day. 6.1.2 Proper use of centrifuge Centrifuges are frequently the source of infectious aerosols. The following rules should be applied when using centrifuges. • The centrifuge must be placed on a flat and secure surface. • The centrifuge must be ‘balanced’ before operation by placing containers of equal volume opposite each other. Clean tubes containing water can be used as balance tubes. • Only a centrifuge with a cover should be used, and the cover must be closed before operation. • Special care must be taken when containers are broken in the centrifuge. Plastic centrifuge tubes and bottles should be used. The lid should be left closed for a few minutes to allow the aerosol to settle. If particularly hazardous samples are involved, a microbiological safety mask and gloves should be worn when opening and disinfecting the centrifuge. The contents should be disinfected with 1 % hypochlorite solution containing a little detergent and then discarded. The rotor and inside of the chamber should then be cleaned with a cloth soaked in a disinfectant such as glutaraldehyde, 70% (V/V) alcohol, or 10% formalin solution before further centrifugation. (Do not use bleach on metals). 6.2 Disinfection The term ‘disinfection’ includes various physical and chemical procedures intended to prevent the spread of infective agents by inactivating or killing vegetative forms of harmful bacteria, fungi, protozoa and viruses. Waste, laboratory equipment, and disposables are commonly disinfected by chemical disinfectants or their aqueous or alcoholic solutions. Table 6.1 Disinfectants and their mode of application Disinfection target Blood Disinfectant 5 % cresol (pH 9) 1 % calcium hypochlorite1 Application Minimum time of Stock (disinfectant/material V/V) exposure of preparation of material disinfectant 2:1 6h crystalline/liquid 2:1 powder 24 Stool 5 % cresol (pH 9) 1 % calcium or sodium hypochlorite1 20 % calcium hydroxide 4 % chloramine T 5 % cresol (pH 9) 5 % cresol (pH 9) 0.05 chloramine T Lysol Urine Sputum Water Skin Hypodermic needles Work benches Laboratory instruments Glassware 1 2:1 3:1 6h crystalline/liquid powder powder powder 2:1 80 % ethanol 1 % iodine (Lugol) povidone iodine 70 % isopropanol 60 % n − propanol 1 % chloramine T quarternary ammonium compounds (QUATS) 0.1 % hypochlorite1 direct direct 2 min 2 min powder crystallin/liquid crystalline/liquid powder solution 50 % cresol in soap 95 % solution 5 % solution direct direct direct direct 2 min 2 min 2 min 2 min pure pure powder solution Lysol direct 4h 5 % cresol 5 % chloramine T 1 % hypochlorite1 0.1 % hypochlorite1 direct direct 4h 4h direct 4h 5, 10, or 15 % solution 70 % isopropanol 1 % hypochlorite1 direct direct 4h 5, 10, or 15 % solution 1:1 1:1 direct direct 4h 4h 2 min direct 5, 10, or 15% solution solution 50 % cresol in soap crystalline/liquid powder With a small amount of detergent. Notes to Table 6.1 1. Cresols may be solid or liquid. Cresols are not very water soluble, but a 5 % aqueous solution can be kept as stock solution. Cresols are more effective at alkaline pH (pH 9.0). Cresols are well emulsified in soap solutions. Lysol is an emulsion of 50 % cresol in an aqueous solution of soap. Cresol can be replaced by phenol; however, phenol is a less powerful disinfectant. Therefore, the time of exposure of material to phenol solution must be prolonged. Phenol and cresol solutions cause irritations of the skin and the eyes. Cresols and phenols, although they have strong odours, can be used where hypochlorites are corrosive. 2. Hypochlorite solutions (sodium or calcium) are very active disinfectants and are therefore used for a number of laboratory, household and industrial applications (in the form of household bleaches). Hypochlorites are active disinfectants against the hepatitis and human immunodeficiency viruses. Hypochlorites are rapidly inactivated by particles such as dust and organic materials. Hypochlorite solution must be prepared from stock solutions once a day. Hypochlorites cause irritation of the skin, eyes and lungs. They require contact time of 10 to 30 minutes. They are corrosive against metals, have toxic properties and are inactivated by organic matter. 3. Calcium hypochlorite (70 % available chlorine) is a solid (powder, granules). It decomposes at a slower rate than sodium hypochlorite. A solution of 1 % available chlorine is obtained by dissolving 14 g of 25 calcium hypochlorite in 1 litre of water. 4. Chloramine−T is a crystalline powder which releases chlorine as the active disinfectant agent, although at a slower rate than the hypochlorites. It is also used for disinfecting water; chlorinated water has a concentration of 0.05 % chloramine−T. However, it should be remembered that chlorinated water can interfere with some laboratory tests, in which case distilled or deionized water must be the diluent used. 5. Calcium hydroxide solution is prepared from the powder or granules of quicklime dissolved in water (1 part : 3 parts [W/V]). Calcium hydroxide solution is not suitable for disinfecting stools from patients with tuberculosis. 6. Quaternary ammonium compounds (QUATS) are effective against vegetative bacteria and some fungi. They are not effective against spores, viruses, and mycobacteria. QUATS are not toxic and are harmless to the skin. 7. Alcohols (ethanol, isopropanol, n−propanol) are fast acting, but relatively expensive disinfectants and are usually used for skin disinfection. They are bactericidal, partially viricidal, but not fungicidal. The penetrative power of alcohols is poor, so they are not recommended for use with organic material. Because they need water to be absorbed by bacteria, alcohols should be diluted with water to be used as disinfectants; normally these disinfectants consist of 70 % to 90 % ethanol or 50 % isopropanol. Their shelf life is greater than one week. They are not corrosive and not inactivated by organic material. 8. Iodine is an excellent, fast acting disinfectant with a wide range of action. It kills bacteria, many spores, viruses and fungi. At lower temperatures iodine is more active than other disinfectants. Some persons may have a sensitivity to iodine, which will appear as a rash on the skin. This can be avoided by using iodophores (polymer solutions binding iodine such as povidone iodine). Depending on the type of disinfectant, the principles for inactivating or killing microorganisms are different. The conditions for disinfection must be strictly followed in order to: a) achieve maximum inactivation of the microorganisms; b) prevent injury to laboratory workers who may come in contact with the disinfectant during their work. A number of chemical disinfectants are commercially available. Many of these disinfectants can also be prepared locally. The selection of one or another disinfectant will depend on the specific use. Inactivation of different microorganisms by a disinfectant may vary. For example, some disinfectants inactivate protozoa and bacteria but not viruses; some disinfectants effectively inactivate certain types of viruses but not other types; some disinfectants or their solutions can cause irritation or inflammation of the skin, eyes, or the respiratory tract. The proper use of disinfectants depends on the time and temperature of exposure. Some disinfectants are rapidly inactivated under certain conditions. Disinfectants for waste disposal and work surfaces are only active for a short time (up to several hours). Increasing temperature accelerates disinfection, but it can also accelerate the inactivation of the disinfectant by other materials. Therefore, the temperature for chemical disinfection should be moderate (20°C to 40°C). Another important factor for optimal disinfection is the concentration of the disinfectant and the presence of water. For example, 60 to 80 % aqueous solutions alcohol are good disinfectants whereas the pure alcohols have little or no effect. Some disinfectants, such as chlorine solutions (household bleach), should contain a small amount of non−ionic detergent to ensure complete wetting of the surface or item being disinfected. Information about selected disinfectants can be found in Table 6.1. REMEMBER: always disinfect used equipment and supplies before cleaning with soap and water. 26 6.3 Decontamination and disposal of specimens and infectious material 6.3.1 General IMPORTANT. The specimens examined in the laboratory (stools, pus, sputum, blood, urine, etc.) are often infectious. After examination they must be treated in such a way that further risk of infection is avoided. The specimens may be in: • cardboard cartons or plastic pots that can be destroyed (stools, sputum); or • glass jars and bottles that can be cleaned, sterilized and used again. Most disposable containers should be used once only, but polypropylene pots and tubes can be sterilized, cleaned, and reused. Specimen containers should be discarded into special disinfectant−filled containers (such as buckets), plastic disposal boxes, or hazardous waste bags. Reusable plastics, slides, and other materials should be kept separate from disposables for later decontamination and cleaning before reuse. 6.3.2 Methods of sterilization or decontamination Incineration An incinerator is a device designed to completely burn up combustible materials, rendering them sterile ash. Simple but effective incinerators can be made on site in emergency situations. Making such an incinerator and incineration are shown in Figures 6.1 and 6.2. Incineration should be done at least once a week, or as often as necessary. 1. Use an old metal petrol drum (200 litres/40 gallons). 2. Fix a strong metal grating (g) firmly about 1/3 of the way up the drum. Steel rods will keep it in place. 3. Cut a wide opening or vent (v) below the level of the grating. 4. Find a removable lid (l) for the drum. Figure 6.1 Making an incinerator 1. At the end of each morning’s and afternoon’s work, place all used stool and sputum boxes on the grating of the incinerator. 27 2. Always keep the metal drum tightly closed (both lid and vent) except during incineration. 3. Fill the bottom of the drum with paper, sticks wood shavings, etc. 4. Remove the lid. Light the fire and keep it burning until all the infected material has been reduced to ash. 5. The ash produced is not dangerous and can be thrown on the refuse heap. The ash should be buried in a deep pit if it contains needles, lancets, etc. Figure 6.2 Incineration Autoclaving Anything can be sterilized in an autoclave. Heat−stable items such as glass containers, polypropylene tubes and cups, polycarbonate tubes and cups, cloth, instruments, etc. will survive autoclaving intact. These can be emptied, washed, and put back into service. Autoclaving is done at 121°C with pure steam (not a steam−air mixture) for 30 minutes. Sputum pots, urine bottles, and blood sample containers can be autoclaved before being cleaned. A number of field autoclaves are commercially available (Figure 6.3). They can be heated by electricity, solar energy, gas burner, primus stove or cooking fire. Electrically−heated models consume a large amount of electricity and so are not usually suited to field laboratories. A pressure cooker designed for food preparation can also be used. 28 Figure 6.3 Autoclave Boiling in detergent When an autoclave is not available, boiling in detergent (Figure 6.4) is a satisfactory method of decontaminating most specimen containers. However, it does not kill spores and does not inactivate certain viruses. Boil specimen containers for 30 minutes in a large pail containing a strong solution of washing powder or sodium carbonate crystals (60 grams per litre of water). Figure 6.4 Boiling in detergent Burial Burial (Figure 6.5) does not decontaminate infectious material but it does prevent the material from being a hazard. 1. Dig a pit 4−5 metres deep and 1−2 metres wide. 2. Make a lid that fits tightly over the pit. It is advisable to strengthen the upper rim of the pit by lining it with bricks and stones. 3. Throw stool or sputum boxes and other infected material into the pit twice a day. Replace the lid immediately. 4. Once a week, cover the refuse with a layer of quicklime. Alternatively, if quicklime is not available, cover the refuse with a layer of dried leaves (10 cm thick) once a week. 29 Figure 6.5 Burial of contaminated material 6.3.3 Disinfection of specific equipment Reusable stool containers can be decontaminated by autoclaving or with strong disinfectant before cleaning. Autoclave at 121°C for 3 minutes or fill the jars containing stools with a 5 % solution of phenol or similar disinfectant. Leave for 24 hours. Empty into the lavatory*. *NOTE. If the lavatory is connected to a septic tank, phenol or other antiseptic should not be put into the lavatory. Clean the jars with detergent and water (see Table 6.1). They can also be autoclaved before cleaning. Reusable sputum pots and tubes of pus and CSF can be decontaminated by several methods before cleaning. In order of preference these are: − autoclaving; − boiling in detergent. Follow the directions given for autoclaving or boiling. Urine bottles should be emptied into the lavatory. Autoclave the bottles or fill them with a 1 % solution of commercial bleach, or 2 % solution of phenol. Leave them for at least 4 hours before cleaning them with detergent. Blood sample containers should be autoclaved. Alternatively, they should be soaked overnight in a strong disinfectant, 5 % cresol or 1 % calcium hypochlorite, 1:2 V/V. Containers of fresh blood collected the same day should be rinsed in cold water and left to soak in a soap or detergent solution. Containers containing blood which has been kept for several days and in which organisms may have multiplied should be filled with a 1 % solution of commercial bleach and left for at least 6 hours before rinsing and cleaning. Glass microscope slides used for tuberculosis should be soaked overnight disinfectant and then discarded. Slides used for Gram stain and Romanovsky stain should be soaked overnight in disinfectant. The immersion oil should then be removed with xylene, washed in detergent and rinsed in several changes of clean water. The slides should then be air dried, or dried using a lint−free towel. 30 Chapter 7 Laboratory kits and modules 7.1 Introduction to the use of modules and kits A laboratory kit will allow a selected number of investigations to be carried out. Equipment and supplies will be required, and these can be made up and provided in modules. (Annex 8 lists some non profit−making suppliers of tropical laboratories. Annexes 9 to 16 list manufacturers of equipment and supplies.) The following definitions apply: Kit everything required to carry out selected laboratory investigations. Module the separate components making up a kit; a module is a sub unit of a kit. Selected items provided in a kit will allow the technician to perform tests for a single disease, a group of related diseases, or indirect tests such as those for haematology or urinalysis. The concept of kit assembly is illustrated in Figure 7.1. In this example a kit has been assembled from appropriate modules to detect and diagnose malaria cases. Note that not all modules are required and only part of the energy module is required, since a centrifuge and haemoglobinometer are not needed. Experience has shown that it is better to select equipment and supplies according to the particular need. This will lead to a rapid and appropriate response. The initial assessment will provide data leading to an indication of the specific needs in an emergency or disaster. Prior preparation of a laboratory kit makes the immediate provision of the essential possible. 7.2 Use of kits and modules The initial field laboratory will be established by using relevant modules to make up a kit. At a later date there may be a need to send additional modules. The contents of the modules can be considered as independent items. Twenty−two modules are described. The composition of each module is listed in 7.3. 1. Basic module Contains the essential equipment and supplies to establish a laboratory. Simple and robust items have been chosen. 2. Energy module Will provide a constant and reliable source of electrical energy. 3. Water testing module Will allow the testing of water for turbidity, chlorine faecal coliform bacteria and pH. It should be portable and may include a built−in battery. 4. Microscope module Consists of an ordinary microscope with a complete set of accessories suitable for work in harsh conditions, such as high temperature, humidity and dust. It can be connected to a reliable and constant source of electricity, run on a battery which may be recharged by solar energy, or use direct sunlight. 31 5. Tuberculosis module Contains the materials for staining acid−fast bacilli in sputum smears, using hot or cold techniques. 6. Bacteriology module Contains media, equipment and material for bacterial culture, if appropriate laboratory facilities are already available in the field (incubator, heat source, alcohol or gas burner, etc.). 7. Urinalysis module Contains test strips or chemical powder reagents allowing the detection of proteins, blood, glucose and nitrite in urine specimens. 8. Faecal parasite module Contains reagents for staining specimens for detection of ova and parasites. 9. Blood parasite module Contains material for staining thick and thin blood smears (Giemsa, Field, RAL 555). 10. Haematology module Contains reagents for the determination of haemoglobin or packed red cell volume (PCV), white blood cell count, platelet count and differential white cell count. 11. Centrifuge module Provides the means to separate blood serum or plasma or to concentrate deposits of cells from urine or cerebrospinal fluid (CSF). 12. Portable incubator module Can be used for on−site bacteriological culture and, in conjunction with the water testing module, to assess water sanitation. 13. Refrigerator module Necessary for the safe storage of reagents, transport media and blood. 14. Specimen transport module (except stools) Contains equipment and material required to transport specimens. 15. Water purification module Contains equipment and material required to provide clean water for the preparation of stains and reagents. 32 16. Electrolyte analyser module Contains the instruments and calibration solutions for analysing electrolytes. 17. Cleaning, disinfection, sterilization and specimen disposal module Contains equipment and supplies to sterilize and safely dispose of specimens. It also contains the material necessary to clean containers, slides, cover−glasses, etc. for reuse. 18. Bacteriology−Gram stain module Contains Gram stains for microscopical identification of bacteria. 19. Stool specimen transport module Contains devices and material for the transportation of faecal specimens. 20. Serodiagnostic test module Contains rapid diagnostic kits or reagents, except for fluorescence reagents. The kits will have to be chosen according to the available knowledge of the endemic diseases in the area concerned and of anticipated epidemic diseases. 21. Fluorescence microscopy module Contains either a fluorescence objective lens or a portable fluorescence microscope with associated supplies. This will permit using fluorescent antibody and fluorescent acid−fast rapid diagnostic tests in the field. 22. Blood transfusion module Contains devices, reagents and material for blood testing and transfusion. 