REPORT OF VISIT TO PAKISTAN-SEATO CHOLERA RESEARCH LABORATORY

BY NIH CHOLERA ADVISORY COMMITTEE, JANUARY, 1962

I INTRODUCTION

11 PROPOSED PLANS FOR IMMEDIATE DEVELOPMENT

III BROAD POLICY RECOMMENDATIONS

Iv SUMMARY
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3 INTRODUCTION

The Pakistan-SEATO Cholera Research Laboratory (CRL) in Dacca has
developed considerably during the past year, both as regards its staff
and its scientific accomp]ishnents. |

Dr. Fred L. Soper, one of the world's renowned public health experts,
recently retired from the Directorship of the Pan American Sanitary
Bureau, assumed the Directorship of the Cholera Research Laboratory in
February, 1961, T,rough his efforts, the administrative procedures and
the administrative staff have been put on a working basis, During the
year a revised agreement between the Government of Pakistan and the
United States has been negotiated in order to facilitate the research
effort, Among other things, this provides greater autonomy for the
CRL and gives it a Directing Council] and a Technical Advisory Committee,

A new Section on Clinical Research hag been established with
Dr, RObert S, Gordon, one of the senior investigators of the NIH, in
charge, Assisting him is another USPHS officer, Dr, ©. Ross McIntyre.
These two have cfeated a research laboratory for biochemical and
physiological investigations and are in the final stages of establishing
a 20 bed ward in which they will study cholera cases in the acute phase
of the disease,

A functioning water analysis laboratory, with equipment and trained
Pakistani technicians, was added to the CRL through the good offices of
the Agency for International Development (AID) Mission to Pakistan when

the Parsons Company completed its survey of water resources in Fast
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Pakistan for AID, This laboratory has already proved to be a considerable
asset in the field studies on cholera,

Dr, K, A, Monsur, the Chief of the Bacteriology Section of the CRL,
has developed improved techniques for the diagnostic isolation of Vinrip
cholerae, the cause of the disease, Of greatest interest is his
maintenance media used in transporting specimens, The usually fragile
vibrio survives in this media, even when held for weeks, The availability
of such a new tool has enabled Dr. Soper and CRL to formulate a plan
for the continuing surveillance of cholera in East Pakistan, Thus, samples
of the media and swabs for obtaining rectal specimens will be sent to
Rural Health Centers and to villages; in the latter they may be placed
in the care of the school teacher, When any diarrheal disease appears
in the populations under observation, specimens will be obtained bythe
teacher and sent by ordinary mail to the CRL for bacteriological diagnostic
studies.

Increasing interest in CRL in Dacca has been demonstrated by other
governments, For instance, the United Kingdom has contributed to the
CRL Laboratory equipment in the amount of 810,000. These funds were
utilized for the purchase of laboratory equipment for the physiology
laboratory of CRL and fo¥ certain equipment for general use by the CRL.

The proceedings of the International Conference on Cholera, held
in December, 1960, in Dacca, 18 now at the printer, This 150-page
monograph will make available to scientists throughout the world the most .

current information on cholera,
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II PROPOSED PLANS FOR IMMEDIATE DEVELOPMENT

As outlined above, notable progress has been made in completing the
agreement which defines the status of CRL as an autonomous unit and in
specifying the mechanisns for its financial support. ‘The agreement defines
Clearly the framework in which the work of the laboratory can progress and
provides the basis for its successful operation in the future, Great
credit ia due to Dr, Soper for his skill and patience in bringing these
negotiations to such a happy conclusion,

With the completion of this agreement it is now possible to nove
forward to remedy the deficiencies in organization, staffing and program
of the laboratory,

1. Replacement and augmentation of scientific staff.

The imminent departure of Dr, Fred L. Soper, to assume
responsible duties elsewhere, not only will create a vacancy difficult
to fi11 but also will impose a need for restructuring the senior staffing
pattern of CRL, It is vital for the continued development of CRL that
a senior scientist or public health expert with broad experience in
administration and in international affairs be recruited promptly to serve
as Director of CRL,

