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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
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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.
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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
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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.
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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
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