33 Figure 7.1 Assembling modules to make a kit (Example kit for malaria detection) 7.3 Contents of modules Module 1: Basic Consumables, (renewable Quantity supplies) Small, re−sealable plastic 1000 bags for specimens or Whirl−Pac bags, polyethylene Containers, polypropylene 20 (not polystyrene), screw−cap, leakproof, 60 mL capacity Xylene 250 mL Microscope slides, frosted 1000 end, 76 mm x 26 mm, 1 mm thick Cotton wool swabs 34 or Gauze squares, 5 cm x 5 1 pack of 200 cm Ethyl alcohol, denatured 500 mL technical grade Pasteur bulb pipettes, 100 polyethylene, 3 mL (transfer pipettes) Toilet paper 4 rolls Ball point pen, black 6 Ball point pen, red 2 Pencil with eraser 2 Pencil sharpener 2 Felt−tip pen, large, 2 waterproof, black or blue Pot cleaner, non−abrasive 2 Exercise books, A4, hard 3 cover, squared paper Laboratory cloths 2 Standard items Slide box, wood (for 100 1 slides) Beaker, polypropylene, 250 2 mL Beaker, polypropylene, 500 1 mL Beaker, glass, low form, 2 spouted, 500 mL Rubber gloves, heavy duty 1 Balance 1 Plastic bags, polyethylene Containers, polypropylene, 20 each screw−cap leakproof, 60 mL capacity Filter paper, Whatman No. 300 1 circles, 12.5 cm or sheets Funnels, polypropylene, 90 2 mm diameter Funnels, polypropylene, 65 5 mm diameter Label, self−adhesive, 150 removable in water, 65 mm x 45 mm Drying rack, plastic (for 1 slides) Rods, stainless steel, 2 minimum length 290 mm (with levelling screws) Metal spirit burner with 1 screw−cap, with spare wick Diamond marker, preferably 1 with aluminum handle 35 Timer, mechanical, 1 minute steps, 60 minutes Basin, plastic, diameter 285 − 290 mm (for staining) Basin, plastic, diameter 300 − 310 mm (for washing) Slide mailer, polyethylene, with integral push−in lid Pipettes, graduated, polypropylene, 1 mL Pipettes, graduated, polypropylene, 10 mL Containers, polypropylene (for blood collection), flat bottom, leakproof, screw−cap, 10 mL Dropper bottle, translucent, polyethylene with lid, 15 mL Pipette filler (safety)1 Test tube rack, 24 place, white nylon coated−wire, for tubes 100−125 mm x 15 − 20 mm diameter Measuring cylinder, graduated, polypropylene, 100 mL Measuring cylinder, graduated, polypropylene, 500 mL Microbiological safety mask Reagent bottles, high density polyethylene, leakproof cap, 250 mL Forceps, stainless steel, flattened bent and blunt−ended, 105 mm long Hazard safety labels with official symbols on yellow background, measuring 38 mm x 380 mm Glass stirring rods Spatulas, polypropylene, length 100 mm Tripod, metal Gauze, stainless steel, ceramic (for tripod) Paint brush 12 mm, soft bristles or Camera brush (for cleaning microscope) Ruler 30 cm Test−tube small 12 mm diameter brushes, medium 18 mm diameter 1 1 1 10 5 5 50 3 1 1 1 1 2 boxes 20 1 pair 1 pack 5 2 1 1 1 1 1 1 36 large 50 mm diameter Scrubbing brush Scissors, sharp tip Thermometer, 0−100°C (for water and refrigerator) with holder to protect it from breaking. Wash bottle, polyethylene, integrated tube spout, 250 mL Eyewash bottle (safety), 500 mL Eye−shield (goggles, clear shatter−resistant polycarbonate and fitted with side shields) Glutaraldehyde or formalin to decontaminate centrifuge Protective clothing e.g. plastic apron Rubber gloves (washable) size 7 or 8 1 1 1 1 pair 2 2 1 1 1L 3 1 box A bulb pipette filler can be used, but a Pi−pump is much easier to control. Module 2: Energy Solar module, 57 W maximum peak power Charge regulator, 12V Battery, 100 Ah, 12 VT Solar battery charger NiCd, size AAA−D Battery charger NiCd, size AAA−D (11 − 36 V d.c. input) Batteries, size AA2 Batteries, size C2 Cable 20m, 1.5 mm2 Light 11 W low consumption bulb Spare bulb 11 W Distilled water Crocodile clips Spare charge regulator 1 2 Quantity 1 1 1 1 1 8 8 2 1 1 5L 2 pairs 1 Sufficient for a microscope, centrifuge, haemoglobinometer and light. Alkaline or lithium are recommended. Although more expensive, they last longer. Module 3: Water testing (for 200 tests) Quantity Del Agua kit, consisting of Del Agua kit, complete (state 110 V or 220 V) plus 37 1 kit − Spare fuse (110 v or 220 v) − Forceps − Bottles, very high density polypropylene, 60 mL Consumables for 200 tests: − Membrane lauryl sulfate broth1 38.1 g − Filter membranes and pads, 200 or Millipore kit, complete (switchable for 110 V, 220 V, 6 V, 12 V, 24V) or Inexpensive alternative (requiring separate incubator2 and external battery, vehicle battery or mains) and the following: − Sample cup, graduated, polypropylene 100 mL − Hand vacuum pump assembly, plastic with 2 way valve and tube) − Microbiological analysis monitors, filters 37 mm, 0.45 mm pore size − BROM MF, ENRO medium, ampoules, 0.8 mL 1 2 2 1 10 2 packs 1 pack 1 kit 1 1 1 pack of 200 200 ampoules The broth is best kept in a well sealed container in the refrigerator An inexpensive portable incubator, e.g. GQF will be required as a separate module. Module 4: Microscope Quantity Complete binocular microscope with an all−metal stand with stable base, coaxial fine and coarse focus control on both sides, built−in transformer, built−in illumination diaphragm, conversion filter; and including the following: Achromat objectives x10, numerical aperture 0.25 Achromat objectives x40, numerical aperture 0.65, spring−loaded Achromat objectives x100 (oil immersion, numerical aperture 1.25, spring−loaded Eyepieces x10 (wide field) Condenser (bright field), pre−adjusted Iris diaphragm Filter holder (with centering screws) Optional: Dark−field condenser (or condenser stops for x10 and x40 objectives) Eyepiece micrometer with calibrated graticule or micrometer/small glass measuring disc (to measure cysts and ova) Binocular head Mirror, one side flat and the other concave Lamp, built−in (Halogen, 6 V, 10 W) Mechanical stage with specimen holder Jeweller’s screwdrivers, set Dust cover Lamp and fuse, spare Lens paper, box Manual on the function and maintenance of the microscope Optional: Stage micrometer (engraved with 100 of 0.01 mm divisions) Oil immersion 1 1 1 1 1 matched pair 1 1 1 1 1 1 1 1 1 1 set 1 1 1 1 1 50 mL 38 Silica gel (humid areas)1 100 g 1 Under conditions of high humidity it may be necessary to pack (using a cloth bag or sock) silica gel with the microscope. This will help to reduce the growth of fungi on the lenses. Note. A binocular microscope with a light system which can be connected to a rechargeable battery may be useful under field conditions. For such a microscope a battery adapter suitable for a 6 V or 12 V battery must be provided. Module 5: Tuberculosis (for 200 tests) Carbol fuchsin liquid stain1 or Basic fuchsin powder Methylene blue or malachite green Hydrochloric acid (concentrated) or sulfuric acid (25%) Loop wire holder Nickel chromium loop, 24 gauge Ethanol (if fuchsin powder used) Phenol (if fuchsin powder used) or Phenol crystals Optional: Tween 80 or Teepol 1 Quantity 1L 25 g 25 g 500 mL 2 5 500 mL 500 mL 250 g 500 mL In emergencies it might be better to use ready−made stain, available in bulk (5 L). Module 6a: Cholera bacteriology (for 50 tests) Rectal swab Cary−Blair medium (See Module 19 Stool specimen transport) TCBS medium, 500 g 39 Quantity 100 50 g 2 Nutrient agar Bacto Peptone, 500 g Disposable plastic Petri dishes, diameter 9 cm Test tube 13 mm x 100 mm Test tube cap, 13 mm test tube, plastic Disposable Bijou bottles with screw−caps Polyvalent or O−group V. cholerae−antiserum, 2 mL Agglutination slide, 10 wells Grease (wax) pencil 100 g 1 100 300 300 100 5 6 1 1 Incubators may be available in nearby laboratories or the local ambient temperature may be high enough for incubation. Module 6b: Cholera and enteric bacteriology (for 50 tests) DCLS agar or SS agar or Desoxycholate agar Kligler iron agar Lysine iron agar Motility indole ornithine medium Acetate agar Test tube rack, 40 tube, foam Bacteriologic needle and handle, nichrome Bacteriologic loop and handle, 3 mm, nichrome Alcohol or gas burner Fuel (alcohol) or Gas (may be local Butane) Antiserum, Salmonella polyvalent Antiserum, Salmonella Vi Antiserum, Shigella A Antiserum, Shigella B Antiserum, Shigella C Antiserum, Shigella D Test tube, 16 mm x 125 mm Cap, test tube, plastic, 16 mm Test tube, 13 mm x 100 mm Cap, test tube, plastic, 13 mm Quantity 500 g 300 g 200 g 200 g 100 g 20 2 2 1 500 mL 1 tank 5 mL 3 mL 2 mL 2 mL 2 mL 2 mL 100 100 350 350 Module 7: Urinalysis (for 100 tests) Quantity Biochemistry Protein test strip for protein 100 strips 1 Glucose test strip or all on one strip 100 strips 40 Strip test strip (bacteria) Haemoglobin test 100 strips 100 strips Microscopy Hand centrifuge 4 x 15 mL Tubes, conical, polypropylene, 15 mL Coverslips 20 mm x 20 mm Pregnancy test kit 1 10 500 1 kit If required Schistosoma haematobium urine microscopy: Swinnex filter holder 13 mm diameter (Cat No. SX00 02500, Millipore Ltd.) Polycarbonate membrane (15 m or 20 m pore size), Cat No. 110616 Sterilin Ltd Polycarbonate filter, 12 m pore size 1 2 100 100 Alternatively, reagent powders can be assembled as described in Annex 5. Module 8: Faecal parasites (for a large number of tests) Quantity Microscope 10 boxes of 72 slides Microscope 5 boxes of 100 coverslips, 20 mm x 20 mm Potassium 100 g iodide, analar Iodine, analar 100 g Sodium 500 g chloride Eosin Y 25 g Applicator 1 box of 1000 sticks Dropper 2 bottle, polyethylene, opaque, 15 mL Dropper 1 bottle, polyethylene, translucent, 15 mL Reagent 2 bottle, high density polyethylene, 41 opaque fitted with leakproof cap, 250 mL KATO1 test kit 1 kit (for Schistosoma ova) Cellophane 15 sheets coverslips (22 cm x 40 cm) or Water 1 roll wettable cellophane, 22 mm width Glycerol 500 mL Malachite 10 g green Metal sieve, 1 105 mesh or 105 nylon 1 roll mesh sieve or nylon mesh (102 cm x 25 mm roll) Stage 1 micrometer (specially engraved slide) total scale measures 1 mm, each of the 100 engraved dimensions is 10 m 1 Recommended for surveys Module 9: Blood parasites (for 1000 tests) Quantity Giemsa’s stain2 500 mL Field’s A stain, powder 25 g Field’s B stain, powder 25 g or RAL I stain, pre−weighed, 250 mL 1 bottle 555 II stain, pre−weighed, 250 mL 1 bottle Methanol AR or other pure 1000 mL grade, 250 mL 42 Blood lancet 1000 Buffer tablets, pH = 7.2 1 bottle or Buffer RAL pre−weighed for 1 1 bottle litre or Buffer ampoule 500 mL for 1 litre 1 ampoule (for Giemsa use only) Strips indicator pH paper 1−10 50 strips Optional: Sodium azide (0.1 % for Field’s 25 g stain preservation) For Microfilariae: Swinnex filter holder 25 mm diameter (Cat No. SX00 02500, Millipore 2 Ltd.) Polycarbonate membrane (3 m pore size), 25 mm diameter Cat. No. 1000 110612 Sterilin Ltd. Plastic container to hold 2.5 mL of EDTA anticoagulated blood 20 Polycarbonate membrane (15 m or 20 m pore size), Cat. No. 110616 Sterlin Ltd. 1000 1 2 For the powder form, it is recommended that suppliers provide pre−weighed reagents. Alternative: Wright−Giemsa rapid stain Module 10: Haematology (for 100 tests) Quantity White blood cells Counting chamber 2 (improved Neubauer) Coverslip, optically 5 plain, 20 mm x 26 x 0.4 mm Pipette, 50 L 2 or Pipette, 20 L (using 2 safety bulb) Hand tally counter (1 1 parameter) Turk solution 100 mL 43 Blood lancet Safety pipetter 110 4 Differential count Same items as 110 Module 9: Blood parasites Tubes to make WBC dilution (10 mL) Platelets Same items as Module 9: Blood parasites or Ammonium oxalate 1 10 g Haemoglobin Haemoglobinometer (see equipment) 1 Haematocrit Haematocrit 1 centrifuge (see equipment) Capillary tubes 120 (heparinized) for the centrifuge Sealing compound 1 pack for capillary tubes Module 11: Centrifuge Portable centrifuge with fixed rotor (battery driven) Portable haematocrit centrifuge with fixed rotor (battery driven) Haematocrit capillaries (size as advisable by the manufacturer) Centrifuge tube, plastic, screw−cap Sealing compound Quantity 1 1 1000 50 1 pack Module 12: Portable incubator Quantity GQF portable 1 laboratory incubator, 12 V d.c. Transformer, 1 110 V a.c. or 44 220 V a.c. to 12 V d.c. or WHO incubator or Millipore portable incubator (not suitable for use with Module 6: Enteric bacteriology) or Portable waterbath incubator (tubes only) 1 1 1 Module 13: Portable refrigerator Portable refrigerator, minimum volume 40 L (photovoltaic or gasoline) Cool box, minimum volume 5 L Ice bricks or similar with cool box Quantity 1 2 2 Module 14: Collection and transport of sera/blood specimens (for 100 specimens) No.41 Whatman filter paper Silica gel Plastic bag, re−sealable Blood lancet Dry tube, screw−cap (sera) Anticoagulant tube (blood) EDTA or sodium citrate or Li−heparin Needles 21 G/19 G Syringe disposable, 5 mL Labels, self adhesive 35 mm x 20 mm 1 Quantity 100 250 g 100 100 100 100 100 100 100 Supplied in paper sheets or paper discs. One basic unit will be at least 3 cm diameter. Instructions for use: see Annex 4. Module 15: Water purification Gravity water filter, used with sterasyl (self−sterilizing) ceramic 45 Quantity 1 elements (candle filter) Spare sterasyl candle, 18 cm Stiff bristled brush (to clean filters) Aluminium sulfate (or alum cake) pH paper, pH 1−11 or Deionizer using ion exchange cartridges (bench unit or hand unit) or Simple still 2 1 1g 2 sets 4 1 Module 16: Electrolyte analyser 1 Quantity Portable, photovoltaic ion selective electrolyte analyser Spare ion selective electrodes Reference buffer, 200 mL Capillary tubes, anticoagulant 1 1 1 1 bottle 2 boxes of 100 Optional Module 17: Cleaning, disinfection, sterilization and specimen disposal Field autoclave (pressure cooker), top loading; volume of 20 litres Primus stove Bucket (10−12 litres), may be obtained locally1 Incinerator (may be made locally) Detergent containing enzyme Detergent, ordinary Brush, scrub Bag for hazardous waste Bowl, plastic, may be obtained locally Iodophor (Povidione) Calcium hypochlorite Isopropanol 1 Quantity 1 1 2 1 2L 2 200 4 1L 1 kg 1.5 L Already included in the basic module. 46 Module 18: Bacteriology − Gram stain (For 200 tests) Crystal violet, powder Ammonium oxalate Carbol fuchsin (1/10 diluted), Safranin or neutral red Iodine, analar Potassium iodide, analar Acetone Methanol Mortar and pestle Grease (wax) pencil1 or lead pencils Frosted slides Dispensing containers for staining 100 mL, polyethelene, leakproof Gram stain pack (for 50 tests) Quantity 75 g 50 g 500 mL 20 g 20 g 20 g 1000 mL 2000 mL 1 set 2 5 220 4 1 pack 1 It is better to use frosted slides and lead pencils, as grease pencil is soluble in acetone and adheres poorly in hot climates under field conditions. Module 19: Stool specimen transport 1 (For 20 tests) Quantity 20 tubes Transport medium (Cary−Blair), 3 mL in 5 mL screw−capped tubes or Filter paper disc, 20 non−impregnated, 6 mm diameter Tube, 5 mL, 20 polypropylene, screw−cap, sterile Saline 50 Forceps 1 or Dacron swab 20 Tube, screw−cap 20 Saline solution 50 mL Labels, 100 self−adhesive 35 mm x 20 mm 1 47 Maximum transportation time for reliable results is 8 days at ambient temperature. Module 20: Sero−diagnostic test module Diagnostic kits (LA, COAG, ELISA), as required for prevalent diseases Microscope slides Bacteriologic loop and handle or Applicator sticks Dropper pipette Wax pencil Beaker, 250 mL Disinfectant, (calcium hypochlorite) Detergent Quantity 2 kits 2 boxes of 72 1 1 box of 1000 10 1 2 25 g 25 g Module 21: Fluorescence microscopy Quantity 1 Fluorescence objective, x50 oil or x60 oil or Portable 1 fluorescence microscope with x5 ocular Power supply for 1 either of the above Battery cables 1 set and clips Immersion oil, 28.5 g non−fluorescing Buffered 50 mL glycerine, pH 8.6 Microscope slide 2 boxes of 72 Coverslip, 22 28.5 g mm x 22 mm Coverslip, 22 28.5 g mm x 40 mm Auramine O 25 mL Fluorescent 25 mL 48 conjugate, anti−rabbit serum Rabbit antisera to selected infectious agents, each agent Phosphate buffered saline, pH 7.2, powder Bottle, plastic, 100 mL Beaker, 100 mL 5 mL 25 g 2 3 Module 22a: Blood transfusion (For simple testing, storage, and administration of 50 units of whole blood, or red cells) Quantity Equipment Tiles, porcelain Test tube rack, 30−hole, plasticized wire Refrigerator module Access to: Centrifuge Incubator (or waterbath) Microscope 4 4 1 Consumables Adhesive tape, zinc oxide, 75 mm x 5 m Aprons, disposable plastic Beakers, polystyrene, 250 mL Disinfectant, hypochlorite granules, 70 % Gloves, disposable Marker pens, permanent Microscope slides, plain, 25 mm x 75 mm Pipettes, plastic, reusable, 3 mL Pipettes, plastic, reusable, 5 mL Sample tubes, 10 mL, plain Test tubes, 75 mm x 12 mm Transfusion sets, with filter Wash bottles, polystyrene, 500 mL 2 roll 100 4 5 kg 50 pair 5 500 100 100 100 1000 60 4 Reagents Anti−A, monoclonal, 10 mL Anti−B, monoclonal, 10 mL Anti−D, monoclonal, 10 mL Anti−human globulin reagent, monoclonal, 10 mL 49 4 4 4 4 Sodium chloride, reagent grade Saline, low ionic strength, ready−made Access to: Deionized water 1000 g 500 mL Stationery Labels for blood bags Laboratory register Request forms 200 1 100 Module 22b: Blood transfusion (For collection, testing and transfusion of 50 units of whole blood) Quantity Equipment Forceps, artery Scales, spring balance Scissors Tiles, porcelain Test tube racks, 30−hole, plasticized wire Tourniquet Refrigerator module Access to: Centrifuge Incubator (or waterbath) Microscope 1 1 1 4 4 1 1 Consumables Adhesive tape, zinc oxide, 75 mm x 5 m Anticiseptic, Hibitane, 5 % per litre Aprons, disposable plastic Beakers, polystyrene, 250 mL Blood bags, single, CPDA−1, 450 mL Capillary tubes, 75 mm heparinized Cotton wool, absorbent, non−sterile Disinfectant, hypochlorite granules 70 % Gloves, disposable Lancets, disposable Marker pens, permanent Microscope slides, ground−edge, plain 25 mm x 75 m Needles, disposable, 22 gauge x 40 mm Pipettes, plastic, reusable, 3 mL Pipettes, plastic, reusable, 50 I Sample tubes, plain, 10 mL Sharps containers, disposable (10 L volume) Syringes, plastic, disposable, 10 mL 4 rolls 1L 1 4 50 100 500 9 5 kg 50 pairs 100 5 500 100 5 packs of 20 5 packs of 20 200 10 100 50 Test tubes, 75 mm x 12 mm Transfusion sets, with filter Wash bottles, polystyrene, 500 mL 2000 60 4 Reagents Copper sulfate solution, 1.053 s.g. Copper sulfate solution, 1.055 s.g. HIV test kits, rapid, simple HBsAg test kits, simple VDRL test kits, simple Anti−A, monoclonal, 10 mL Anti−B, monoclonal, 10 mL Anti−D, monoclonal, 10 mL Anti−human globulin reagent, monoclonal, 10 mL Sodium chloride, reagent grade Saline, low ionic strength, ready−made Access to: Deionized water 1L 1L 100 100 100 2 2 2 2 500 g 500 mL Stationery Donor cards Labels for blood bags Laboratory register Request forms 100 200 1 100 Chapter 8 Energy supply 8.1 General It is essential that a reliable energy supply is available to ensure continuity of the work in an emergency laboratory. Energy may be provided by the following sources: • combustion−powered generators • solar energy supply systems • energy modules. 8.2 Combustion powered generators Electrical energy can be provided by a fuel generator. The generator may be the combustion engine of a motor car or a separate generator. A separate generator, producing an alternating current of 110 V or 220 V, can usually generate more energy than a car engine, which provides a direct current of 12 V or 24 V. The electricity can be fed into rechargeable batteries (see 8.3.3). The type of current available will limit the selection of laboratory equipment; for example, an instrument that requires direct current can be supplied with energy from: • batteries • a direct current network 51 • an alternating current network with converter1. 1 A converter changes the type of current. The installation of a direct current electrical network is simple and biohazards do not occur during operation. For instruments working with low voltage direct current, the high voltage from the direct current network has to be converted by means of a transformer. Alternatively, for instruments running on alternating current, the direct current must be converted into alternating current by means of a converter. Converters are heavy and expensive instruments and significant losses of electrical energy occur in the conversion process. Therefore, it is preferable to use direct current appliances to avoid the need for a converter. Generators may not always be available. Even when a main power supply is accessible, the electric current may fluctuate or be subject to frequent breakdown. This can cause considerable problems for analytical equipment used in a laboratory. 8.3 Solar energy supply systems (photovoltaic systems) 8.3.1 Cost effectiveness An emergency laboratory with a small number of low energy consuming instruments can work with a small energy supply. For such a laboratory, a solar energy supply system meets the requirements better than a generator system. Moreover, the installation of a photovoltaic system eliminates fuel supply problems. Manufacturers of photovoltaic equipment are listed in Annex 9. At present, the investment cost of a photovoltaic system far exceeds that of a suitable generator system. Therefore, the installation of a generator system may be more cost effective in countries where a well developed oil supply network exists. In other countries, the installation of a photovoltaic system will provide a more reliable source of energy and one which requires less maintenance. Moreover, the running costs of a photovoltaic system are almost nil, counterbalancing the initial investment cost. A solar energy supply system, (Figure 8.1), consists of three components: • solar panel • electronic charge regulator • batteries. Figure 8.1 Solar energy supply scheme 8.3.2 Solar panels TYPES There are two different kinds of solar panel commercially available: crystalline silicon and amorphous silicon. The panels differ in their physical properties and cost. Amorphous silicon panels are less expensive but are 52 also less effective in producing electricity than crystalline silicon panels. However, it is expected that further development will improve the quality of the amorphous silicon panels. Some important differences in the properties of the panels are shown in Table 8.1. TABLE 8.1 Properties of commercially available solar panels Properties of commercially available solar panels Power of largest available panel Expected lifespan (years) Guaranteed lifespan (years) Mechanical stability Reliability State of development Power supply from 1 m2 Installation Panel with cells of crystalline silicon 70 W 25 10 Good Good Finalized 130 W Panel with cells of amorphous silicon 20 W 10 5 Good Variable In progress 60 W The power output of a solar panel is dependent on solar radiation and temperature of the solar cells. The output current of the panel will increase as the solar radiation increases. Conversely, the voltage will significantly decrease, resulting in a decrease of power, as the cell temperature decreases. The power output is maximal when the operating conditions for the panel are chosen at their optimum. The maximal power output is also called the peak power (Wp) of a panel. Solar panels must be installed so that they are exposed to light. Shadow will not obscure the panel. The panel should be positioned at an angle as close as possible to the degree of latitude of the site location; for example, if the panel is to be used in a country near or on the equator, the panel should be at an angle of at least 15°. However, if it is to be used at a latitude of 25°, the panel will need to be tilted to 25°. Place the panel on the sunny side of the building. The panel must face north if it is used in the southern hemisphere and south if it is used in northern hemisphere. The back of the panel must be freely ventilated. The minimum distance between the back of the panel and the surface of the supporting construction should be 5 cm to avoid overheating the panel, which will reduce the efficiency of the energy production. Solar panels are wired for 12 V direct current. 