It ig recommended that the position of Scientific Director
by created promptly in CRL, The individual who occupies this position
would be responsible to the Director of CRL for all the scientific activities
of the laboratory, He would provide general scientific direction to the

dntets / the Sections ef Ciinical Investigations, Epidemiology, Bacteriology
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and the Sectiong $f Water and Sanitation, At the present stage of
development of CRL, one of the Section Chiefs could also serve as
Scientific Director, It is recommended that Dr, Robert Gordon, currently
Chief of the Section in Clinical Investigations be given the additional
responsibility of serving as Scientific Director of CRL,

The position: of Deputy Director should be retained with responsibilities
limited to those of serving for the Director in his absence and of assuming certain
administrative activities which are specifically assigned to him by the
Director, Dr, Joe Stockard should continue to serve as Deputy Director
but this responsibility should not be permitted to interfere with his
primary duty as Chief of the Section on Epidemiology,

2. The need for a senior bacterio

 

Because of the departure of Dr, K, A. Monsur from the
laboratory to become director of the Institute of Public Health, a serious
deficiency has been created, It is imperative that a vigorous search be
begun immediately to find a guecessor to Dr, Monsur, On the success of
this search hinges the entire future of CRL,

Because of his knowledgeableness in the field of cholera
and because the work of CRL and the Institute of Public Health are
complementary, itis recommended that Dr. Monsur be retained as a
consuj tant to CRL with appropriate remuneration, While this is important
for the long range program of CRL it is essential that his services be

obtained pending the appointment of a full time senior bacteriologist,
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3. Opening of ward facilities:

The present scientific staff of the laboratory is concerned
mainly with the clinical aspects of the disease, elucidation of the
physiological abnormalities and their treatment, It is essential that
operation of the ward be started at an early date so that advantage can
be taken of the scientific opportunities that will cccur with the beginning
of the epidemic that can be expected in the spring. In addition to the
prime scientific reason for an early opening of the clinical facility,
there are other reasons which make this move important such as the
following: provision of a demonstration unit for instruction of Pakistani
physicians in scientific therapy of cholera; recruitwent of young clinicians
into the program; development of a basis for good public relations with
Pakistani physicians and health workers; putting into use needed clinical
facilities which are standing idle,

For these reasons it is recommended that the ward be opened carly
in the spring of 1962 even though expedients must be devised for food and
laundry services. .

4. Relationship of CRL to neighboring scientific institutions:

Further development of collaboration between CRL, Dacca Medical
College and Mitford Hospital are essential for the scientific growth of the
laboratory, Tis is of particular impQrtance in order to provide effective
training for young Pakistanis,in the epidemiology and treatment of cholera
as well as for the recruitment of clinical and scientific personnel.

The close association, understanding and collaboration now existing

between CRL and the Institute of Public Health should be fostered and
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developed further, This can be accomplished by joint appointments and
consultantships, by the provision of facilities and equipment to be used
in common, and by carrying out joint soientific programs.
5. Collaboration of CRL with institutions and agencies in other countries:

The associations and collaborative efforta of CRL should be
extended beyond its neighboring organizations, Tey should embrace other
interested groups in distant regions including those in the NIH, Jefferson
Medical College, NAMRU 2, and the SEATO Medical Research Laboratory,
Bangkok,

Experience during the past twelve months with cholera in mainland
China, Indonesia, Sarawak, Hong Kong and the Philippines emphasizes the
need for intensifications of work on all aspects of this disease by
individual sefentists and by national and international groups. Furthermore,
the rolling front of cholera in the Western Pacific demands that CRL
assume some of the obligations implied under its SEATO banner, With the
latter point in mind it is recommended that as soon as the first neeting
of the Directing Council of CRL is completed both Dr. Soper and Dr. Stockard
visit a number of the affected and potentially threatened areas. Dr. Soper
could profitably spend the interval before completing his duties with CRL
in discussions with officials of SEATO Nations regarding participation in
international aspects of cholera control, It is also recommended that Dr,
Stockard spend a month or so in the Philippines studying the epidemblogy of

cholera, particularly the mode of spread in this non-endemic area,
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6. Epidemiologicn) and Vaccine Studies;