8.3.3 Electronic charge regulators A charge regulator is an essential part of the solar energy supply system (Figure 8.2). It controls the charging and discharging of the batteries automatically. When the battery voltage falls below the threshold during discharge, the instrument will be disconnected from the battery. On the other hand, if the voltage increases above a threshold when recharging the battery, the panel is disconnected from the battery. A good charge regulator adapts the maximum voltage of the battery to the change in temperature of the battery environment. This adaptation prevents loss of water in the battery from evaporation. It is important to keep a spare charge regulator in stock in case of breakdown. Figure 8.2 Electronic charge regulator Attention must be paid to the stability of the charge regulator under tropical conditions. It is advisable to choose a charge regulator with an integrated digital display indicating the battery voltage. 8.3.4 Batteries Lead Batteries 53 Solar energy systems require rechargeable batteries. These may be lead batteries or nickel−cadmium (NiCd) batteries. High efficiency lead batteries are preferred. A great variety of lead batteries are commercially available (see Table 8.2). Batteries with high efficiency have practical advantages, although they are more expensive than normal batteries. When purchasing batteries, 12 V batteries with the highest capacity (100 Ah) should be chosen. Maintenance−free lead batteries are commercially available, but are expensive. The development of this type of battery is still in progress, and it has not been thoroughly tested in tropical climates. For the time being, caution is advised in the use of maintenance−free batteries. Transportation It is important to remember that, in accordance with the regulations of the International Air Transport Association (IATA) [2], lead batteries for transportation by air must be empty of electrolytes. For safety reasons the same precaution should also be taken during any other form of transportation. Maintenance The daily discharge of lead solar batteries should not exceed 20 % of the total capacity of the batteries, otherwise the lifespan of the batteries, normally about 1100 cycles, will be shortened. If the batteries are repeatedly discharged up to 40 % of their capacity they will only last for about 600 cycles, although there are certain kinds of lead battery that can be discharged to 40 % of capacity, while lasting for about 3000 recharge cycles. For maintenance, the fluid level should be checked regularly and refilled with distilled water, as for car batteries, when necessary. High efficiency batteries cannot simply be replaced by normal car batteries in case of breakdown. When only car batteries are available to replace a defective high efficiency battery, the batteries of the energy storage system must all be replaced together with the same type of battery. TABLE 8.2 Specifications of batteries used for solar power supply Plate type Lead calcium Electrolyte type Liquid Maximum discharge 50% Discharge during 20% normal operation Voltage/cell 2V Self discharge rate Low Topping−up required Infrequent Capital costs Low Suitability for Not photovoltaic use recommended Nickel−cadmium (NiCd) batteries Lead calcium antimony (6 %) Liquid 80% 20% Lead calcium antimony (2 %) Liquid 80% 20% Nickel cadmium 2V Medium Frequent Mid−range Recommended 2V Low Infrequent Mid−range Highly recommended 1 V, 2 V High Minimal Very high Highly recommended Liquid 100% 20% NiCd batteries can be recharged by a solar panel. There are NiCd batteries that are the same size but have different capacities. The AA size NiCd battery is available from 500 mAh up to 700 mAh capacity. Batteries with the highest capacity should be chosen. Small NiCd batteries, type AAA to D, for use in instruments should be recharged in advance for continuous operation of a laboratory. The lifespan of NiCd batteries may be up to 1000 recharging cycles. Maintenance NiCd batteries do not always work reliably in tropical countries, causing problems to arise. The reason for this apparent unreliability is an increased rate of discharge, rather than less efficient recharging of the battery at higher ambient temperatures. This may be partially circumvented by taking the following precautions: a) NiCd batteries should be recharged just before being used and at low ambient temperatures (e.g. in a refrigerator or in a specially constructed recharging box). For example, only 62 % of the potential energy is made available from a NiCd battery that is charged at 54 40°C. b) Recharged NiCd batteries should be stored at low temperature as they have a high degree of self−discharge when stored at elevated temperatures. For example, a NiCd battery stored under dry conditions for two weeks at 40°C will have a residual capacity of 32 %. High humidity will accelerate the self−discharge of a NiCd battery. NiCd batteries have a ‘memory’ and are therefore less efficient if they are not fully charged and then completely discharged. A battery should not be put on the charger for a few hours only. It is better to carry a spare NiCd battery which can be put on the charger when the other battery is being used. 8.4 Energy modules 8.4.1 Basic energy modules A basic energy module can provide an independent small electricity supply. All batteries of types AAA to D can be recharged with the equipment of the basic energy module (Figure 8.3). In the field, the NiCd batteries can be recharged either by a car battery or by solar energy. The equipment for recharging batteries is listed in Module 2: Energy (Chapter 7). 8.4.2 Portable solar energy supply systems Various portable solar energy supply systems are commercially available (Table 8.3). The portable solar power station has a foldable solar panel and a charge regulator assembled in a medium−sized suitcase. Figure 8.3 Basic energy module equipment TABLE 8.3 Portable solar energy supply systems Item Size Costs Small solar battery charger Very small Small Inexpensive Advanced solar battery charger (prevents over charging) Battery charger Small solar power station Small Brief case Less expensive Less expensive Expensive Batteries to be used 4 AA batteries only All types of NiCd battery All types of NiCd battery 6 V d.c. 12 V d.c. Power supply Integrated solar panel Separate solar panels 11−32 V d.c. car battery Foldable solar panel delivers 140 Wh/day 8.5 Calculation of the energy requirements of an emergency laboratory The energy demand of a laboratory is determined by the number of electrical instruments. Solar energy is recommended as a source of energy for a low energy demand. On the other hand, fuel−powered generators should be considered if the power demand for a laboratory is more than 500 W. The flowchart in Figure 8.4 can be used to decide what kind of energy supply should be used. 55 The investment cost of a solar energy supply system is high. Therefore, the calculations for energy requirements should be made carefully in order to ensure that the power produced meets the energy demand. The daily energy demand is calculated from the average daily energy consumption of each item of electrical equipment. This figure is used to calculate the size of the solar energy supply system, including the number of solar panels and the battery capacity (see Table 8.4). An emergency laboratory will normally have the following electrical items: • light • refrigerator • microscope • centrifuge • colorimeters • incubator The calculation of the daily energy demand for a laboratory equipped with these items is explained below. Figure 8.4 Energy supply flowchart for laboratory equipment TABLE 8.4 Calculation of energy demands and size of a solar energy supply system Equipment 56 Power demand (W) 11 50 Light (4 bulbs) Refrigerator (110L) Microscope HCT−centrifuge Blood centrifuge Colorimeter Incubator Total Notes to Table 8.4. 20 10 30 4 30 Daily operating hours of equipment 12 24 8 3 3 4 24 Daily energy demand (Wh) 528 600 80 30 90 16 360 1704 Wh Number of photovoltaic Battery standard modules capacity (Kwh) 3.8 2.6 4.3 3.0 0.6 0.2 0.6 0.11 2.6 13.2 0.40 0.15 0.45 0.08 1.80 8.48 KWh 1. Low energy consumption light bulbs should be used. These bulbs emit about 4 to 6 times more light intensity for a given energy consumption than conventional bulbs. For example, a low energy 11 w bulb emits as much light as a conventional 75 w bulb. Although low energy consumption bulbs are more expensive than conventional bulbs, their lifespan is far longer. For solar powered systems, ordinary car headlight bulbs can be used if no low energy consumption bulbs are available. Note Spare bulbs should be kept in stock, one for each lamp. 2. The calculation for a refrigerator is based on the use of a compressor refrigerator. The energy supply is based on a maximum of 12 hours per day. This is an arbitrary assumption, which may vary according to the local temperature conditions (see also Chapter 9). 3. The number of solar panels required is calculated from the daily energy requirement and the energy that can be provided by a standard solar panel. The standard solar panel provides 140 Wh during a day. This panel has a maximum peak power (Wp) of 50W. The number of panels with Wp differing from the standard panel must be calculated accordingly. 4. In calculating the battery capacity, it must be remembered that only 20 % of the total energy capacity of the lead battery should be made available for daily use. 5. The purchase cost of a solar energy supply system comprises the costs of the solar panels, charge regulator, batteries, and installation material. If the expected daily operating hours of an instrument are different from those listed in the table, or if instruments with a different power consumption are used, the daily energy demand can be calculated using the following formula: Daily energy demand = number of instruments × power demand × daily operating hours Example: three lights and a microscope are used in a laboratory. Light (3 lamps) 3 × 11 W × 8 h = 264 Wh Microscope 1 × 20 W × 4 h = 80 Wh Total daily energy demand = 344 Wh To set up a solar power system for the laboratory the solar peak power required and battery capacity have to be determined. Required solar peak power 57 Total storage capacity of the batteries = Daily energy demand × 5* = 344Wh × 5= 1720Wh Battery capacity required of a 12 V battery system * The coefficient 5 results from the fact that the battery can only be discharged by 20% (1/5), if appropriately used. The energy requirement of a solar power system for the example described would be therefore as follows: Solar panels 123Wp 12 V battery 143Ah Solar charge regulator 12 V, 123Wp Chapter 9 Laboratory equipment 9.1 General The requirements of laboratory instruments used in an emergency laboratory are different from those used in a routine laboratory. Fully automated equipment is too sophisticated. The instruments must be reliable and maintenance must be easy. In this chapter the following laboratory equipment is discussed: • microscope • centrifuge • colorimeter and haemoglobinometer • incubator • refrigerator • water purification systems. Annexes 8 to 16 list suppliers and manufacturers of laboratory equipment. 9.2 Microscopes In many emergency situations the microscope is the instrument which is used most in the laboratory. The procurement of a microscope is a long−term investment. Therefore, price should not be the primary consideration. Reliable, medium−priced microscopes are commercially available. When purchasing a microscope, attention should be paid not only to the magnification but also to the resolution and curvature of the field, which are important criteria. These are not satisfactory in less expensive microscopes, which may also have mechanical problems. Microscopes should be supplied with a socket in the base where a plug from a 12 volt battery can be connected. The microscope should be supplied with a stable light source connected to a battery which can be charged by a solar panel or local power supply. The case should be made out of strong plastic with an interior that is moulded and foam−lined. The microscope base should be held firmly in place with a screw. The advantages and disadvantages of different microscopes and their accessories are outlined in Table 9.1. The addresses of suppliers are listed in Annex 10. 58 Work conditions should be taken into consideration when choosing a microscope. A standard binocular microscope is recommended for a mobile or stationary laboratory, but a monocular model can also be used if resources are limited. A small and compact microscope (e.g. McArthur microscope) can be used for a portable laboratory. Table 9.2 lists some properties of commercially available microscopes. TABLE 9.1 Advantages and disadvantages of portable light microscope types and accessories Type/Accessory Monocular Binocular Disadvantages Tiring over longer periods of use Higher investment cost More light needed Mirror lamp Allows the microscope to be used in the In poor sunlight an external light absence of electricity supply; inexpensive source may be required Built−in base lamp Gives good, constant and even field of More expensive than a mirror light Bulbs may be difficult to obtain Controllable light intensity Requires an external power source Built−in base socket for 6 V/12 V Usable in the field without alternate for battery connection current supply TABLE 9.2 Some properties of commercially available microscopes Microscope Gillet and Sibert Olympus CH2 Zeiss, KF2 Nikon LSK McArthur Optics Very good Very good Excellent Excellent Very good Advantages Less expensive Easy to use Light and energy sources All power sources Mirror, 110V, 220V All power sources All power sources AA batteries, mirror 9.3 Centrifuges Centrifuges are needed to: • measure haematocrit (PCV) • separate blood cells from plasma • concentrate casts and cells in urine • concentrate cells in CSF. Centrifuges can be driven mechanically, by batteries or by a main source of electricity. While the separation of cells or casts from body fluids requires only a low speed centrifuge, haematocrit centrifuges are used for quantitative measurement and must have good stability to maintain a high and constant rotor speed. Determination of haematocrit is a useful method for diagnosis of anaemia and obviates the need for haemoglobin determination. Battery−operated portable and bench centrifuges are available that can also be supplied with solar energy. Some of these instruments can also operate at 110 V/220 V a.c. The energy required to run a centrifuge increases proportionally to the weight of the specimen to be centrifuged. Therefore, haematocrit centrifuges require less energy than other centrifuges. Electrically driven centrifuges have practical advantages for routine work. However, they are more expensive and require a continuous supply of electricity. Portable mechanical centrifuges have also been developed. Some properties of portable centrifuges are listed in Table 9.3. The addresses of suppliers are listed in Annex 7. TABLE 9.3 List and specifications of commercially available mechanical and battery−driven haematocrit and multipurpose centrifuges Name 59 Type1 Voltage Specimen capacity Company Ames microspin Hettich EBA11 1100 − Hemata Stat C−70B H Multipurpose centrifuge M Saturn − Multipurpose centrifuge Spectrum Jabus Rickman Multipurpose centrifuge M − − M 6 V d.c. 12 V d.c/ 110−220 V a.c. 12 V d.c./ 110−220 V a.c. 12 V d.c./ 110−220 V a.c. 12 V d.c./ 220 V a.c. 6 V d.c. Mechanical Mechanical Mechanical 6 4−8 Bayer Diagnostics Hettich 6 Separation Technology Inc. 20 Technical Research Association Roy Rickman 2 10 20 4 Dr Kendall Smith Roy Rickman Roy Rickman Solmedia Tropical Laboratory Supplies 1 H haematocrit M multipurpose 9.4 Colorimeters and haemoglobinometers Colorimeters are used for the quantitative determination of haemoglobin, serum glucose and sometimes other analytes in an emergency laboratory. Haemoglobinometers are designed to measure only haemoglobin. Haemoglobin can be measured by a variety of means including: • comparative estimation of the transmission of daylight through a thin capillary blood film; • comparative estimation of light transmission of haemolysed undiluted blood by means of a portable battery−driven haemoglobinometer; • determination of haemoglobin in diluted blood after chemical reaction. The accuracy of haemoglobin determination is highest with methods using chemical reactions such as the conversion of haemoglobin to cyanhaemoglobin, and is lowest in the comparative procedures. However, in emergency situations the accuracy in haemoglobin determination of some comparative methods may still be acceptable. For example, the Lovibond method using undiluted blood has been found suitable. Comparative estimation of haemoglobin after conversion of haemoglobin into acid haematin has an unacceptably low accuracy and precision (e.g. the Sahli method). Table 9.4 outlines some of the available techniques for detecting anaemia in the field, together with their advantages and disadvantages. Measurement of haemoglobin after chemical reaction requires additional disposables and pipetting steps that can introduce error. Table 9.5 lists some features of commercially available portable, battery−operated colorimeters and haemoglobinometers. The addresses of manufacturers are listed in Annex 12. TABLE 9.4 Advantages and disadvantages of some techniques used for anaemia detection Technique Advantages Cyanmethamoglobin Standardized, good for large−scale screening, accurate Oxyhaemoglobin Sahli Haematocrit Accurate, simple reagents Quick, simple, inexpensive Fast, accurate, simple, well−standardized Disadvantages Difficult to make reagents, solutions require refrigeration, expensive, labour intensive, requires colorimeter No international standards, requires colorimeter Inaccurate, subjective, unreliable, difficult to use Requires haematocrit, centrifuge and capillaries 60 Copper sulfate Talquist Filter paper Clinical examination Accurate, inexpensive easy to use Inexpensive, easy to use Inexpensive, easy to use Inexpensive, reliable Lovibond1 Undiluted Accurate2, no reagents required, simple, reliable, no battery, no disposables Difficult to make solutions Inaccurate, unreliable Inaccurate Sensitive to severe anaemia, inaccurate, not quantitative Moderately expensive 1 This method, without dilution, is extensively used by Médecins sans Frontières, with a glass wedge−slide. 2 In contrast to the normal Lovibond method, using ammonia as a diluent, which is inaccurate. TABLE 9.5 List of battery−operated portable haemoglobinometers Name Digital display Biotron Yes Delphi Yes HemoCue Yes Miniphotometer MPA Yes Miniphotometer XJY 1 Yes WPA CO 700 D Yes Primechem, Nutrichem Yes Minilab PC Yes Miniphotometer Yes Chematests Yes Light source Wavelength LED 564 nm LED 555 nm LED 546 nm LED 546 nm LED 560 nm Tungsten 10 wave−lengths LED 580 nm LED 546 nm Halogen Filter Tungsten 505 nm Manufacturer Biotron True Test Ltd. HemoCue Karl Hecht Beijing Film Machinery Industry Walden Precision Apparatus Primecare Bayer Diagnostics Dr Lange S.E.R.O.A SA LED Light−emitting diode 9.5 Portable incubators The field applications of incubators include diagnostic bacteria culture, parasite culture in human body fluids and bacteriological water analysis. A variety of field incubators have been developed that meet these requirements. Four field incubation systems are discussed here. a) WHO portable incubator The WHO incubator is supplied with the accessories necessary for water testing and a 12 V d.c. battery. It can also be operated from a.c. mains (via rectifier) or from a solar panel system. It is approximately 50 cm x 35 cm x 30 cm in size and lightweight. It can be used for any incubation from ambient to 50°C. (See Annex 13 for supply.) b) GQF Portable laboratory incubator The GQF incubator can operate with 110 V or 220 V a.c. or with 12 V d.c. Maximum energy requirement is 30 W. Its external dimensions are 43 cm x 36 cm x 43 cm and those of the chamber 35 cm x 27 cm x 26 cm. It can be operated from ambient to 45°C, but the most efficient operating range is 35−37°C. It comes with a dial thermometer. It is made of thermal plastic with an outer shell of high impact styrene and weighs approximately 3 kg. (See Annex 13 for supply.) c) Millipore portable incubator This incubator was developed for water sanitation bacteriology using membrane filter technology. It can be adapted for other uses, especially enrichment broth culture, but it has 61 limited capacity. It operates on 6V, 12 V and 24 V d.c. or 110 V/220 V a.c. The chamber is approximately 15 cm x 15 cm x 15 cm. It has a sturdy case and weighs approximately 4 kg. Incubation temperature ranges from ambient to 45°C. d) Portable waterbath incubator This instrument is 30 cm x 13 cm x 13 cm in size and weighs 1 kg. It operates on one of two interchangeable heaters, on 12 V d.c. or 110 V/220 V d.c. The heaters can be easily exchanged to accommodate a local power source. The instrument was specifically designed to incubate tubes of selective enrichment broth, 16 at a time. The holding holes in the lid adapt automatically to test tubes of various diameters. It comes with a dial thermometer and temperatures can be adjusted from ambient to 45°C. e) Other incubators There are other instruments available which can be used either as a refrigerator or as an incubator. Their energy demand is very high and they should be used only where the energy supply is inexpensive. 9.6 Refrigerators 9.6.1 General Electric refrigerators have high energy consumption. They are available in 110V/220V a.c versions and 12 V/24 V d.c. versions. Refrigerators working on the absorption principle cool without making noise. However, they require much more energy than refrigerators working on the compressor principle. Refrigerators operating on 12 V/24 V d.c. usually have no freezing compartment and so consume considerably less energy. Refrigerators operating on 110 V/220 V a.c. may have an integrated freezing compartment and if so, consume considerably more energy. Refrigerators with a top opening preserve their temperature better than refrigerators with a front opening, and therefore consume less energy. There are also small refrigerators (18 litres) available which can be used for incubation to keep things warm. They are powered by 12 V d.c. or 110V/220V a.c. As their energy consumption is very high, they are only recommended where cheap electricity is available. A suitable refrigerator for a field laboratory has a cooling chamber of 120 litres or less. The size of the refrigerator should not be larger than necessary, because the dead volume in the cooling chamber must also be kept at low temperature, which requires additional energy. If blood for transfusion is to be stored in the refrigerator, it must maintain a temperature range of +2°C to +8°C and have a temperature monitoring system. Manufacturers of refrigerators, including solar powered refrigerators, are listed in Annexes 14 and 15. 9.6.2 Installation and use The correct installation and use of a refrigerator can reduce energy consumption considerably. When installing a refrigerator, it should placed in a position that allows maximum air circulation at the condenser. It should be placed at least 10 cm away from the wall behind it and should not be covered. The air convection behind the refrigerator can be improved by providing a suitable small ventilator fan. The energy consumption of a refrigerator depends mainly on the frequency of use. The degree of heat exchange is proportional to the number of times the door is opened and for how long. These facts are important to remember in daily use, particularly if the refrigerator runs on photovoltaic energy. 9.7 Water purification systems Pure water is a basic requirement for laboratory services. Pure water is needed to prepare stains and other reagents, for equipment and general cleaning, and for sterilization. Good sources of clean water are rain, collected from a roof, or springs. Make sure that the container used for collection and storage of water is 62 protected by a cover or lid at all times. A list of manufacturers of water purification systems is give in Annex 16. A number of simple methods can be used to treat water for laboratory use. a) Removal of suspended solids 1. Place the water in a container such as a tank or bucket, and leave it to stand overnight. Slowly pour off the clearer supernatant water, and discard the muddy part at the bottom. 2. Add aluminum sulfate (alum cake) to the supernatant water at a rate of 5 g to 1 bucket (10 litres) of water. Leave it to stand for 20 minutes, then carefully pour off the clear supernatant water. b) Adjustment of pH 1. Test clear water with a pH paper strip. 2. If the pH is above 8.0, add dilute hydrochloric acid (0.1 molar) while continuously stirring to lower the pH to 7.0. If the pH is low, add dilute sodium hydroxide (NaOH) solution while continuously stirring until the pH is 7.0. c) Sterilization of contaminated water The pores of ceramic filters quickly become clogged by muddy water. The water should be treated first for excess suspended solids. Add 500 mg alum, or alum sulfate, to one litre of water, mix, allow to settle and then pour off the supernatant water into the filter. Filter the clear water through a filter with a pore size greater than 0.22 m, e.g. a gravity ceramic filter such as the Doulton A1 or LP Model. This removes all sediment, ova, cysts, protozoa, and bacteria (but not viruses). The filter does not remove inorganic and low molecular organic solutes. d) Distillation In water stills, water is purified by evaporation and steam or water vapour condensation. The condensed steam is collected as distilled water. Water stills remove non−volatile and all inorganic material. Stills with a water flask and heating device are costly to maintain. They require a source of cool water and a reliable energy source. Water with a high salt content cannot be distilled with this method. A simple solar−powered water still can be built using local materials to overcome pure water supply problems in sunny remote areas (Figure 9.1). A glass sheet covers a clean plastic container with a large surface area (1 m x 1 m) at an angle of about 30°. Water in the container is evaporated by the sun, condenses on the glass cover, and drops into a water collector placed at the lower end. From there the distilled water drops into a flask. In hot climates, 2−7 litres of distilled water with a conductivity of 30−60 S can be produced daily from a solar still with a surface area of 1 m. e) Demineralization Demineralizers contain ion−absorbing resins, which remove inorganic and organic ions from water. Demineralizers operate without an energy input, but they do not produce sterile water and do not remove all organic impurities. They may be subject to bacterial contamination, particularly in a warm environment. Their capacity for demineralization of water is limited, and they require routine control and maintenance. Portable demineralizers are commercially available. Good quality water can also be obtained by means of carbon filters and reverse osmosis. Carbon filters have a limited capacity and the filters, resins or membranes have to be replaced. 63 Figure 9.1 Solar still Note. The Doulton and British Berkfeld sterasyl candle (ceramic element) filters are self−sterilizing and last for 6−12 months. They require weekly cleaning with a stiff−bristled brush and clear water (with no detergent). Chapter 10 Supply of blood for transfusion in emergencies 10.1 General The first decision to make in any emergency is whether blood for transfusion is required. This will depend upon factors such as: • the type of patient involved (e.g. epidemics or natural disasters such as floods are not likely to result in conditions requiring urgent blood transfusions); • the availability and accessibility of blood from existing blood transfusion services; • the availability of plasma substitutes, or volume expanders, such as crystalloid or colloid solutions. These factors should be considered during preliminary assessment of the emergency situation. 10.2 Situations involving patients with acute blood loss 10.2.1 Basic equipment and consumables for blood transfusion in emergency situations Crystalloids and colloids must always be available in situations involving patients with acute blood loss. The decision to provide such supplies should be based on the preliminary assessment and they should be included in emergency surgery/pharmaceutical kits. For details of equipment and consumables for blood transfusion needed in emergency situations, see Modules 22a and 22b: Blood transfusion (Chapter 7). 64 The management of patients with acute blood loss may involve any or a combination of the following: • plasma substitutes • blood supplied from existing transfusion services • blood from selected donors on site • blood salvage. 10.2.2 Plasma substitutes The infusion of plasma substitutes (crystalloid or colloid solutions) must always be the first choice for volume replacement therapy in patients with acute hypovolaemia due to haemorrhage. The administration of such solutions will not normally involve the laboratory service. Guidelines on the indications for use of crystalloids and colloids and on the general management of acute haemorrhage can be found in Plasma and Plasma Substitutes in Developing Countries [3]. 10.2.3 Blood supply from existing transfusion services If plasma substitutes are not available or have been used and blood is still required, the patient must be transferred to a health facility where safe blood is available. Alternatively, the blood must be transported to the site depending upon the number of patients involved. In most emergency situations involving large numbers of patients, blood should be transported from existing transfusion services, but certain prerequisites are necessary: • an adequate supply of blood • adequate communications • adequate transport facilities whether by road, rail, river or air • adequate cold chain for transport and storage of blood • power supply for storage (see equipment list of Module 2: Energy) • materials for rapid blood typing (see Module 22a: Blood transfusion). 10.2.4 Blood from selected donors on site In emergency situations where blood from existing transfusion services is not available, it may be necessary to take blood from selected donors on site, but this should not be done without the basic materials necessary to collect, test and transfuse blood safely. Donors should be selected, as far as possible, to comply with standard selection criteria (see 10.4) and must be grouped and tested for human immunodeficiency virus (HIV), Hepatitis B surface antigen (HBsAg) and syphilis, using simple, rapid tests (see equipment and consumables of Module 22a: Blood transfusion). 10.2.5 Blood salvage In emergency situations where plasma substitutes are not available and there is no access to a blood supply of any kind, autologous transfusions using blood salvage techniques may be employed with basic equipment and training. These procedures would not usually involve the laboratory services. Guidelines on blood salvage can be found in the publication Autologous Transfusion in Developing Countries [4]. 10.3 Blood transfusion in refugee camps Blood from existing transfusion services should be the first choice for emergency transfusion in refugee camps. Where such blood is not available, it may be necessary to collect blood from ‘walking donors’. A ‘walking donor’ system involves the selection, grouping and screening of voluntary potential donors who can provide blood in an emergency. The prerequisites involved in setting up such a system are: • access to testing facilities for initial grouping, screening for relevant transmissible agents such as HIV, HBsAg, syphilis etc., and regular monitoring of donors; • basic equipment and consumables for collecting and transfusing blood; 65 • basic laboratory services on site for simple grouping and compatibility testing and rapid, simple testing for HIV, HBsAg and syphilis where relevant; • adequate on−site record system. 10.4 Bleeding donors on site 10.4.1 Selection of donors International criteria (for example those of WHO) should be applied as far as possible. • Weight: local standard • Haemoglobin (Hb) local standard • Health status: donor should be interviewed; haemoglobin and temperature should be checked Exclude or avoid as far as possible: • younger sexually active males and females • women of childbearing age. Include and prefer: • older children • men over 50 • women past the menopause. 10.4.2 Testing blood donors Donors are tested for ABO and Rh blood groups. They are also tested for transfusion transmissible agents, including HIV, HBsAg, syphilis and malaria (where appropriate). Transfusion recipients are also tested for their ABO and Rh blood groups. 10.4.3 Crossmatching Saline room temperature immediate spin method should be done, followed up by an anti−human globulin test, if possible. 10.4.4 Blood collection volume The local standard should be applied, based on 8% of blood volume. 10.5 Summary The first choice of therapy for volume replacement in emergencies must always be plasma substitutes and, if necessary, blood from existing transfusion services. Blood from other sources should only be used when absolutely necessary. Blood transfusion must always be used appropriately and should always be the therapy of last resort, never the first. Chapter 11 Collection, storage and transport of specimens 66 11.1 General While many medical diagnostic laboratory tests can be done at the patient’s bedside, at small clinics, or in the field, there may be occasions that require more elaborate or extensive tests. This potential need can be met in several ways. The patient can be transported to a central medical facility, or specimens obtained from the patient can be sent to a laboratory for analysis. The latter is usually more convenient and cost−effective. For specimens to be stored and transported it is essential that: • the appropriate specimen is taken and correctly labelled; • a suitable container, with transport medium where necessary, is used; • appropriate storage temperatures are used; • an effective system of transport from the field is established; • appropriate safety precautions are taken; • specimens to be transported to another country are packed correctly, according to current IATA regulations. TABLE 11.1 Specimen transport: purposes, methods, and conditions Specimen Bacteria CSF Vaginal, urethral secretion Faeces Purpose Specimen amount Blood culture Tube/sodium polyanethol sulfonate 8.3 mL Serology Filter paper/dried 1−2 drops Culture, bacteria Bottle/Transgrow medium 1−2 mL Tube, Cary−Blair medium or 1−2 mL Amies medium Serodiagnostic test Tube/sterile 1 mL Culture, Bottle/Transgrow medium Swab gonococcus Culture bacteria Container/preservative Tube/Cary−Blair Medium or Amies Swab Medium Tube/Cary−Blair medium or Amies Swab medium Tube/MIF preservative (5mL) 1−2 g Microscopy, protozoa, worm eggs Hair, nails, Microscopy, fungus Envelope or screw−cap tube/none Several skin scraping pieces Pus Culture, bacteria Tube/sterile 1 mL Tube/Cary−Blair medium or Amies Swab medium Serum Biochemistry Tube/sterile 5−7 mL Serology test Tube/sterile, merthiolate 1:5000 or 5−7 mL sodium azide 1 g/L Sputum Culture, Bottle/0.6 % cetylpyridinium 5−10 mL tuberculosis bromide (25 mL) Throat Culture, C. Tube/silica gel Swab diphtheria Tube/Loeffler’s medium Swab Culture, Tube/silica gel Swab Streptococcus Serodiagnostic test Tube or envelope/none Swab Urine Culture, bacteria Bottle or tube/sterile 10 mL Culture, bacteria or Tube/boric acid 1 % 10 mL chemistry 67 Holding temperature RT1 RT RT to 37°C RT Storage time 24 hours 3 weeks 4 days 2 days 4°C to RT RT to 37°C 1 week 4 days RT 2 days RT 2 weeks RT Indefinite RT 1 week 4°C to RT RT 1 day 3 days 4°C to RT 4°C to RT 2 days 2−3 days RT 10 days RT 3 days RT to 37°C RT 24 hours 3 days RT 4°C to RT 4°C 3 days 1 hour 2 days Count, Tube/commercial bleach, 0.2 mL Schistosoma eggs (4 drops); hydrochloric acid, 0.1 mL (2 drops) 1 10 mL RT Indefinite Room temperature (RT) is 20°C; storage time will be less if RT is higher than this. Several systems for specimen transport are described. Preservatives are included in some of these. The following containers can be used: • envelope • screw−cap tube, clean • screw−cap tube, sterile • wide−mouth screw−cap jar • syringe • bottle • plastic bag, sterile, ‘Whirl−Top’ • plastic bag, zip−lock • double screw−cap cylinder (for international transport and high risk specimens). Information regarding the transport of various specimens is given in Table 11.1. 11.2 Collection and storage 11.2.1 Microorganisms Various transportation systems and preservatives are used to maintain the viability of microorganisms while suppressing their growth in specimens. Preservatives will also suppress the growth of contaminating organisms in the specimen while keeping the pathogenic bacteria alive. Any clinical specimen should be transported to the reference laboratory as soon as possible. The fresher the specimen, the greater the likelihood of a successful laboratory analysis. Specimens thought to contain dangerous pathogens must be handled and transported with great caution. Examples of such specimens and diseases suspected are outlined in Table 11.2. These specimens should be sealed in containers with tightly fitting lids or in sealed double plastic bags. TABLE 11.2 High risk specimens1 1 Specimens from viral haemorrhagic fever cases are a serious infectious biohazard. Minimize handling of these specimens in the field. Wear protective gloves, clothing and respirators when handling specimens and caring for patients. Specimen Disease suspected Blood AIDS, hepatitis, plague, viralhaemorrhagic fever Faeces Typhoid or paratyphoid fever, cholera Sputum Tuberculosis, plague, anthrax Ulcer or pustule fluid Anthrax, treponematosis Urine Viral haemorrhagic fevers1 Preservation methods for microorganisms and other substances in clinical specimens vary widely. Some methods work with moisture while others require the dry state. Optimal preserving temperatures also cover a wide range. While refrigeration may be best for many specimens, it is bad for others. During transportation the infecting pathogenic microorganisms should be kept alive while limiting or eliminating growth of non−pathogenic commensals that may be present in the specimen and that may overgrow and mask the presence of pathogens. For specimens intended for chemical or serological analysis, complete suppression of bacterial or fungal growth is a prerequisite. Any specimens for microbiological analysis should be collected prior to antimicrobial therapy. For some specimens, like skin scraping, nail clippings or hair, no special preservation methods are needed. Pus can be kept in a plain sterile tube for 1 day, preferably at 4°C. Organisms requiring moisture survive but 68 do not grow in transport media such as Cary−Blair medium and Aimes medium, which are designed to support the life of bacteria. They maintain the viability of enteric bacteria, including V. cholerae, Yersinia pestis and the plague bacillus. These media also preserve meningococci and gonococci in specimens over short periods at room temperature. Less fragile bacteria remain alive in these transport media for several days. Drying is a good way to preserve certain bacteria on swab specimens. These bacteria include C. diphtheriae, S. pyogenes, and Staphylococcus aureus. Throat swab specimens can be preserved by drying in silica gel. Mycobacteria in sputum specimens are preserved in a solution of cetylpyridinium bromide or chloride. The solution tends to kill commensal bacteria in the specimen, liquefies the sputum in 24 hours, and preserves the viability of M. tuberculosis for at least one week. Bacteria remain viable and chemicals can be preserved in urine treated with boric acid (1 % V/V). The urine specimen should also be refrigerated. Transgrow medium, an enriched medium containing antibiotic, is the best to maintain the viability of N. gonorrhoeae and N. meningitidis. Once inoculated, the bottles or tubes should be kept at 35−37°C. Loeffler’s medium (Loeffler serum agar) is a good medium for transporting throat swab specimens at low temperature for diphtheria diagnosis. If kept at 35−37°C, diphtheria bacilli will grow. It also has the advantage that C. diphtheriae grown on this medium will show typical volutin granules when stained by the Albert method. Complete suppression of bacterial growth is advisable for specimens destined for chemical or serological tests. Collecting and storing the specimens under sterile conditions may be difficult under field conditions. Chemicals can be added to these specimens to suppress bacterial and fungal growth. It is also helpful to store these specimens at 4°C or below. Parasites in specimens to be transported to a reference laboratory or base of operations are usually completely preserved. The merthiolate−iodine−formaldehyde (MIF) preservation method is easy to use and is effective. Faecal specimens can be preserved in MIF and will last for an indefinite period. Schistosoma haematobium eggs in urine can be preserved indefinitely with commercial household bleach (2 mL per 100 mL urine) or hydrochloric acid 0.1 molar. 