Epidemiological studies of two general kinds should be started
as soon as possible:

(a) Intensive study should be undertaken of a population in a
defined area with the primary aim of determining the effectiveness of
cholera vaccines and secondary aims such as the relationship of nutritional
status to pathogenesis, This study should be set up in an accessible area
such as the Health District at Masinpur where a Health Center has just
heen established, To be fully effective studies of cholera should be
coordinated with other studies or surveys to be carried out by the Pakistan
Government either by itcelf or in collaboration with official agencies
such as AID or private agencies such as the Population Council, These
studies should include an intensive nutritional survey in a population
group of approximately 50,000 persons as well as a sanitary survey, Of
fundamental importance to the success of all of these studies is an accurate
census and demographic analysis of the population of the Health District,

(b>) Study of the persistence of cholera vibrio in a highly
endemic area, This study should be directed tovardboth overt cases and
inapperent infections or carriers and to the presence of the vibrio in
the environment, Its purpose would be to determine how the vibrio is
maintained in a population between epidenics,

Because of the extensive efforts involved in accunulating
necessary information on a population group before studies of the type mentioned

in “a) can be undertaken profitably, it is recommended that initial
epideniological efforts be concentrated in the intensive survey, When the
mechanions for this are operative, then attention can be concentrated on
the area and population which can be studied for persistence of yvibrio
cholerae. It is the concensus of the visiting group that the same site
will not be suitable for both types of epideniologic study,

IIZ BROAD POLICY RECOMMENDATIONS

The committee has concerned itself primarily with technical
and administrative matters that bear directly on CRL and are pertinent
for the immediate future, At this point, howdver, it feels constrained
to comment on long range objectives that should be brought to the attention
of the Directing Council, the Staff of the Laboratory and the Supporting
Groups, and hopefully will become incorporated into the philosophy of
CRL.

1, It is the opinion of the Committee that the problem of
cholera is of such breed significance to world health that any activity
short of one which brings the techniques of science to bear directly and
importantly on the many problems of the disease is shortsighted and inadequate.

2. @RL has already established itself as a key factor in the
apparatus that will be required to eradicate the disease, Support for CRL
is imperative in obtaining funde, physical facilities and the high level
scientific staff it requires to contribute its share to the accomplishment
of the enormous tasks ahead,

3. Consequently, it is recommended that the staff of CRL continue
their planning with less regard to the funds which have been available up

to the present than to the importance of the task they address themselves to,
Tv SUMMARY

2. CRL has made solid progress during the past year especially in the
administrative area, This has resulted in an agreement which defines its status
as an autonomous wit, which outlines its program and responsibilities in
broad terms and which specifies the mechanisms for its support.

2, With its status clearly defined CRL should proceed forthwith to
replace the scientific staff it has lost and to augment it as indicated
above; to Hegin ite clinical and epidemiological programs; and to develop

in detail its long range progran,

This report ie based on a visit to Dacca, January 21 to 26, 1962
by Drs, Kenneth Goodner, Colin MacLeod, Joseph B, Smadel and Theodore
Woodward, members of the NIH Cholera Adviscry Committee, and by Drs, .
Robert Phillips and James Shannon who served as Consultants, Other
members of the Committee, who for one reason or another wera unable
to participate in this activity, are Dre, A.8. Benenson, Williem Burrows,

Janes Kingston, and Clifford Pease,

 

Kenneth Gocdner

 

Colin M, MacLeod

 

Robert A. Phillips

 

James A, Spannon

 

Joseph E, Smadel

 

Theodore E. Woodward