11.2.2 Blood For the collection of blood specimens (see Figure 11.1), patients may come to the laboratory, or blood films can be taken directly onto slides during surveys in the field. Blood specimens for bacteriological culture can be preserved using liquoid (sodium polyanethol sulfonate) in normal saline solution. The tube and preservative must be sterile. Liquoid is an anticoagulant and also neutralizes bactericidal substances in fresh blood. It can be autoclaved in the collection tube for sterilization. For approximately 8.3 mL of blood sample, 1.7 mL of 0.35 % liquoid is used. Blood specimens can also be preserved for subsequent serology tests. Materials needed are lancets, Whatman No. 1 filter paper (4 cm x 3 cm strips) and small plastic bags (see Annex 17). Capillary blood is obtained by the standard fingerstick method. A large drop or several drops of blood are placed in the middle of a filter paper strip. The filter paper absorbs the blood and is left to dry completely in the air. The edge of the paper is labelled with the patient’s name or number. The dried filter paper blood sample is transferred into the small plastic bag. Other storage methods can also be used for large surveys. The dried blood can be used for such things as serology tests for syphilis, yaws, and protozoan diseases. 69 Figure 11.1 Blood collecting box 11.2.3 Cerebrospinal fluid (CSF) Specific aetiologic diagnosis of meningitis cases requires culture of CSF or serodiagnostic tests on CSF, e.g. coagglutination or latex agglutination. The bacteria that cause meningitis tend to die quickly in specimens, especially N. meningitidis. The preferred medium for transport of meningococci is Transgrow medium, in which the bacteria will grow at 35−37°C, but a transport medium that maintains viability without growth, like Cary−Blair medium or Amies medium, can also be used. These transport media also help preserve the viability of other bacteria that commonly cause meningitis such as Haemophilus influenzae and Streptococcus pneumoniae. Specimens should be kept at 35−37°C if possible, never in the refrigerator. The antigens of bacteria that commonly cause meningitis are quite stable and will not deteriorate over long periods of time, even at high (40°C) or low (freezing) temperatures. The CSF specimen should be kept in a sterile tube to avoid overgrowth by other bacteria. CSF itself is a good culture medium, and antigen concentration of the infecting bacteria may be enhanced at incubation temperatures. Preservatives such as merthiolate 1:10 000 (0.01 % V/V) or sodium azide 1:1000 (0.1 % V/V) can also be used to suppress microbial growth. 11.2.4 Exudate Diagnosis of acute gonorrhea in the male can often be made from a Gram−stained direct smear of exudate from the urethra. However, culture is usually necessary to diagnose gonorrhea in the female and to diagnose chronic gonorrhea. Transport of specimens is done on Transgrow medium, at 35−37°C if possible. The specimen is taken and streaked on the surface of the medium with a swab or bacteriological loop. A non−growth transport medium such as Cary−Blair medium or Amies medium can also be used, the sampling swab being thrust into the tube of medium and broken off at the tube lip before capping the tube. This method is a second choice for exudate specimen transport. 11.2.5 Faeces For some investigations of diarrhoea, culture of enteric pathogens at a laboratory will be necessary. Transport media such as Cary−Blair medium or Amies medium are excellent for preserving the viability of enteric bacteria, including cholera vibrios. A swab with a sample of faeces is thrust into a tube of transport medium and is kept at room temperature until it can be cultured. In field surveys for parasites, faecal specimens can be collected and brought to a laboratory for examination. A good fixative for this purpose is MIF. It is both a preservative and a stain. One or two grams of faeces are emulsified in 5 mL of MIF solution. Protozoa trophozoites and cysts both become stained and can be identified in wet mounts. For many specimens, filter paper techniques can be used for specimen transport (Figure 11.2), particularly for cholera and haemorrhagic fever investigations. Liquid stools can also be absorbed on a filter paper for transport. This simple procedure is reliable for confirmatory tests (culture, agglutinations, etc.). For the materials required see Module 19: Stool specimen transport module. The procedure is as follows. 70 1. Soak one disc in the liquid stool using forceps. 2. Place it in a small tube (2 mL) and attach a self−adhesive label with patient’s details, date and site. 3. Add a few drops of saline 0.9% to the tube. 4. Close the tube tightly with the screw−cap. 5. Attach a form with the relevant information and place it in a proper shipping container. Figure 11.2 Filter paper for transport of liquid stool 11.2.6 Hair, nail clippings, skin scrapings Specimens for diagnosis of superficial fungus infections are easy to transport. They can be placed in an envelope or a clean screw−cap tube, and can be kept for at least one week at room temperature. 11.2.7 Pus Samples taken from the periphery of ulcers or from infected wounds can be sent to the laboratory for bacterial culture to detect and identify the infecting bacteria and for antimicrobial susceptibility tests. The specimen material, preferably on a Dacron swab, can be transported in a plain sterile tube. Enough specimen should be collected to prevent drying. The swab can also be thrust into a tube of transport medium. Since the infecting bacterium will probably not be known, the specimen should be kept cool at room temperature and transported to the laboratory as soon as possible, preferably within one day. 11.2.8 Serum Blood chemistry tests are preferably done on serum rather than on whole blood. The serum specimen should be sterile and should be transported in a sterile tube. It should be kept refrigerated if possible. Transport time should be a maximum of 2 days. 11.2.9 Sputum Culture may be necessary to diagnose tuberculosis. Sputum specimens for M. tuberculosis culture can be preserved and transported quite easily. The patient expectorates the sputum into a screw−cap bottle or cup containing 25 mL of 0.6 % cetylpyridinium bromide (or chloride). The specimen and viable tubercle bacilli will be preserved for at least 10 days. Precautions should be taken to prevent bottle breakage in transport because positive specimens are extremely infectious. Ensure that the bottle cap is securely fastened and then place the bottle in a sturdy container, preferably a double cylinder specimen shipping container. 11.2.10 Throat swab specimens Culture is necessary to confirm a diagnosis of diphtheria. Throat swab specimens for C. diphtheriae can be transported in Loeffler’s medium or on coagulated serum in a screw−cap tube, or in silica gel in a tube. The freshly obtained throat swab is streaked on the slant of the coagulated serum in a screw−cap test tube, or is thrust into the Loeffler’s medium. The specimen should be transported at room temperature within 24 hours. However, it is preferable to transport freshly obtained throat swab specimens to the laboratory for culturing C. diphtheriae and S. pyogenes, and also for serodiagnostic tests, in sterile silica gel. C. diphtheriae and S. 71 pyogenes remain alive on throat swabs in silica gel for at least 3 days at room temperature. Dacron swabs are preferable to cotton swabs. The transport tube contains 3−5 g of dry silica gel sterilized at 170°C for 2−3 hours. If plastic tubes are used, they must be sterilized separately by autoclaving before adding the oven−sterilized silica gel. The gel and tubes can be resterilized and used again to reduce expense. Throat specimens can also be used for serodiagnostic testing for streptococcal pharyngitis. In serodiagnostic tests, the streptococcal antigens are extracted from the swab and are then tested with coagglutination (COAG) or latex (LA) reagents. The extract can also be used in spot tests. The antigens are quite stable, so swab specimens for these tests can be stored dry in a clean test tube or envelope. 11.2.11 Urine Urine specimens for bacteriological culture are collected in a sterile bottle or tube. A midstream specimen should be obtained. The 30 mL tubes are good for this purpose. The urine specimen should be cultured as soon as possible, preferably within one hour after collection. Boric acid at a 1 % concentration in urine will maintain viability of bacteria but suppress growth and multiplication. If any delay in testing is expected, urine specimens should be refrigerated. Urine specimens can be collected in field surveys for S. haematobium infections and stored. indefinitely at room temperature. The urine is easily preserved by adding 0.1 mL (2 drops) of 0.1 molar concentrated hydrochloric acid or 0.2 mL (4 drops) of commercial bleach to 10 mL of urine. 11.3 Shipment of samples Packing must be in three layers as detailed below. a) Primary container This contains the specimen. The primary container must be leakproof with a screw−cap. To avoid cracking or bending this container, never use mechanical devices to tighten the cap. Make sure that the specimen is correctly labelled. b) Secondary container This must be a durable waterproof container, made of metal or polycarbonate plastic with a screw−cap. It must be large enough to hold the primary container and sufficient absorbent material (absorptive paper, cotton, or cloth) to absorb all the fluid in the primary container should it be accidentally broken. Several primary containers can be enclosed in the secondary container under the following conditions. • The total volume in the primary containers should not exceed 50 mL. • Each primary container must be individually protected to reduce shock, prevent breakage, and provide absorption. • Enough space must be left between the inner side of the secondary container and the primary containers for sufficient absorbent material to absorb fluid from all the containers in case of accidental leakage or breakage. Tape one copy of the specimen data form and information about the specimen on the outside of each secondary container. c) Outer (tertiary) container The outer package is the outer shipping container. It should be of corrugated fibreboard, cardboard, wood, or other material strong enough to withstand the weight and shock commonly associated with handling and shipment. An example of the arrangement of a shipping container to transport dangerous or potentially dangerous specimens is shown in 72 Figure 11.3. When packing specimen volumes of 50 mL or more, a shock−absorbent material should be added (a volume equal to the sample volume) between the outer sides of the secondary container and the outer shipping container. If dry ice is used for shipping frozen and refrigerated specimens the following should be remembered. • Dry ice must be placed between the secondary container and the outer shipping container. • Shock absorbent material should be placed so as not to permit the secondary container to become loose inside the outer container as dry ice sublimates and disappears. • The outer container must permit the release of carbon dioxide gas in order to prevent the built−up of pressure leading to rupture of the container. Figure 11.3 Arrangement of a shipping container In emergency situations, all specimens should be considered potentially dangerous. All packages shipped must bear biohazard labels (Figure 11.4). Under certain provisions, infectious substances may be sent by air. The International Air Transport Association (IATA) Dangerous Goods Regulations 1992 [2] must be followed. Briefing on the subject may be obtained from local airline or forwarding agents. Proper packing of infectious material should follow the procedure outlined above. 73 Figure 11.4 Biohazard labels Every package containing potentially infectious material must have its contents marked on it, durably and legibly, both on the outside of the primary container and on the secondary and outer containers. Every outer container must bear an infectious substances label and an address label indicating: • the address and telephone number of the consignee; • the ‘proper shipping name(s)’ (that portion of the entry most accurately describing the contents), supplemented by technical names if appropriate; • the corresponding ‘UN numbers’ (as listed in the IATA Dangerous Goods Regulations, 1992); • the name and address of the shipper (consigner) and the name and telephone number of a responsible person. The recommended storage conditions should also be indicated. The shipper is responsible for the completion and signature of two copies of the ‘Shipper’s Declaration for Dangerous Goods’. The declaration must be completed in the English language. If required by the country of origin and/or destination, the wording in English may be accompanied by an accurate translation in another language. The forwarding agent may assist and provide guidance to the shipper but is not entitled to complete the declaration. The forwarding agent may only enter the airwaybill (AWB) number and the airports of departure and destination on the declaration. The shipper must enter all other items. Any correction must be countersigned by the same signatory. A packing list (proforma invoice) is required for nearly all categories of consignment and must include: the consignee’s address, number of containers, detail of contents, gross weight (optional) and value (for customs), together with a short statement stating that the items are supplied free of charge. Even for medical samples a symbolic value must be entered. The forwarding agent or an airline representative usually completes the airwaybill. The airwaybill is the airfreight document made out by or on behalf of the shipper, which determines the contract for carriage of goods over routes of the carrier(s). The shipper should complete the ‘Export Declaration’. However, the export declaration may be prepared by the agent or airline representative who then presents it for signature. 74 It is recommended that an advisory telex/telegram be sent to the consignee 48 hours before arrival of the shipment. The telex/telegram should include the following information: place of departure, place of arrival, number of containers, flight arrival details (avoid, if possible, arrival of the consignment over the weekend), airwaybill number, and recommended storage temperature. Chapter 12 Field laboratory record keeping and reports 12.1 General Data collected by the laboratory is an important component of a disease surveillance system. Systematic reporting, daily, weekly and monthly, provides information contributing to the assessment of the health status of the affected population, a disease notification system, and early detection of disease outbreaks. 12.2 The role of the laboratory in the investigation of disease outbreaks and epidemics While laboratory surveillance data may sometimes give an early warning of a disease outbreak, most disease outbreaks or epidemics first become apparent through an increase in cases with a common pattern of symptoms. Detailed methods for investigation of disease outbreaks are available in the WHO publication Public Health Action in Emergencies Caused by Epidemics [5]. For some diseases, such as measles, the clinical picture is sufficiently diagnostic that laboratory tests are not required. For other outbreak diseases, the laboratory plays a number of important roles. a) Confirmation of aetiology Appropriate specimens should be taken from a sample of clinical cases. Depending on the suspected disease, as indicated in Table 4.1, tests may be performed in the field, or appropriate specimens (Table 11.1) despatched to a referral laboratory. A laboratory request form should be filled in and sent to the laboratory with each specimen for required investigations (Figure 12.1). b) Case confirmation If the clinical diagnosis is not sufficiently specific for case definition, laboratory confirmation of cases may be required. It is, however, usually inappropriate to attempt to obtain specimens of all suspected cases. c) Contribution to the epidemic investigation Laboratory investigations may be required to investigate asymptomatic carriers of the disease and environmental samples, and to confirm when no new cases exist. Figure 12.1 Laboratory request form Name of patient _____________________________________ Age __________ Sex ________ Address/Site/Location __________________________________________________________ Ward/OPD ____________________________________ Registration No. _________________ Brief clinical history (please indicate medication, if any) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Specimen and investigation required ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 75 Ordered by (name) __________________ Signed _________________ Date ______________ For laboratory use only Laboratory reference No. ________________________________________________________ Laboratory results ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Examined by (name) ____________________________________________________________ Signed _______________________________________________________________________ Date _________________________________________________________________________ Note. Laboratory request forms can be printed, or prepared using a stencil and duplicator or a rubber stamp. 12.3 Recording test results The assessment of the epidemiological situation in a population will be facilitated by a proper recording system. In field laboratories, record keeping using books is still the best method. The fewer books and the simpler the specimen entry system the better. Use a large hard−back book each, for example, for malaria parasites, faecal specimens and miscellaneous tests. Some numbering systems start with the date, followed by the specimen number. For example on the 28th of the month, the first specimen would be ‘Lab. no. 28−1’, the second specimen ‘28−2’, and so on. Figure 12.2 gives an example of a page for a ‘malaria book’. It is recommended that the inside back cover of the malaria book be kept for recording a sample of the doctors’ signatures. Doctors should also be asked to provide specimen handwriting of ‘Blood smear’ and ‘Malaria smear’. Local health workers approved to request malaria smears should do the same. In this way it is possible to check who has requested malaria smears. Figure 12.2 Example of a page in a malaria book MALARIA BOOK Lab. no. Patient’s name Age Sex Village & zone/house no. Result 28−1 28−2 28−3 The back of the book may also be used for keeping daily statistics, as shown in Figure 12.3, starting from the last page and working backwards. Figure 12.3 Example of a statistics page in a malaria book Date 16.8.85 Total 22 No. positive 7 Details 4 P. falciparum 2 P. vivax 17.8.85 17 10 6 P. falciparum 4 P. vivax The pages of a ‘faeces book’ may be set out as shown in Figure 12.4. The same numbering system may be used as for the malaria book; so for the first faeces specimen the number would be 28−1. Statistics for faecal specimens can be recorded daily in the back of the book, starting from the last page and working backwards. Figure 12.4 Example of a page in faeces book FAECES BOOK 76 Lab. no. Patient’s name Age Sex Village & zone/house no. Result 28−1 28−2 28−3 A third hard−back foolscap book can be prepared to record the results of haemoglobin tests, urinalysis, CSF analysis and Gram stains. A different section of the book should be used for each type of test. Each patient has a medical card. Alongside the test requested, write the test number (obtained from the laboratory report book). To avoid confusion, put a circle around all laboratory numbers (Lab. no.) on patients’ cards. Next day the patient will return for the result. This can be found by linking the circled number on the medical card to the same number in the report book and the result with it. Only trained laboratory staff should write results on patients’ medical cards. 12.4 Laboratory procedure book If the laboratory is to continue operating after the departure of the laboratory technologist who initiated the activity, a set of notes giving the methods used in the laboratory, together with the addresses of local and national laboratory suppliers and a map showing their location, should be prepared. For reordering of basic stains and reagents, a record should be kept of usage rate of, for example, Field’s or Giemsa’s stains (e.g. 300−400 malaria smears a month required 1000 mL of Field’s A and 1000 mL of Field’s B). It is important for epidemiological assessment that monthly statistics are compiled. Figures 12.5, 12.6 and 12.7 show how specific and summary monthly reports may be presented. Figure 12.5 Example of a page from a laboratory monthly report LABORATORY MONTHLY REPORT From: 29.11.80 To: 28.12.80 Date: 31.12.80 Bacteriology specimens Camp Urine Gram stain TB sputum Faeces (positive) (parasite) Kok Tahan 7 3 4 (1) NIL Phnom Chat NIL NIL NIL NIL Samet 13 25 29 (5) 48 (2) NW 9 NIL NIL NIL NIL Nong Chan 1 8 34 (4) 28 Nong Pru 1 NIL NIL NIL Taprik 7 2 1 (1) 1 Figure 12.6 Example of a page from a malaria monthly report MALARIA MONTHLY REPORT Malaria Camp Total Positive P. falciparum P. vivax Mixed Kok Tahan 447 198 8 183 7 Ban Sa Ngae 346 187 34 133 20 Phnom Chat 93 37 4 32 1 NW 9 211 51 7 43 1 Samet 583 288 11 265 12 Nong Chan 538 233 18 195 20 Nong Pru 1584 1135 221 447 467 Taprik 4710 3649 1007 1927 715 Malu Kalui 917 121 96 18 7 Grand total 9429 5899 1406 3243 1250 77 Positive 5899 Negative 3530 62.6% Positive P. falciparum 1406 P. vivax 3243 Mixed 1250 Figure 12.7 Example of a monthly summary sheet for laboratory tests LABORATORY REPORT NOVEMBER 1985 1. Malaria Total number of smears 484 Number positive 170 Number of P. vivax 45 Number of P. falciparum 101 Number of P. falciparum plus P. vivax 24 2. Faecal specimens Total number of faecal specimens 74 Number of bacillary dysentery 37 Number of amoebic dysentery 7 Number of Ascaris 2 Number of hookworm 4 Number of giardia 4 Number of others 5 Number negative 15 3. Haemoglobin Total number of tests 333 RESULT Hb Age 20 g/L 20−40 g/L 40−80 g/L 80−100 g/L >100g/L 0−2 years − 21 72 27 10 2−5 years − 12 60 33 2 5−10 years 1 2 26 16 15 +10 years 1 4 25 11 6 Annexes Annex 1. Agencies providing health relief UNITED NATIONS AGENCIES United Nations High Commissioner for Refugees Palais des Nations, CH−1211 Geneva 10, Switzerland Tel: (0041)22−7398111 Fax: (0041)22−7319546; 7310776 Telex: 27492 The Emergency Operation Unit, UNICEF, 866 UN Plaza, New York, NY 1007, USA United Nations Disasters Relief Operations (UNDRO) Palais des Nations, CH−1211, Geneve 10, Switzerland Tel: (0041)22 7346011; 7332010 (Emergency number) Fax: (0041)22 7335623 Telex: 414242 DRO CH United Nations Children’s Fund (UNICEF) UNICEF (UNIPAC), Arhusgade 129, Freeport, DK 2100 Copenhagen, Denmark 78 Tel: (0045)35−273527 Fax: (0045)31 269421 Telex: 19813 World Food Program (WFP) Via Cristoforo Colombo, 426, Rome 00145, Italy Tel: (0039)6−57971 Fax: (0039)57975652; 5133537 Telex: 626675 Food and Agriculture Organization (FAO) P.O. Box 2223, Cairo, Egypt Tel: (0020)2−702229; 702789; 3497184 Fax: (0020)2−3495981 Telex: 21055 FAONE UN CAIRO WORLD HEALTH ORGANIZATION (WHO) WHO Headquarters Geneva (WHO/HQ) 20 Avenue Appia, CH−1211 Geneva 27, Switzerland Tel: (0041)22 7912111 Fax: (0041)22 7910746 Telex: 415416 WHO Regional Office for Africa (AFRO) P.O. Box 6, Brazzaville, Congo Tel: (00242)833860; 833865 Fax: (00242)831879 Telex: 5217 KG; 5364 KG WHO Regional Office for the Americas/Pan American Sanitary Bureau (AMRO) 525, 23rd Street N.W., Washington D.C. 20037, USA Tel: (001)861−3200 Fax: (001)2235971 Telex: 248338; 440057; 892744 WHO Regional Office for the Eastern Mediterranean (EMRO) P.O. Box 1517, Alexandria 21511, Egypt Tel: (0020)3−4830090/6/7; 4839240 Fax: (0020)3−4838916 Telex: 54028 WHO UN; 54684 WHO UN WHO Regional Office for Europe (EURO) 8 Scherfigsvej, DK − 2100 Copenhagen O, Denmark Tel: (0045)39−171717 Fax: (0045)39−181120 Telex: 15348 WHO Regional Office for South−East Asia (SEARO) World Health House, Indraprastha Estate, Mahatma Ghandi Road, New Delhi 110002, India Tel: (0091)11−3317804 to 3317823 Fax: (0091)11−3318607; 3327972 Telex: 65095; 65031 WHO Regional Office for the Western Pacific (WPRO) P.O. Box 2932, Manila 1099, Philippines Tel: (632)5218421 Fax: (632)5211036 Telex: 27652; 63260; 40365 NONGOVERNMENTAL ORGANIZATIONS League of Red Cross and Red Crescent Societies P.O. Box 372, CH−1211 Geneva 19, Switzerland Tel: (0041)22−7345580 Fax: (4100)22−7330395 Telex: 414226 International Committee of the Red Cross (ICRC) 19, Avenue de la Paix, CH−1202 Geneva, Switzerland Tel: (0041)22−7346001 Fax: (0041)22−7332057 Telex: 414226 CARE (Cooperative for American Relief Everywhere) 660 1st Avenue, New York, N.Y. 10016, USA Tel: (001)212−6863110 Fax: (001)212 6964005 Telex: rca 238896 CARITAS International Bredgade 69, 1260 Copenhagen K, Denmark Tel: (0033)127261 Fax: (0033)324711 Telex: 19362 79 Catholic Relief Services (CRS) 209 West La Fayette Street, Baltimore, Maryland 21202−3403, USA Tel: (001)301−6252220 Fax: (001)301−6851635 Telex: 9100000951 (CRS UQ) HALMO (Aid for Medical Laboratories in Developing Countries) Wilhelminapark 52, 3581 UTRE HT, The Netherlands IAMLT (International Association of Laboratory Technologists) östermalmogtan 19, S−114 26 Stockholm, Sweden Tel: (0046)8−103031 Fax: (0046)8−109061 LAB AID P.O. Box 98/M, Jakarta, Pusat, Indonesia Lutheran World Relief Federation (LWR) World Service, P.O. Box 2100, 1211 Geneva 2, Switzerland Tel: (0041)22−791−6434 Fax: (0041) 22 791 0528 Telex: 415546 LWS CH Christian Medical Commission of the World Council of Churches P.O. Box 66, CH 1211 Geneva 20, Switzerland Tel: (0041)22−7916111 Fax: (0041)22−7910361 Telex: 23423 Medical Mission Institute Würzburg (MMIW) Salvatorstrasse 22, 8700 Würzburg, Germany Tel: (0049)931−804850 Fax: (0049)931−8048525 Telex: 680177 MIHIV The International Council of Voluntary Agencies 17, Avenue de la Paix, CH 1202 Geneva, Switzerland The American Council of Voluntary Agencies for Foreign Service Technical Assistance Information Clearing House (TAICH) 200 Park Avenue South, New York, New York 10003, USA EUROPEAN AGENCIES IN DISASTER RELIEF OXFAM Health Unit 274 Banbury Road, Oxford OX2 7DZ, United Kingdom Tel: (0044)865−311311 Fax: (0044)865−312600 Telex: 83610 OXFAM G SAVE THE CHILDREN FUND 17 Grove Lane, London SE5 8RD, United Kingdom Tel: (0044)71−7035400 Fax: (0044)71−7032278 Telex: 892809 SCFLON G Disasters Emergency Committee 9 Grosvenor Crescent, London SWIX 7EJ, United Kingdom Tel: (0044)71−235−5454 Fax: (0044)71−245−6315 Telex: 918657 BRCS G Tropical Microbiology Unit Medical Microbiology Department, Liverpool University, P.O. Box 147, Liverpool, United Kingdom Tel: (0044)51−7064381 Fax: (0044)51−7065805 Telex: 627095 UNILPL G Refugee and Disaster Health Group International Community Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom Tel: (0044)51−7089393 Fax: (0044)51−7088733 London School of Hygiene and Tropical Medicine Keppel Street, London WC1E 7HT, United Kingdom Tel: (0044)71−6368636 Fax: (0044)71−4365389 Telex: 8953474 80 Royal Tropical Institute Department of Tropical Hygiene, Mauritskade 13, 1092 AD Amsterdam, The Netherlands International Dispensary Association P.O. Box 3098, 1003 AB Amsterdam, The Netherlands Tel: (0031)2903−3051 Fax: (0031)2903−1854 Telex: 13566 MEDECINS SANS FRONTIERES FRANCE Médecins sans Frontières 8 rue Saint−Sabin, 75011 Paris Tel: (0033)1−40212929 Fax: (0033)1−48066868 Telex: (042) 214360 BELGIUM Médecins sans Frontières 24/26 rue Deschampheleer, 1080 Brussels Tel: (0032)2−4250300 Fax: (0032)2−4253460 Telex: (046) 63607 HOLLAND Artsen zonder Grenzen (MSF Holland) Postadres − Postbus 10014, 1001 EA Amsterdam Tel: (0031)20−5208700 Fax: (0031)20−205170 Telex: (044) 10773 SWITZERLAND Médecins sans Frontières 10, Chemin Malombre, 1206 Geneva Tel: (0041)22−471500 Fax: (0041)22−475511 Telex (045) 421927 SPAIN Médicos sin Fronteras Avenida Puerta del Anger, 1, 08002 Barcelona Tel: (0034)3−4125252 Fax: (0034)3−3022889 Telex: 97309 MSF E LUXEMBOURG Médecins sans Frontières 110 Avenue Gaston Diderich, LI 420 Luxembourg Tel: (00352)458812 Fax: (00352) 459239 Telex: (0402) 60811 Annex 2. Reference laboratories for communicable diseases EPICENTRE 8 Rue Saint Sabin, 75011 Paris, France CRED (Centre for Research on Epidemiology of Disasters) Clos Chapelle−aux−Champs, 30, 1200 Brussels, Belgium ENVIRONMENTAL MICROBIOLOGY AND SAFETY REFERENCE LABORATORY CAMR, Porton Down, Salisbury SP4 OJ6, United Kingdom Tel: (0044)980−610391 PUBLIC HEALTH LABORATORY SERVICE 61 Colindale Avenue, London NW9 5EQ, United Kingdom Tel: (0044)81−200−4400 CENTER FOR DISEASE CONTROL Atlanta, Georgia 30333, USA STATENS SERUMINSTITUT Centre for Prevention and Control of Infectious Diseases and Congenital Disorders, Artllervej 5, DK−2300 Copenhagen S, Denmark 81 Tel: (0045)32683268 Fax: (0045)32683868 Telex 31316 Reference laboratories for diagnostic testing of viral haemorrhagic fever specimens CENTER FOR DISEASE CONTROL Special Pathogens Branch, Virology Division, Bureau of Laboratories Atlanta, Georgia 30333, USA US ARMY MEDICAL RESEARCH INSTITUTE OF INFECTIOUS DISEASES Medical Division, Fort Detrick, Frederick, MD 21701, USA CENTER FOR APPLIED MICROBIOLOGY AND RESEARCH Special Pathogens Unit, Salisbury, Porton Down, Wiltshire, SP4 OJG, United Kingdom INSTITUT DE MEDICINE TROPICALE PRINCE LEOPOLD Nationalestraat 155, B−2000 Antwerp, Belgium NATIONAL INSTITUTE FOR VIROLOGY Private Bag X4, Sandringham, Johannesburg, South Africa NATIONAL INSTITUTE OF HEALTH OF JAPAN Gakuen 4−7−1, Masashimur ayama−shi, Tokyo, Japan 190−12, INSTITUTO NACIONAL DE ESTUDIOS SOBRE VIROSIS HEMORRAGICAS Casilla Correo 195, 2700 Pergamino, Argentina NOTE. Specimens should be forwarded to these laboratories only following consultation. Proper shipping containers must be used. All regulations for shipping hazardous high−risk specimens must be observed. Annex 3. Manufacturers of portable or mobile laboratories PORTABLE MEDICAL LABORATORIES INC. P.O. Box 667, Solana Beach Ca 92075, USA Tel: (001)619 755−7385 Fax: (001)619 259−6022 Telex: 4945486 PMLAB COLES MINIMEDLAB Dept. of Microbiology, The University of Texas Health Science Centre, 7703 Floyd Curl Drive, San Antonio, Texas 78284−7758, USA MEDICOACH 7 NC Hemlock Road, P.O. Box 129, Oneonta, NY 13820−0129, USA Tel: (001)607 432−1333 Fax: (001)607 432 8190 Telex: (607)432 1333 M & M CUSTOM COUCHES 1458 Country Line Road, Department C, Huntington Valley, Pennsylvania, USA Tel: (001)215−355−7035 CLINOMOBIL HOSPITALWECK GmbH Carl Leverkus Strasse 16, D−4018 Langenfeld, GERMANY Tel: (0049)2173−770112 Telex 8515605 CLIND MODULMED INDUSTRIE S.A. Ch. de Fossabot 3, CH 1196 Gland, Switzerland Tel: (0041)22−644221 Fax: (0041)22−644213 Telex 419648 MODUCH ROY RICKMAN Riverdale, Beaford, Winkleigh, EX19 8AD, North Devon, United Kingdom Tel: (0044)8053 267 82 Annex 4. Commercially available rapid diagnostic kits and reagents and their manufacturers The following is a listing of fluorescent antibody, enzyme immunoassay, and passive agglutination diagnostic kits and reagents that are commercially available. The sources for these materials are listed for potential users to contact. This list is not exhaustive, and the source companies listed may carry other rapid diagnostic reagents. Furthermore, a wide variety of monoclonal and polyclonal antibodies are available that can be used for indirect fluorescent antibody tests or to make other rapid diagnostic test reagents. A. FLUORESCENT ANTIBODY (FA) KITS Antibody detection, anti− Adenovirus, enteric Borrelia burgdorferi Brucella Candida Chlamydia trachomatis Cytomegalovirus Entamoeba histolytica Epstein−Barr virus Giardia intestinalis Herpes simplex virus HIV HLTV Legionella SA Leishmania Mumps Mycoplasma Plasmodium falciparum Respiratory syncytial virus Rickettsia conorii R. prowasekii R. rickettsii R. typhi Rubella Rubeola Toxoplasma gondii Treponema pallidum Trypanosoma cruzi Varicella−Zoster virus Source 39 2, 25, 33, 34, 56 40, 77 25 29 29, 34, 49 56 33, 49, 74 56 29, 34 8, 29 8, 29, 105 27, 56 56 29, 34, 74 33, 34 40 49 40 52 52 52 29, 34, 74 49, 52 29, 34, 49, 77, 58 27, 33, 40, 56, 74, 77, 58, 91, 103 56 49, 74 Agent (antigen) detected Adenovirus Chlamydia trachomatis Cryptosporidium oocyst Cytomegalovirus Escherichia coli 0157:H7 Giardia intestinalis Herpes simplex virus Legionella pneumophila Neisseria gonorrhoeae 39 13, 17, 30, 25, 68, 71, 74, 76, 78, 99 21 30, 74, 82 18 21 4, 17, 30, 56, 68, 74 25, 33 30 83 Pneumocystis Renibacterium salmoninarum Respiratory syncytial virus Respiratory viruses (7) Salmonella common structural Ag Toxoplasma Trichomonas 21 18 74, 81 68 18, 82 74, 82 21, 76 B. POLYCLONAL ANTIBODY (FA) CONJUGATES Agent (antigen) detected Actinomyces israeli Adenovirus, enteric Adenovirus hexon Bordetella parapertussis B. pertussis Chlamydia trachomatis Coxiella burnetii Cytomegalovirus Escherichia coli 0157:H7 Gardnereiglla vaginalis Giardia intestinalis Haemophilus influenzae a, b Hepatitis B surface Ag Herpes simplex virus HIV Influenza A and B Legionella pneumophila gp 1 Listeria O Ag polyvalent Mumps Mycoplasma 20 strains Neisseria catarrhalis N. gonorrhoeae Parainfluenza type 1, 2, 3, 4 Rabies Respiratory syncytial virus Rickettsia conorii Rotavirus, all Ags Rubella Rubeola Salmonella Streptococcus groups A, B, C, D, F, G Toxoplasma gondii Treponema pallidum 10 39 5, 32 13 13 5, 9, 32 52 5, 32 18 10 6 13 1, 7 1, 5, 9, 12, 14, 32, 34, 94 5, 32, 94 1, 5, 9, 14, 39 10, 27 13, 18 34, 94 3, 22 10 13, 27 1, 5, 14, 32, 94 1, 14, 35, 77 1, 5, 9, 13, 14, 36, 39, 49, 63, 64, 94 52 5, 32 1, 14 1, 14 13, 18 13, 35, 82 49 27, 35, 95 C. MONOCLONAL ANTIBODY FA CONJUGATES Agent (antigen) detected Adenovirus Chlamydia trachomatis 34 1, 5, 11, 14, 17, 23, 24, 25, 32, 34, 99 84 Cytomegalovirus Epstein−Barr virus Giardia intestinalis cysts Herpes simplex types 1 and 2 HIV Influenza A and B Legionella pneumophila gp 1 Parainfluenza types 1, 2, 3 Pneumocystis carinii Respiratory syncytial virus Trichomonas vaginalis Varicella−Zoster virus Yersinia enterocolitica 1, 9, 12 32 6 24, 32, 34 31 34 10, 11, 23, 25 34 32 32, 34 24 11, 23, 25, 34 23 D. ENZYME IMMUNOASSAY DIAGNOSTIC KITS 1. Antibody detection and identification Antibody Detected, Anti− Adenovirus Bordetella pertussis Borrelia burgdorferi Brucella abortus Chlamydia trachomatis Clostridium tetani Corynebacterium diphtheriae Cytomegalovirus Echinococcus Entamoeba histolytica Epstein−Barr virus Giardia intestinalis Helicobacter pylori Hepatitis A, B, Delta Ag Herpes simplex virus 1 and 2 HIV HTLV Influenza virus Leishmania Mumps virus Mycoplasma Parainfluenza virus Plasmodium falciparum Rickettsia prowasekii Rickettsia rickettsii Rickettsia typhi Rotavirus Rubella Rubeola Syphilis reagin Taenia solium 85 39, 86 53, 86 12, 33, 34, 39, 45, 48, 49, 56, 76, 81, 86 43, 86 34, 53, 66, 79, 81, 86 86 86 34, 43, 45, 48, 49, 53, 66, 82, 83, 86, 92, 94, 99 57 43, 45, 55, 57 41, 43, 48, 49, 59, 82, 83, 86 55 86 37, 98, 99, 100, 102 43, 48, 49, 79, 82, 83, 86, 94, 99 4, 8, 37, 41, 57, 79, 85, 89 85, 107 86 57 34, 43, 86, 94 86 86 57 52 52 52 86 34, 37, 43, 45, 48, 49, 53, 64, 73, 81, 82, 86, 94, 99 34, 43, 49, 82 2 57 Toxoplasma gondii Treponema pallidum Varicella−Zoster 48, 49, 55, 66, 82, 83, 86, 99 44, 57 34, 43, 45, 82, 86, 94 2. Antigen detection Antigen (agent) detected Adenovirus, enteric 39, 76 Chlamydia trachomatis 30, 37, 62, 70, 71, 72, 79 Clostridium difficile 13, 76 Cytomegalovirus 13 Epstein−Barr virus 13, 63, 71, 81 Giardia intestinalis 2, 38, 4 Hepatitis B virus 37, 57, 81, 96, 98, 99, 102 Herpes virus 71, 79, 81 HIV 8, 51, 85 HTLV−1 8, 81 Legionella 81 Mycoplasma pneumoniae 82 Neisseria gonorrhoeae 37 Neisseria meningitis 60 Plasmodium falciparum 57 Pneumocystis carinii 81 Respiratory syncytial virus 17, 35, 37, 71 Rotavirus 1, 4, 13, 17, 37, 39, 40, 76, 81 Rubella 13 Salmonella (common structural Ag) 18 Streptococcus Group A 13, 35, 42, 59, 62, 64, 66, 73, 79, 84 Streptococcus Group B 42, 59, 84 Taenia solium 55 Trichomonas 21, 70 E. PASSIVE AGGLUTINATION TESTS Antibody Detected Entamoeba histolytica Aspergillus Candida albicans Coccidioides Ab Cytomegalovirus Echinococcus granulosus Epstein−Barr heterophile Ab Epstein−Barr heterophile Ab Fasciola hepatica Hepatitis B e Ab Hepatitis B s Ab Herpes simplex Ab HIV Legionella Rickettsia typhi Test type HA HA HA LA LA HA HA LA HA HA HA LA LA La LA Test source 58, 91 90 90 21, 50 33 58, 90 33, 40, 54 33 90 47, 99 d 37, 47, 93, 96, 98, 99, 100 33 76 86 52 86 Rickettsia rickettsii Rubella Ab Rubella Ab LA HA LA 52 1, 37, 40 33 Antigen (Agent) Detected Schistosoma Sporothrix Toxoplasma gondii Toxoplasma gondii Treponema pallidum HA LA HA LA HA 58, 90 50 58, 88, 90, 103 90, 91, 95, 103 35, 44, 58, 93, 96, 97, 99, 103 86 21, 86 13, 50, 61, 86 35 21, 33, 34, 40, 50, 95 1, 40 63, 58 60 33, 40 47, 58, 93, 96, 98, 99, 100 33 58 21, 60 60 33, 35, 40, 63 21, 33, 40, 86, 95, 101 33 58, 94, 104, 106 33, 94 33 13, 50, 63, 94 40 90 2, 33, 35, 46, 63, 86, 94, 95 25, 33, 40, 46, 63 21, 60 13, 46, 95, 96 33, 35, 40, 63 60 1, 40 63 58, 88 58 69, 94 25 58 86 Trichinella Campylobacter Candida albicans Clostridium difficile Cryptococcusneoformans Echinococcus Escherichia coli K−1 H. influenzae b Haemophilus influence Hepatitis B e, surface Herpes simplex Leishmania donovani Neisseria gonorrhoeae Neisseria meningitidis Neisseria meningitidis Rotavirus Rubella Rubella Salmonella Shigella Staphylococcus aureus Staphylococcus aureus Staphylococcus aureus Streptococcus Group A LA LA LA Streptococcus Group B Streptococcus Groups: A, B, C, F, G Streptococcus Groups: A, B, C, F, G Streptococcus pneumoniae Streptococcus pneumoniae Toxoplasma Toxoplasma gondii Treponema pallidum Treponema cruzei Vibrio cholerae Yersinia enterocolitica Yersinia enterocolitica Yersinia LA COAG LA LA COAG HI HA HA HA LA AGG HI LA 87 LA HI AGG COAG LA HA LA HA COAG COAG LA LA LA HI LA LA LAca COAG HA LA F. DNA PROBE Antigen (agent) detected Blastomyces dermatitidis Chlamydia trachomatis Coccidioides immitis Cryptococcus neoformans Histoplasma capsulatum M. avium M. gordonae M. intracellulare Mycobacterium tuberculosis Neisseria gonorrhoeae Key to test type 80 80 80 80 80 80 80 80 80 80 80 AGG: Agglutination COAG: Coagglutination HI: Haemagglutination inhibition HA: Haemagglutination LA: Latex agglutination No. Name, address, telephone 1. ACCURATE CHEMICAL & SCIENTIFIC CORPORATION 300 Shames Drive, Westbury, NY 11590, USA Tel: (001)516−333−2221; (001)800−645−6264 Fax: (001)516−997−4948 2. ANTIBODIES INC. P.O. Box 1560, Davis, CA 95617, USA Tel: (001)916−758−4400; (001)800−824−8540 Fax: (001)916−758−6307 3. AMERICAN TYPE CULTURE COLLECTION Sales Department, 12301 Parklawn Drive, Rockville, MD 20852, USA Tel: (001)301−881−2600; (001)800−638−6597 Fax: (001)301−231−5826 4. BIO/CAN AMERICA INC. P.O. Box 8129, Portland, ME 04104, USA Tel: (001)207−767−7305; (001)800−343−7305 Fax: (001)207−767−7305 5. BIODESIGN INC. 432 Beachwood Avenue, Kennebunkport, ME 04046, USA Tel: (001)207−967−4173 Fax: (001)207−967−4014 6. BIOVIR LABORATORIES INC. 685 Stone Road, No.6, Benicia, CA 9_]4510, USA Tel: (001)707−747−5906; (001)800−442−7342 7. CENTRAL LABORATORIE NETHERLANDS RED CROSS Blood Transfusion Service, P.O. Box 9190, Dept. Immune Reagents, 1006 AD Amsterdam, The Netherlands Tel: (0031)3120−5123246 Fax: (0031)3120−5123332 8. CELLULAR PRODUCTS INC. 688 Main Street, Buffalo, NY 14202, USA Tel: (001)716−842−6270 Fax: (001)716−842−1093 88 9. CHEMICON INTERNATIONAL INC. 27515 Enterprise Circle West, Temecula, CA 92390, USA Tel: (001)714−676−8080; 800−437−7500 Fax: (001)714−676− ^209 10. CHEMUNEX S.A. 41 rue du 11 Novembre 1918, F−94700 Maisons Alfort, France Tel: (0033)(1)−43969200 11. CYMBUS BIOSCIENCE LTD. 2 Venture Road, Chilworth Research Centre, Southampton, Hampshire SO1 7NP, United Kingdom Tel: (0044) 703−766280 12. DAKO CORPORATION 6392 Via Real, Carpinteria, CA 93013, USA Tel: (001)805−566−6655; 800−235−5763 Fax: (001)805−566−6688 13. DIFCO LABORATORIES P.O. Box 331058, Detroit, MI 48232−1058 Tel: (001)313−961−0800 Fax: (001)313−591−3530 13.a DENKA SEIKEN Co. Ltd. 12−1, Nihonbashi, Kabuto−Cho, Chuo−Ku, Tokyo, Japan 103 Tel: (81) 03−3669 9421 Fax: (81) 03−3664 1005 14. EUROBIO LABS 20 Boulevard St−Germain, FD−75005, Paris, France Tel: (0033)143−252033 15. HEMAGEN DIAGNOSTICS INC. 34 Bear Hill Road, Waltham, MA 02154, USA Tel: (001)617−890−3766; 800−722−2730 Fax: (001)617−890−3748 16. IMMUNON/LIPSHAW CORP. 7446 Central Avenue, Detroit, MI 48210, USA Tel: (001)800−547 Y−7429 Fax: (001)313−834−1534 17. KALLESTAD DIAGNOSTICS 1000 Lake Hazeltine Drive, Chaska, MN 55318, USA Tel: (001)612−448−4848; 800−666−5111 Fax: (001)612−368−1110 18. KIRKEGAARD & PERRY LABS INC. 2 Cessna Court, Gaithersburg, MD 20879, USA Tel: (001)301−948−7755; 800−638−3167 Fax: (001)301−948−0169 19. MEDICA INC. 2382 Camino Vida Roble, Suite I, Carlsbad, CA 92009, USA Tel: (001)619−438−1886 Fax: (001)619−438−3171 20. MEDICAL & BIOLOGICAL LABS LTD. 5F Sumitomo−Shoji Marunouchi Bldg 5−10 Marunouchi 3−Chome Naka−ku, Nagoya 460, Japan Tel: (0081)(0)52−9712081 89 21. MERIDIAN DIAGNOSTICS INC. 3471 River Hills Drive, Cincinnati, OH 45244, USA Tel: (001)513−271−3700; 800−543−1980 Fax: (001)513−271−3762 22. NIH RESEARCH RESOURCES BRANCH c/o Biotech Res. Labs NIAID Repository 1600 East Gude Drive, Rockville, MD 20850, USA Tel: (001)301−251−0800 23. PAESEL + LOREI GmbH & Co. Borsigallee 6 Postfach 630347 D−6000 Frankfurt/Main 63, Germany Tel: (0049)(0)69−422095 to 99 Fax: (0049)(0)69−423084 24. PHARMINGEN 11555 Sorrento Valley Rd. #E, San Diego, CA 92121, USA Tel: (001)619−792−5730 Fax: (001)619−792−5238 25. PROGEN BIOTECHNIK GmbH Im Neuenheimer Feld 519, D−6900 Heidelberg, Germany Tel: (0049)(0)6221−40350 Fax: (0049)(0)6221−403535 26. QUIDEL 10165 McKellar Court, San Diego, CA 92121, USA Tel: (001)619−552−1100; 800−874−1517 Fax: (001)619−453−4338 27. SCIMEDX 400 Ford Road, Denville, NJ 07834, USA Tel: (001)201−625−8822; 800−221−5598 Fax: (001)201−625−8796 28. SERA−LAB LTD. Crawley Down, Sussex RH10 4FF, United Kingdom Tel: (0044)(0)342−716366 Fax: (0044)(0)342−717351 29. STELLAR BIO SYSTEMS INC. 9075 Guilford Road, Columbia, MD 21046, USA Tel: (001)301−381−8550; 800−962−6790 Fax: (001)301−381−8984 30. SYVA CO. 900 Arastradero Road, Palo Alto, CA 94303−0847, USA Tel: (001)800−227−9948 Fax: (001)415−962−0461 31. UNIVERSITY OF LOUVAIN Experimental Immunology Unit, Clos Chapelle−aux−Champs 30−56 B−1200 Bruxelles, Belgium Tel: (0032)2−7643430 Fax: (0032)2−7643946 32. VIROSTAT P.O. Box 8522, Portland, ME 04104, USA Tel: (001)207−871−0118 Fax: (001)207−775−0594 33. WAMPOLE LABORATORIES Half Acre Road, Cranbury, NJ 08512, USA Tel: (001)609−655−6000; (001)800−257−9525 34. WHITTAKER BIOPRODUCTS 90 8830 Biggs Ford Road, Walkersville MD 21793−0127, USA Tel: (001)301−898−7025; 800−654−4452 Fax: (001)301−845−8291 35. BECTON DICKINSON MICROBIOLOGY SYSTEMS P.O. Box 243, Cockeysville, MD 21030, USA Tel: (001)301−771−0100; (001)800−638−8663 36. CALTAG LABORATORIES INC. 384 Oyster Point Blvd. #16, South San Francisco, CA 94080, USA Tel: (001)415−873−6106; 800−874−4007 Fax: (001)415−873−2113 37. ABBOTT LABORATORIES Diagnostics Division, D−921 AP6C−6, Abbott Park, IL 60064, USA Tel: (001)312−937−6161; 800−323−9100 Fax: (001)312−937 S−9559 38. ALEXON BIOMEDICAL, INC. 1500 Hicks Road, Rolling Meadow, IL 60008, USA Tel: (001)312−259−9797; (001)800−262−6990 39. API LABORATORY PRODUCTS Ltd. 8114 B Trans Canada Highway, St. Laurent, Quebec H45 1M5, CANADA Tel: (001)514−336−7321; (001)800−336−7321 40. BIOMERIEUX Marcy−l’Etoile, F−69280 Charbonnières−les−Bains, France Tel; (0033)78872000; Fax: (0033)78872090 41. BIOTECH RESEARCH LABS INC. 1600 East Guide Drive, Rockville, MD 20850, USA Tel: (001)301−251−0800 42. BINAX 95 Darling Avenue, South Portland, ME 04106, USA Tel: (001)207−772−3544; (001)800−323−3199 Fax: (001)207−761−2074 43. CLARK LABORATORIES INC. P.O. Box 1059, Jamestown, NY 14702−1059, USA Tel: (001)716−483−3851 Fax: (001)716−468−1990 44. COMMONWEALTH SERUM LABORATORIES 45, Poplar Road, Parkville, Victoria 3052, AUSTRALIA Tel: (0061)389−1911 45. DIAMEDIX CORPORATION 2140 North Miami Ave., Miami, FL 33127, USA Tel: (001)305−324−2300; (001)800−327−4565 Fax: (001)305−324−2395 46. DIAGNOSTIC PRODUCTS CORP. 5700 West 96th Street, Los Angeles, CA 90045, USA Tel: (001)213−776−0180; (001)800−654−3707 Fax: (001)213−642−0192 47. GREEN CROSS CORPORATION 3−3 Imabashi 1−Chome, Osaka, Japan Tel: (0081)06−2274615 Fax: (0081)06−2280788 91 48. GENERAL BIOMETRICS, INC. 15222 Avenue of Science, San Diego, CA 92128−9814, USA Tel: (001)619−592−9300; (001)800−288−4368 Fax: (001)619−592−9400 49. GULL LABORATORIES, INC. 1011 East 4800 South, Salt Lake City, UT 84117, USA Tel: (001)801−263−3524; (001)800−448−4855 Fax: (001)801−265−9268 50. IMMUNO−MYCOLOGICS INC. P.O. Box 1151, Norman, OK 73070, USA Tel: (001)405−288−2458; (001)800−654−3639 Fax: (001)405−288−2228 51. INNOGENETICS S.A. Kronenburgstraat 45, 2000 Antwerp, Belgium Tel: (0032)3−2164820 Fax: (0032)3−2164497 52. INTEGRATED DIAGNOSTICS, INC. P.O. Box 24124, Baltimore, MD 212227, USA Tel: (001)301−247−2570 Fax: (001)301−536−1398 53. LABSYSTEMS INC. P.O. Box 13970, Research Triangle Park, NC 27709−3970, USA Tel: (001)919−460−1800; (001)800−572−8270 Fax: (001)919−469−2623 54. LAMPIRE BIOLOGICALLABS P.O. Box 170, Pipersville, PA 18947, USA Tel: (001)215−795−2838 55. LMD LABORATORIES INC. 2792 Loker Ave., West #103, Carlsbad, CA 92008, USA Tel: (001)619−929−0110 Fax: (001)619−929−0115 56. MARDX DIAGNOSTICS, INC. 5919 Farnsworth Court, Carlsbad, CA 92008, USA Tel: (001)800−331−2291; (001)619−929−0500 Fax: (001)619−929−0124 57. MELOTEC S.A. P.O. Box 195, San Cugat del Valles, 08190 Barcelona, Spain Tel: (0034)35820202 Fax: (0034)35820100 58. BEHRINGWERKE AG Diagnostika, P.O. Box 1140, D−3550 Marburg, Germany Tel: (0049)6421 390 Fax: (0049)6421 31388 59. PACIFIC BIOTECH, INC. 9050 Camino Santa Fe, San Diego CA 92121, USA Tel: (001)619−695−2688; (001)800−225−0730 Fax: (001)619−695−3408 60. PHARMACIA DIAGNOSTICS AB Box 17, S−751 03 Uppsala 1, Sweden Tel: (0046)18−16−3000 Fax: (0046)18−14−3820 61. RAMCO LABORATORIES INC. 4507 Mt. Vernon, Houston, TX 77006, USA Tel: (001)713−526−9677; (001)800−231−6238 Fax: (001)713−526−1528 92 62. UNIPATH 850 Mande Avenue, Mountain View, CA 94043, USA Tel: (001) (415)969−5533 63. WELLCOME DIAGNOSTICS Division of Burroughs Wellcome Co., 3030 Cornwallis Road, Research Triangle Park, NC 27709, USA Tel: (001) 919−758−3436; (001) 800−334−9332 64. VENTREX;LABORATORIES INC. 217 Read St., Portland, ME 04104, USA Tel: (001)207−773−7231; (001)800−341−0463 Fax: (001)207−775−4734 65. BINDING SITE LTD. 97 Vincent Dr. Edgbaston, Birmingham B 15 2 SQ, United Kingdom Tel: (0044)21−4714197 Fax: (0044)21−4726017 66. MEDIX BIOTECH INC. 420 Lincoln Center Dr., Foster City, CA 94404, USA Tel: (001)415−573−3315 Fax: (001)415−573−6734 67. BIONIQUE LABORATORIES INC. Bloomingdale Rd., Saranalac Lake, NY 12983, USA Tel: (001)518−891−2356 68. BAXTER HEALTHCARE CORP. MicroSoam Division, 1584 Enterprise Blvd., W. Sacramento, CA 95691, USA Tel: (001)800−631−7216 69. DENKA SEIKEN CO., LTD. 12−1, Nihonbashi−Kabutocho, Chuo−Ku, Tokyo 103, Japan 70. ORGANON TEKNIKA−CAPPEL 800 Capitola Dr., Durham, NC 27713, USA Tel: (001)800−682−2666 71. ORTHO−DIAGNOSTIC SYSTEMS Raritan, Route 202, NJ 08869, USA Tel: (001)800−631−5807 72. NOVO BIOLABS St Johns Innovation Centre, Cowley Road, Cambridge CB4 4WS, United Kingdom Tel: (001)223−421060 73. MUREX CORP. P.O. Box 2003, Norcross, GA 30091, USA Tel: (001)800−826−8739 74. VIRGO ELECTRO−NUCLEONICS 7101 Riverwood Dr., Columbia, MD 21046, USA Tel: (001)301−964−2800; (001)800−638−4543 75. VIRION (U.S.), INC. 4, Upperfield Rd., Morristown, NJ 07960, USA 93 Tel: (001)(201) 993−8219 76. CAMBRIDGE BIOTECH 365 Plantation Street, Biotechnology Research Park, Worcester, MA 01605, USA Tel: (001)508−797−5777; (001)800−637−8376 77. INSTITUT PASTEUR PRODUCTION 3 Bd. Raymond Poincaré, 92430 Marnes la Coquette, France Tel: (033)1−47956082 Fax: (033)1 − 47419133 78. SYNBIOTICS CORPORATION 11011 Via Frontera, San Diego, CA 92127, USA Tel: (001)619−451−3770 Fax: (001)619−451−3826 79. KODAK 343 State Street, Rochester, NY 14650, USA Tel: (001)800−445−6325 Ext. 449; (001)716−725−3460 Fax: (001)716−781−9544 80. GEN−PROBE 9880 Campus Point Drive, San Diego, CA 92121, USA Tel: (001)800−523−5001; (001)619−546−8000 Fax: (001)619−546−7952 81. SANOFI DIAGNOSTICS PASTEUR 1000 Lake Hazeltine Drive, Chaska, MN 55318−1084, USA Tel: (001)800−472−8378; (001)206−881−8300 Fax: (001)206−861−5010 82. INESTAR CORPORATION 1990 Industrial Blvd., P.O. Box 283, Stillwater, MN 55082−0285, USA Tel: (001)800−328−1482; (001)612−439−9710 Fax: (001)612−779−7847 83. IMMUNO−DIAGNOSTIC PRODUCTS, INC. P.O. Box 193, North Salt Lake, UT 84054, USA Tel: (001)801−198−7535 Fax: (001)801−292−6906 84. HYBRITECH, INC. P.O. Box 269006, San Diego, CA 92196−9006, USA Tel: (001)800−854−1957 85. DUPONT COMPANY Medical Products, Walmington, DE 19898, USA Tel: (001)800−527−2601 86. BIO−MEDICAL PRODUCTS CORP. 59 White Meadow Road, Rockaway, NJ 07866, USA Tel: (001)201−627−6010 Fax: (001)201−627−7632 87. ENZO BIOCHEM INC. 325 Hudson Street, New York, NY 10013, USA Tel: (001)800−221−7705; (001)212−741−3838 Fax: (001)212−645−9469 88. BIOKIT S.A. Corcega 603−605, Sp−08025 Barcelona, Spain 89. 94 CAMBRIDGE VIRUCELLS 38 Topcliff Way, Cambridge CB1 4SH, United Kingdom Tel: (0044) 223 336823 Fax; (0044) 223 214788 90. FUMOUZE 7 Place des Martyrs, F−92110 Clichy, France Tel: (0033)(1)473 111 82 Fax: (0033)(1)47310410 91. LABORADIAGNOSTIKA GmbH Industriestrasse 12, D− 4284 Heiden, Germany Tel: (0049)2867 8083 Fax: (0049)2867 990719 92. SANGSTAT MEDICAL CORPORATION 1505−B Adams Drive, Menlo Park, California 94025, USA Tel: (001)415 328 0300 Fax: (001)415 328 8892 93. THE CHEMO−SERO−THERAPEUTIC RESEARCH INSTITUTE 668 Ookubo, Shimizu−cho, Kumamoto City 860, Japan Tel: (0081) 96−344−1211 94. DENKA SEIKEN CO., LTD. Taiyou Building, 12−1 Kabuto−cho, Nihonbashi, Chuo−ku, Tokyo 103, Japan Tel: (0081)3−3669−9091 95. EIKEN CHEMICAL CO., LTD. 1−33−8 Hongou, Bunkyo−ku, Tokyo 113, Japan Tel: (0081)3−3813−5401 96. FUJIREBIO INC. 2−71 Nishishinjuku, Shinjuku−ku, (Shinjuk Daiichi Seimei Building), Tokyo 163, Japan Tel: (0081)3−3348−0691 97. IATRON LABORATORIES INC. 1−11−4 Higashikanda, Chiyoda−ku, Tokyo 101, Japan Tel: (0081)3−3862−1761 98. INSTITUTE OF IMMUNOLOGY CO., LTD. 1−1−15 Kouraku, Bunkyo−ku, (Nihon Seimei Suidobashi Building) Tokyo 112, Japan Tel: (0081)3−3814−4077 99. INTERNATIONAL REAGENTS CORPORATION 2−1−30 Hamabedori, (Sannomiya Kokusai Building), Chuo−ku, Kobe, 651 Japan Tel: (0081)78−231−4151 100. MEGURO INSTITUTE 7−29 Masumi−cho, Ikeda City 563, Japan Tel: (0081)727−51−2927 101. MITSUBISHI KASEI CORPORATION 2−5−2 Marunouchi, Chiyoda−ku, Tokyo 100, Japan Tel: (0081)3−3283−6111 102. MIZUHO MEDY CO., LTD. 3−4−8 Hakataekimae, Hakata−ku, Fukuoka City, E12 Japan 95 Tel: (0081)92−482−8710 103. JAPAN LYOPHILIZATION LABORATORY 2−8−8 Kouji−machi, Chiyoda−ku, Tokyo 102, Japan Tel: (0081)3−3265−5740 104. SHIONOGI AND CO. LTD., 3−18 Dosho−machi, Chyuou−ku, Osaka 541, Japan Tel: (0081)6−202−1221 105. MEDICAL AND BIOLOGICAL LABORATORIES 3−5−10 Marunouchi, Naka−ku, (Sumitomoshouji−Marunouchi Building) Nagoya 460, Japan Tel: (0081)52−971−2081 106. WAKO PURE CHEMICAL INDUSTRIES LTD. 3−1−2 Dosho−machi, Chuo−ku, Osaka 541, Japan Tel: (0081)6−203−1501 107. EISAI CO. LTD. 4−6−10 Koishikawa, Bunkyo−ku, Tokyo 112, Japan Tel: (0081)3−3817−5010 Annex 5. Reagents for urinalysis General Reagents for so−called ‘dry chemistry’ tests offer several advantages over reagents in solutions: • the stability of dry reagent powders is usually far better than that of reagents in solution; • dry reagents can be used for preparation of tablets or test strips, which are simple means of semi−quantitative and, although with more sophisticated equipment, quantitative analysis. The production of dry chemistry reagents is described for urinary analysis. Reagents for serum and blood analysis are beyond the scope of this manual. Simple reagent powders can be prepared even in small quantities with little equipment, such as a mortar and pestle. Reagent powders can be used on glass plates placed upon a sheet of white paper or on plates of white porcelain, the latter permitting the observation of both colour reactions and precipitations. Test papers are easily prepared by impregnation of larger sheets of absorbent material, such as filter paper or chromatographic paper. The preparation of a selected number of dry reagents is described below. Tests for glucose 1. Lestradet test Principle Divalent bismuth is reduced to black metallic bismuth by glucose at boiling temperature. The necessary energy for process is produced by the strongly exothermic reaction which occurs when potassium hydroxide is dissolved in the urine. Preparation • 1 g bismuth nitrate • 100 g dry potassium hydroxide • 100 g calcined sodium chloride 96 Grind the chemicals finely in a mortar. The powder is hygroscopic and must be kept from humidity, tightly sealed. Use Place a pea−sized heap of powder upon a white surface and moisten with one drop of urine. The appearance of a grey or black colour indicates the presence of glucose, the reaction time depending on glucose concentration as follows: • grey colour appearing within 2−3 seconds: 10 g glucose/L or more; • grey colour appearing within 10−20 seconds: approximately 2 g glucose/L; • grey colour appearing within 30−60 seconds: approximately 1 g glucose/L; • grey colour appearing after 60 seconds: less than 1 g glucose/L. Other reducing agents, such as ascorbic acid (vitamin C), lead to false positive reactions. 2. Dry variation of the Benedict reaction Principle The reaction is based on the reduction of bivalent blue copper−citrate ions to monovalent red cuprous oxide, by glucose in boiling water. Copper sulfate and citric acid are provided as stable reagent powders. Preparation • 20 g cupric sulfate pentahydrate • 300 g citric acid Grind the chemicals finely in a mortar. The powder is not hygroscopic and may be stored in screw−cap or snap−cap flasks. Use Place a pea−sized quantity of powder in a test tube and moisten with 3 drops of urine. Add one pellet of dry sodium or potassium hydroxide and shake the mixture to mix it. Continue shaking throughout spontaneous boiling of the mixture, which is caused by the strongly exothermous reaction. Glucose concentrations of 20 g/L or more cause heavy olive−brown precipitate turning rapidly dark brown. 10 g/L of glucose yield an orange precipitate turning brown after standing; 5 g/L cause a persistent orange precipitate. Slight orange precipitate with blue supernatant indicates approximately 2 g/L. Lower concentrations yield unchanged blue solution. False positive reactions may be caused by reducing agents, such as ascorbic acid. Test for ketone bodies Principle A test powder based upon Legal’s classic reaction with sodium nitroprusside is very widely used. Nitroprusside yields a violet−coloured complex with enolizable keto−groups such as acetoacetic acid and acetone, which are excreted in metabolic acidosis. Preparation • 1 g sodium nitroprusside • 200 g anhydrous sodium carbonate • 200 g anhydrous ammonium sulfate Grind the chemicals finely in a mortar. The powder is only very mildly hygroscopic and is stored in screw−cap or snap−cap flasks. Use 97 Moisten a pea−sized heap of powder with one drop of fresh urine. In the presence of 50 mg/L of acetoacetic acid or 500 mg/L of acetone a violet colour appears within one minute. Phenylpyruvic in the urine yields an orange colour, indicating phenylketonuria. Combined test for urinary protein and urobilinogen Principle A piece of filter−paper impregnated with sulfosalicylic acid and dimethylaminobenzaldehyde (p−DMAB, Ehrlich reagent) is placed in the urine to be tested. Sulfosalicylic acid denaturates the proteins, leading to turbidity or precipitation, while p−DMAB yields a cherry−red colour in the presence of urobilinogen. Preparation • 200 g sulfosalicylic acid • 20 g p−DMAB Dissolve the chemicals in distilled water and make up to 1 litre. Dip sheets of filter−paper into this solution and air−dry. Cut the dry sheets into segments 1 cm x 2 cm and store in screw−cap or snap−cap flasks. Use Place one segment of reagent paper into approximately 1 mL of urine. The reaction may be performed in a micro test−tube or on a glass plate. Place the glass tile first on white paper to observe the colour reaction and then on black paper to observe turbidity. Test for bilirubin Principle Bilirubin is concentrated by adsorption of urine on a tablet of plaster. Bilirubin remains on the surface of the tablet, where it is detected by oxidation to blue−green biliverdin by acid ferric chloride. Preparation Mix ordinary white plaster with sufficient water to yield a thick paste which is cast into tablets by pouring it into appropriate moulds. Once hardened, the tablets may be openly stored. Prepare Fouchet reagent by dissolving 20 g trichloracetic acid and 5 g of ferric chloride in 1000 mL water. This solution is extremely stable. Use Place ten drops of well mixed urine one by one upon the tablet. Take care to place each drop only after the preceding drop has been absorbed. Bilirubin concentrates at the surface of the tablet leaving a yellow spot which turns to bluish green after reaction with one drop of Fouchet reagent. This reaction is highly sensitive (detection limit ± 20 mg/L) and specific. Reagent for nitrite detection Principle Detection of urinary nitrite indicates urinary tract infections caused by nitrate−reducing bacteria, provided adequate precautions are taken. Preparation The reaction powder is based upon the classical Griess−reaction. • 6.2 g naphtylamin • 1.0 g sulfanilic acid • 25.0 citric acid 98 Grind the chemicals thoroughly in a mortar. The powder is barely hygroscopic and may be stored in screw−cap or snap−cap vials. Use Moisten a pea−sized heap of powder with one drop of fresh urine. Nitrite in concentrations as low as 1 mg/L yields a carmine−red colour highly specific for the presence of nitrate−reducing bacteria. The test is positive in more than 80 % of urinary tract infections, although a negative test does not rule out significant bacteriuria. Test for haemoglobin and blood in urine or faeces Quick detection of haemoglobin or blood in urine or faeces is based on the property of haemoglobin to act as pseudo−peroxidase, which catalyzes the breakdown of hydrogen peroxide. This catalytic reaction can be detected by means of a colour reaction. Previously, benzidine or orthotolidine were used as reagents, but their use is no longer recommended because of their carcinogenicity. They can be replaced by guaiac resin. Reagents • guaiac resin (gum, Aldrich no. 28.598−6) • ethanol (96 %) • hydrogen peroxide (30 %) • diethyl ether • glacial acetic acid 1. Test for haemoglobin or blood in urine Dissolve 0.5 g guaiac resin in 30 mL ethanol. Prepare a 3 % hydrogen peroxide solution with distilled water. Place 5 mL urine in a test tube. Add the ethanol−guaiac solution to the urine until the mixture turns turbid. Add the 3 % hydrogen peroxide solution drop by drop. The mixture turns blue in the presence of haemoglobin or blood in the urine. 2. Test for haemoglobin or blood in faeces Dilute 30 mL of glacial acetic acid with 70 mL of distilled water. Mix a portion of faeces, about the size of a small walnut, with 3 mL of the acetic acid solution, in a test tube using a glass rod. Boil the emulsion over a small flame for 2 minutes or heat the mixture in a boiling water−bath for 10 minutes to destroy true peroxidase activity. Cool the mixture to room temperature. Add 3 mL of ethyl ether and invert the mixture several times to extract haeme compounds which are soluble in ether. Add a few drops of ethanol to allow for quicker separation of the layers. Pipette a few millilitres of ether extract onto 5 mL guaiac solution. The appearance of a blue ring at the interface of the two layers indicate the presence of haemoglobin or blood cells in the faeces. 1 Hawk, P.B., Oser, B.L. and Summerson, W.H. Practical Physiological Chemistry. Philadelphia; Toronto: Blakiston, 1947, p.774. Annex 6. Manufacturers of water testing kits DEL AGUA, THE ROBENS INSTITUTE University of Surrey, Guilford GU2 5XH, United Kingdom Tel: (0044)483− 572823 Fax: (0044)483− 503517 Telex: 859331 UNIVSY G Field analysis of faecal coliform bacteria, chlorine, pH, turbidity temperature and conductivity. MILLIPORE CORPORATION 80 Ashby Road, Bedford, MA 01730, USA Tel: (001)800−2251380 (East Coast); (001)800−6322708 (West Coast); (001)617 2759200 Fax: (001)617−2758200 Bacteriology tests HACH COMPANY P.O. Box 389, Loreland, CO 80539, USA Tel: (001)800−2274224 99 Bacteriology and chemistry tests ROTHMOORDE ANALYTICAL P.O. Box 38553, Suite 355, Houston, Texas 77238, USA Tel: (001)713−4457744 GUDIMANI ENTERPRISES 403−404 Saraswati House, 27 Nehru Place, New Delhi 110019, INDIA Tel: (0091)11−6417353; (0091)11−6413959 ELE INTERNATIONAL Ltd. Eastman Way, Hemel Hempstead, Hertfordshire HP2 7HB, United Kingdom Tel: (0044)442−2218355; Fax: (0044)442−252474 Telex 825239 WELSH WATER MARKETING Cambrian Way, Brecon LD3 7HP, United Kingdom Tel: (0044)874−3181 Fax: (0044)0874−4167 Telex: 497429 POTEPAK Ltd. 55, Long Avenue, London WC2E 9LJ, United Kingdom Tel: (0044)71−836−1016 Fax: (0044)71−240−1605 Telex: 297922 INTACLG INSTITUTE OF ENVIRONMENTAL HEALTH MONITORING Chinese Academy of Preventive Medicine, 9, Nan Wei Road, Beijing 100050, People’s Republic of China Tel: (0086)33−8761 Annex 7 Collecting water samples for microbiological examination Although it may seem a simple matter to collect a sample of water, errors can occur and special care is therefore needed; problems can also arise independently of the sampling technique used. Unless valid samples are collected, the careful work that is carried out in the subsequent analysis could be a complete waste of time. Water can be divided into three basic types for the purposes of sampling: • water from a tap in a distribution system, or from a fixed hand pump, etc.; • water from a watercourse or reservoir (river, lake, tank); • water from a dug well, etc., where sampling is more difficult than from an open water source. A. Sampling from a tap or pump outlet The steps to be followed in sampling from a tap or pump outlet are described in sequence below: 1. Clean the tap Remove from the tap any attachments that may cause splashing and, using a clean cloth, wipe the outlet in order to remove dirt. 100 2. Open the tap Turn on the tap at maximum flow rate and let the water flow for 1 − 2 minutes. Then turn the tap off again. 3. Sterilize the tap Sterilize the tap for a minute with the flame from an ignited cotton−wool swab soaked in alcohol. Alternatively, a gas burner or cigarette lighter may be used. 4. Open the tap prior to sampling Carefully turn on the tap and allow the water to flow for 1−2 minutes at a medium flow rate. 5. Open a sterilized bottle a) Standard technique: Untie the string the protective brown paper cover and pull out or unscrew the stopper. b) Machine−capping technique: Untie the string the protective brown paper cover and remove the cover, while an assistant opens the packet containing the sterile cap. 6. Fill the bottle Holding the cap and protective cover face downwards so as to prevent entry of dust that might carry microorganisms, place the bottle directly under the water jet, and fill. A small air space should be left to facilitate shaking at the time of inoculation prior to analysis. 101 7. Stopper or cap the bottle a) Standard technique: Place the stopper in the bottle or screw on the cap and fix the brown paper protective cap back in place with the string. b) Machine−capping technique: Place the cap in position and then secure it using the capping machine; attach the protective brown cover with the string. B. Sampling from a watercourse or reservoir 1. Open a sterilized bottle by the techniques described in A.5 above. 102 2. Fill the bottle Holding the bottle by the lower part, submerge it to a depth of about 20 cm, with the mouth facing slightly upwards; if there is a current, the bottle mouth should face towards the current. 3. Stopper or cap the bottle as described in A.7 above. C. Sampling from dug wells and similar sources 1. Prepare the bottle With a piece of string, attach a stone of suitable size to a sterilized sampling bottle. 2. Attach string to bottle Take a 20 metre length of clean string rolled around a stick and tie the end to the bottle neck. Open the bottle as described in A.5 above. 3. Lower the bottle Lower the bottle, weighted down by the stone into the well, unwinding the string slowly. Do not allow the bottle to touch the sides of the well. 4. Fill the bottle Immerse the bottle completely in the water and lower to the bottom of the well. 103 5. Raise the bottle Once the bottle is judged to be filled, rewind the string round the stick to bring up the bottle. If the bottle is completely full, discard some water to provide an air space. Stopper or cap the bottle as described in A.7 above. Annex 8 Non−profit−making suppliers for tropical laboratories INTERNATIONAL DISPENSARY ASSOCIATION (IDA) P.O. Box 3098, 1003 AB Amsterdam, The Netherlands Tel: (0031)2903 3051 Fax: (0031)2903 1854 Telex: 13566 IDA NL TECHNOLOGIE TRANSFER MARBURG Siemenstrasse 18, D−3550 Marburg, Germany Tel: (0049)06421−82031 Fax: (0049)06421−81580 ECHO Ullswater Crescent, Coulsdon Surrey CRS 2 HR, United Kingdom Tel: (0044)81−6602220 Fax: (0044)81−6680751 Telex: 924507 ECHOG SOLMEDIA 6, The Parade, Colchester Rd., Romford, Essex RM3 OAQ, United Kingdom Tel: (0044)04023 43334 Fax: (0044)04023 81790 Telex: 896462 INFORM G UNICEF PROCUREMENT AND ASSEMBLY CENTRE (UNIPAC) Freeport, DK 2100 Copenhagen, Denmark Tel: (0045)31−262444 Fax: (0045) 31−269421 Telex: 19813 FOUNDATION 7 MPAS P.O. Box 596, 1000 Ah Amsterdam, The Netherlands Tel: (0031)020 656541 Telex: 10433 IMPAS NL HAMLO Wilhelminapark 52, 3581 NM Utrecht, The Netherlands Tel: (0031)030−523792 (advice on laboratories; no equipment) Annex 9 Manufactures of photovoltaic equipment ARCO SOLAR EUROPE McGraw Hill House, Shoppenhangers Road, Maidenhead, Berkshire SL6 20L, United Kingdom Tel: (0044)0628−75011 BP INTERNATIONAL LTD. Solar House, 36 Bridge Street, Leatherhead, Surrey KT228BZ, United Kingdom Tel: (0044)0372−377 899 Fax: (0044)0372−377 750 Telex: 263220 BP SIL G CHRONAR LTD. Point West, 1040 Uxbridge Road, Hayes, Middlesex UB4 ORH, United Kingdom Tel: (0044)81−573−9807 Fax: (0044)81−573−5734 Telex: 498012 CHRNAR 104 DULAS ENGINEERING Ltd. Machynlleth, Powys SY20 9AZ. Wales, United Kingdom Tel: (0044)654 2400 HELIOS TECHNOLOGY Spa Via Postunia 11, 35010 Cormignano di Brenta, Italy Tel: (0039)49−943−0288 Fax: (0039)49−595−8255 SIEMENS SOLAR GmbH Frankfurter Ring 152, D−8000 Munich 40, Germany Tel: (0049)89−3500−2411 Fax: (0049)089−3500−2573 SOLAREX P.O. Box 6008, 1335 Piccard Drive, Rockville, Maryland 20850, USA Tel: (001) 301−948−0202 SOLENCO GmbH P.O. Box 100 219, D−4019 Manheim, Germany Tel: (0049)2224−78806 Fax: (0049)2224−79671 TELEFUNKEN SYSTEM TECHNIK GmbH Engineering Solar Energy Systems, Industriestrasse 23−33, D−2000 Wedel (Holstein), Germany Tel: (0049)4103−600 Fax: (0049)4103−604−701 Annex 10 Manufacturers of microscopes CARL ZEISS P.O. Box 1369/1380, D−7082 Oberkochen, Germany Tel: (0049)07364−20 Fax: (0049)07364−202382 Telex: 71375155 Field Microscope KF2, battery connection 12 V on request GILLET & SIBERT Kirktonfield Road, Neilston, Glasgow G78 3PL, United Kingdom Tel: (0044)41−8815825 Fax: (0044)41−8815828 Telex: 777298 Analynx T Microscope OLYMPUS OPTICAL Co. (Europe) Wendenstrasse 14−16, P.O. Box 104908, D−2000 Hamburg 1, Germany Tel: (0049)40−237730 Fax: (0049)40−233765 CH2 Model NIKON Haybrook, Halesfield 9, Telford, Shropshire TF7 4EW, United Kingdom Tel: (0044)952 587444 Fax: (0044)952 588009 Telex: 35509 K.W. KIRK & SONS Ltd. The Winship Industrial Estate, Milton, Cambridge CB4 48D, United Kingdom Tel: (0044)223−420102 McArthur microscope, McArthur fluorescene microscope Annex 11 Manufacturers of battery−driven and mechanical laboratory centrifuges BAYER DIAGNOSTICS (Ames, Technicon) B.P. 10−Z.1−R.N.1, F−95331 Domont Cedex, France Tel: (0033)(1) 39919212 Fax: (0033)(1) 39916531 105 HETTICH P.B. 260 D−7200 Tuttligen, Germany Tel: (0049)(0)7461−7050 Fax: (0049)(0)7461−705 125 STI SEPARATION TECHNOLOGY INC. 2340 South 2700 West, Salt Lake City, Utah, 84119−9801, USA Tel: (001)800−777−6668 Fax: (001)800−972−2533 ROY RICKMAN Riverdale, Beaford, Winkleigh, EX19 8AD, North Devon, United Kingdom Tel: (0044)8053 267 Dr KENDALL SMITH Dept. of Microbiology, University of Texas, San Antonio, Texas 78284−7758, USA Fax:(001)512−567−6612 SEPARATION TECHNOLOGY INC. 2340 South 2700 East, Salt Lake City, UT 84119, USA (Hematocrit centrifuge, battery or mains powered) SOLMEDIA TROPICAL LABORATORY SUPPLIES The Parade, Colchester Road, Romford, Essex RM3 0AQ, United Kingdom Tel: (0044)4023 43334 Fax: (0044)4023 81790 TECHNICAL RESEARCH ASSOCIATES INC. 410 Chipeta Way, Suite 222, Salt Lake City, Utah 84108−1209, USA Tel: (001)801−582−8080 Fax: (001)801−582−8182 Annex 12 Manufacturers of portable colorimeters and haemoglobinometers ARTEL HAEMOGLOBINOMETER 12 Depot street, Windham Maine, 04062, USA Tel: (001)207−8927531 Fax: (001)207−8928371 BAYER DIAGNOSTICS (Ames, Technicon) B.P. 10−Z.I.−R.N.1, F−95331 Domont Cedex, France Tel: (0033)(1)39919212 Fax: (0033)(1)39916531 BEIJING FILM MACHINERY RESEARCH INSTITUTE Jian gu wang Lang jia yuan, Beijing, Peoples’ Republic of China BIOTRON LTD. Church Lane, Bishop Thornton, Harrogate, Yorkshire HG3 3JP, United Kingdom Tel: (0044)423−770184 Fax: (0044)423−771874 HEMOCUE AB P.O. 1204, 262 23 Angelholm, Sweden Tel: (0046)431−17200 Fax: (0046)431−83035 Telex: 72052 HEMOQ S Note: order 1000 (5 packs) microcuvettes. State if a 110v or 220v battery charger is required. Two packs are available for non−rechargeable size AA(R6) or 8 R20 batteries. Dr BRUNO LANGE GmbH Königsweg 10, D 1000 Berlin 37, Germany Tel: (0049)30−81, 6020 Fax: (0049)30−81602270 DELPHI INDUSTRIES LTD. 27 Ben Lomond Crescent, Pakuranga, Auckland, New Zealand Tel: (0064)9−563−259 Telex: NZ 21992 106 KARL HECHT GmbH KG D−8741 Sondheim, Germany Tel: (0049)9779 −221 Fax: (0049)9779−1868 Primecare BV P.O.B. 545, 7500 AN Enschede, The Netherlands Tel: (0031)53− 341111 Fax: (0031)53−341112 S.E.R.O.A. SA 16, rue des Orchidées, MC 9800, Monaco Tel: (0033)92057231 Fax: (0033)93507256 WALDEN PRECISION APPARATUS LTD. The Old Station, Linton, Cambridge CB1 6NW, United Kingdom Tel: (0044)223−892688 Telex: 817330 CROFT−GREINER INSTRUMENT LTD. Technorth, Harrogate Road, Leeds LS7 3NB, United Kingdom Tel: (0044)532 624805 Fax: (0044)532 626446 SWELAB INSTRUMENT AB P.O. Box 839, S−121 08 Johannehov, Sweden Tel: (0046)8−810330 Fax: (0046)8−7229448 Telex: 17493 LOVIBOND Hb test: TINTOMETER Ltd Waterloo Road, Salisbury SP1 2JY, United Kingdom Tel: (0044)722−327242 Telex: 47372 TINTOCO G Annex 13 Suppliers of portable incubators discussed in the guidelines TDR/WPRO World Health Organization, P.O. Box 2932, 1099 Manila, Philippines Telegraph UNISANTE MANILA TELEX 27652 − 63260 − 40365 Portable, includes 12 V, 24 amp/h non−spill battery; unit can be used with any compatible 12 V DC source G.Q.F. MANUFACTURING COMPANY P.O. Box 1552, Savannah, GA 31402, USA Tel: (001)912−236−0651 Portable; 110, 220 or 12 V Annex 14 Cold chain equipment for blood storage and transport Equipment Icelined refrigerator, compression type, 128 litres, top−opening Model MK142. Manufactured by Vestfrost. Icelined refrigerator and icepack freezer, compression type, refrigerator 80 litres, freezer 40 litres, top−opening, Model TCW 1990. Manufactured by Electrolux. Photovoltaic solar refrigerator and icepack freezer, top−opening, refrigerator 45 litres, icepack freezer 5 litres. Model VR50. Manufactured by BP International Ltd. 107 Long range cold box, Model RCW 25 with icepacks, 20.7 litres. Manufactured by Electrolux. Long range cold box, Model RCW 12, 8.9 litres. Manufactured by Electrolux. Long range cold box, Model 788−901 x 28, legend, 20 litres. Manufactured by Igloo Corporation. Insulated carrier, Model 3504/38, 1.7 litres. Manufactured by Thermos Ltd. Manufacturers VESTFROST A/S P.O. Box 2079, Spangsbjerg mollevej 100, DK−6705 Esjeberg O, Denmark Tel: (0045)75−142222 Fax: (0045)75−143939 ELECTROLUX (Luxembourg) 4, rue de la Frontière, L−9412 Vianden, Luxembourg Tel: (00352)84595 Fax: (00352)848 11−300 BP INTERNATIONAL Ltd. Solar House, Bridge Street, Leatherhead, Surrey KT 22 8BZ, United Kingdom Tel: (0044)372−377 899 Fax: (0044)372−377 750 IGLOO CORPORATION P.O. Box 19322, 1001 West Belt Drive, Houston, Texas 77224−9322 USA Tel: (001)713−465−2571 Fax: (001)713−973−4845 THERMOS LTD. Ongar Road, Brentwood, Essex CM 15 9AY, United Kingdom Tel: (0044)277−213−404 Fax: (0044)277−260−071 For further information on these and other items of refrigeration equipment, see WHO/EPI Product Information sheets [6]. Annex 15 Manufacturers of photovoltaic refrigerators ELEXTROLUX 4, rue de la Frontière, L−9412 Viandon, Luxembourg Tel: (00352)84595 Fax: (00352)848−11 300 KISSMANN Gundermannstrasse 7, D−8000 Munchen 45, Germany Tel: (0049)89−313/5632 Fax: (0049)89−314/8115 CHRONAR Ltd. Point West, 1040 Uxbridge Road, Hayes, Middlesex, UB4 ORH, United Kingdom Tel: (0044)81−573−9807 Fax: (0044)81−573−5734 Telex: 498012 CHRNAR ARCO SOLAR EUROPE McGraw Hill House, Shoppenhangers Road, Berkshire SL6 20L, United Kingdom Tel: (0044)628−75011 108 DULAS ENGINEERING Ltd. Machynlleth, Powys SY20 9AZ, United Kingdom Tel: (0044)654−2400 Annex 16 Manufacturers of water purification systems Aluminium filter, gravity, type capacity 9 litres (output: 80 litres per 24 hours) FAIREY INDUSTRIAL CERAMICS LTD. Filleybrooks, Stone, Staffs STI 5 OPU, United Kingdom Tel: (0044)0785−813241 Fax: (0044)0785−818733 (Doulton and British Berkfield Filters, Sterasyl candle filters) ECHO Uhhswater Crescent, Coulsdon Surrey CR5 2HR, United Kingdom Tel: (0044)81−6 60−2220 Fax: (0044)81−668−0751 Telex: 947507 ECHO G Bench Deionizer J. BIBBY SCIENCE PRODUCTS LTD. Stone, Staffordshire, ST15 OSA, United Kingdom Tel: (0044)785−812121 SURE WATER P.O. Box 5, Route 58 Business Highway, Lawrenceville, VA 23868, USA Tel: (001)804 848−0059 Fax: (001)804 848−0959 PERMUTIT COMPANY Ltd. Permutit House, 632−652 London Road, Isleworth, Middlesex TW7 4EX, United Kingdom Tel: (0044)81 560 6431 Fax: (0044)81 568 9772 Telex: 924640 Annex 17 Filter paper technique for collection and transport of body fluid specimens General The transport of liquid specimens soaked on filter paper is a simple and safe procedure. The filter paper can be used in any format but is commonly incorporated into a form or card specifically constructed for sample collection. All kinds of body fluids can be absorbed, although the technique is most often used for the collection of blood. The card can be easily transferred to a distant laboratory for screening or confirmatory testing. Body fluid absorbed on a filter paper can be processed for qualitative and/or quantitative serological and immunological investigations. Suitable filter paper is Whatman no. 1 or Schleicher and Schuell1. Cards with incorporated filter paper, which can also be used for registration of the patient and filing, can be obtained from Schleicher and Schuell. 1 Schleicher and Schuell GmbH, P.O. Box 4, D−3354 Dassel, Germany. Tel: (0049)55612−791−0; Fax (0049)5561−791536 Technique for blood sampling 1. The wearing of gloves is recommended for blood sampling. It is important that the filter paper surface does not come into contact with gloved hands or any other material, solutions and lotions, prior to and during the entire process of sampling. 2. Complete the patient’s data on the card with a ball−point pen. Do not touch the filter paper circle area. 3. Clean the puncture site on the patient’s finger tip, or heel if an infant, with 70 % alcohol. Wipe the site dry with a sterile gauze. Use a sterile disposable lancet for puncture. Wipe away the first drop of blood with dry sterile gauze. 109 4. Gently touch the filter paper against a large drop of blood and allow the blood to soak through, until the preprinted circle on the filter paper is completely filled. Avoid squeezing the punctured site as this will cause haemolysis of the specimen and a dilution of the blood with tissue fluids. Do not layer successive drops of blood in the printed circle because this may cause caking. Do not apply blood to the filter paper more than once. Apply blood to one side of the filter paper only. Incompletely blood−soaked circles are not acceptable 5. Allow the blood specimen to dry for 3 hours in the air in a horizontal and preferably elevated position (to avoid contamination and to allow better circulation of the air around the card for drying). Do not let the specimen come into contact with any surface, direct heat or sunlight. Do not refrigerate the samples. 6. Place each dry specimen card into an envelope or a small plastic bag, add a few granules of desiccant and close the envelope hermetically for mailing. Store the filter paper in a plastic bag in a cool dark dry place. Specimens that have been stored up to three months, under appropriate conditions, may give acceptable results. Figure A.1 Blood sampling on filter paper Recommended literature 1. Benenson, A.S. Control of Communicable Diseases in Man. Washington: American Public Health Association, 1990. 2. Britten, A., Ala, F. and El−Nageh, M. Blood transfusion: Basic text. Alexandria: World Health Organization, Regional Office for the Eastern Mediterranean, 1993. 3. Brés, P. Public Health Action in Emergencies Caused by Epidemics. Geneva: World Health Organization, 1986 4. Cheesbrough, M. Medical Laboratory Manual for Tropical Countries. Volume 1: Anatomy and Physiology, Clinical Chemistry and Parasitology. Volume 2: Micronbiology. Oxford: Butterworth−Heinneman. 1991 5. Dunsmore, D.J. Safety measures for use in outbreaks of communicable disease. Geneva: World Health Organization, 1986 6. Emergencies: special issue. Journal of the World Food Programme 7. Fleck, S.L and Moody A.H. Diagnostic Techniques In Medical Parasitology Oxford. Wright, 1988 8. 110 Johns, W. Establishing a Refugee Camp Laboratory. A Practical Guide. London: Save the Children Fund, 1987. 9. Lacroix, C. Propos sur le laboratoire élémentaire en pays tropicaux. Paris: Médecins sans Frontières, 1989. 10. Levy−Lambert, E. Manual of basic techniques for a health laboratory. Geneva: World Health Organization, 1980. 11. Madely, C.R. Guide to the collection and transport of viral specimens. Geneva: World Health Organization. 12. Pratt, Brian and Boyden, Jo, eds. The Field Director’s Handbook: An Oxfam manual for development workers. Oxford: Oxford University Press, 1985. 13. Prepared for disaster. Appropriate Technology. June 1990, 17(1) 14. DISASTERS: Special Issue. Tropical Doctor, 1991, 21, Suppl. No 1. Available from Royal Society of Medicine, 1 Wimpole St., London WIM 8 AE, United Kingdom. 15. United Nations Children’s Fund. Assisting In Emergencies, A Resource Handbook For UNICEF Field Staff, Copenhagen: UNICEF, 1986. 16. United Nations High Commission for Refugees. Handbook for Emergencies: Field Operations. Geneva: UNHCR, 1982 17. World Health Organization. Basic Laboratory Methods in Medical Parasitology. Geneva: World Health Organization, 1991. 18. World Health Organization. Basic Laboratory Procedures in Clinical Bacteriology. Geneva: World Health Organization, 1991. 19. World Health Organization. Be Prepared (issue theme on disasters). Geneva: World Health Organization 20. World Health Organization. Coping with Natural Disasters: the role of local health personnel and the community. Geneva: World Health Organization, 1989. References [1] Brés, P. Public Health Action in Emergencies Caused by Epidemics. Geneva: World Health Organization, 1986. [2] El−Nageh, M., Heuck, C. Appel, W., Vandepitte, J., Engbaek, K. and Gibbs, N Basics of Quality Assurance for Intermediate and Peripheral Laboratories. Alexandria: World Health Organization, Regional Office for the Eastern Mediterranean, 1992. [3] World Health Organization. WHO Action in Emergencies and Disasters. Geneva: World Health Organization, 1989 (unpublished document PCO/EPR/89.6) [4] International Air Transport Association (IATA). Dangerous Goods Regulations: 33rd ed. International Air Transport Association, 1992 (IATA). 111 [5] World Health Organization. Plasma and Plasma Substitutes in Developing Countries. Geneva: World Health Organization, 1989 (unpublished document WHO/LAB/89.9) [6] World Health Organization. Autologous Transfusion in Developing Countries. Geneva: World Health Organization, 1991 (unpublished document WHO/LBS/91.2) [7] World Health Organization. WHO/EPI Product Information Sheets. Geneva: World Health Organization, 1991 (unpublished document WHO/UNICE/EPI.TS91.1) Note. Unpublished WHO documents are available on request from the World Health Organization, 1211 Geneva 27, Switzerland. Back cover Health Laboratory Facilities in Emergency and Disaster Situations Emergencies and disasters demand prompt and adequate response. In such situations basic medical care is essential to limit morbidity and mortality due to infectious diseases and other medical conditions. The provision of disaster relief includes the support of health laboratory services, as many infectious diseases require laboratory facilities to make or confirm diagnosis, or to collect valid epidemiological data. This publication is intended to provide information on how to provide basic laboratory services in emergency situations. It will also assist international agencies, national authorities and other bodies involved in emergency and disaster relief in drawing up contingency plans for the provision of emergency laboratory services. This publication is also a guide for establishing laboratory facilities that can appropriately respond to emergencies using minimal possible supplies and the appropriate technology. ISBN 92−9021−182−2 112