I believe accurate reporting of infectious diseases, including diarrhoeal diseases, to be a significant issue of consideration in both developed and developing nations. Accurate reporting by the individual, as well as by medical and government institutions, is imperative for analysis of infectious disease epidemiology. With accurate reporting, especially of cholera cases and cholera typing, appropriate therapeutic and preventative measures can be put in place.
Here, Marie Anne Chattaway, a microbiologist from the UK, describes her experiences working with the WHO in Sierra Leone establishing an Enteric Bacteria Laboratory in Sierra Leone. Their goal was to aid cholera diagnosis and reporting in this region. I can’t thank Marie Anne (firstname.lastname@example.org) enough for sharing her project. I wish her and the taskforce every success in the future.
Thank you to Marie Anne, WHO and Sierra Leone.
Marie Anne and Cholera in Sierra Leone
I first became interested in developing countries when I started to volunteer for JIDC (The Journal of Infection in Developing Countries) a couple of years ago as a scientific editor and reviewer where the focus was mentoring scientists to publish their research in a scientific journal. I have been working with enteric pathogens for over five years at the Health Protection Agency of the UK and now realise just how much of an impact bacterial enteric infection has in developing countries. Until now, I had only managed to help from the UK, but the outbreak in Sierra Leone provided me with an opportunity to really use my microbiological skills where it was needed the most.
Cholera outbreak in Sierra Leone
Sierra Leone (Picture 1) has recently battled its worst cholera outbreak in 15 years. In
July and August 2012, the epidemic rapidly spread to all but one of Sierra Leone’s 13 districts. With a combination of crowded housing (Picture 2), unsafe water supplies, poor sanitation and the rainy season ahead, intervention was paramount. On 16 August 2012, the Sierra Leone government declared the outbreak to be a public health emergency, and established the Presidential Taskforce on Cholera. As of 2 October 2012, there had been 20,736 cases, including 280 deaths (case fatality rate or CFR=1.35%). The western area of the country where the capital city of Freetown is located was the most affected area with more than 50% of total cases. Initial training and some supplies were provided to the Central Public Health Reference Laboratory (CPHRL), Lakka and Connaught Hospital, in Freetown by the World Health Organization (WHO) and International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B). The Global Outbreak Alert Response Network (GOARN) later requested a microbiologist to further evaluate laboratory facilities and provide technical advice and assistance to strengthen laboratory services for detection of cholera cases, capacity for confirmation by laboratory identification and for conducting differential diagnosis for main enteric pathogens (e.g., Vibrio cholera, Shigella, Salmonella, E. coli). The Health Protection Agency (HPA), UK, sent a microbiologist from the Gastrointestinal Bacteria Reference Unit (GBRU) to undertake this task from 10 October to 8 November 2012.
Travel to Freetown
The HPA was already involved with the cholera outbreak with a focus on epidemiology and case management; Sarika Desai and William Welfare from the HPA had already been deployed as WHO consultants. The specific request for a microbiologist to go to Sierra Leone for the month came later and though I had volunteered to go, in the end I had only 24 hours’ notice that I was on the flight the next day and that urgent supplies were needed. Needless to say, my two large suitcases were filled with consumables as well as clothes, a ridiculous amount of a range of pharmaceutical products (which I did end up using – unfortunately), and insect repellent (the insects still got me, though). I’m not sure what part of the journey was the worst: the bad turbulence on the plane with the woman behind me screaming; the small speedboat trip across the sea in the pitch black; the jolting of the spine across the dirt tracks in the jeep;, or the sickness on arriving when adapting to the humidity and heat (as you know, we English are used to the cold). Either way, I did make it in one piece and was so happy that I didn’t crash in the plane and impressed by the stunning views (Picture 3) that actually I didn’t mind the bumpy roads.
Assessment of the laboratory
I was fortunate that there was a dedicated laboratory which had been selected to develop testing based at the Central Public Health Reference Laboratory (CPHRL) in Lakka. It was an hour away from the WHO office. Prior to intervention the department was faced with challenges of the lack of supplies, shortage of available trained staff, poor processing systems, and inadequate Health and Safety protocols in the enteric bacteria section of the CPHRL. The icddr-b had done a fantastic emergency response but further work was now required to establish and maintain an enteric bacteria laboratory in Sierra Leone.
Establishing an Enteric Bacteria Laboratory in Sierra Leone
Before training could even begin, a supplies stock system with the support of the WHO, HPA, CDC and Ministry of Health and Sanitation (MoHS) was set up to receive the required equipment and supplies. Molly Freemen from the Enteric Diseases Laboratory Branch of the CDC joined me for 11 days and the collaboration of all these organisations enabled the success of this mission. Intense training of multiple staff was necessary to maintain function after I left and the staff worked incredibly hard, even coming in at weekends and public holidays. A quality accredited process was set up, including the design of request forms for necessary information, the development of protocols for taking samples, receiving and logging the samples into CPHRL, and testing and recording results on the enteric result database for reporting (Picture 4). A surveillance link was also set up
so that regular weekly reporting of confirmed enteric pathogens is fed back. The two weeks of practical (Picture 5) and theoretical training was followed by intense three-day theory and practical competency testing. Staff were then certificated in “Isolation and identification of Vibrio cholerae, Salmonella typhi, non-typhoida, lSalmonella, Shigella sp. and E. coli O157” and “Health and Safety and Quality Systems in the enteric bacteria laboratory” (Picture 6).
Challenges and future Work
To sustain the new laboratory service, there is still much work to be done. The supply system must be managed to ensure stock is available when needed. Regular testing at the laboratory and reporting of results are essential for monitoring the cholera situation in the country. The biggest challenge will be the organisation and implementation of regular sample collection and transport to CPHRL. Without regular samples from the districts, the testing competency and surveillance cannot be maintained. The impact of this part of the international response has been considerable; there is now a system for detecting and confirming cholera and other enteric pathogens within Sierra Leone. If this laboratory component of surveillance is sustained it will lead to a better understanding of the incidence of cholera in the country and provide earlier recognition should the infection become epidemic again, thus enabling a rapid response.
Would I recommend this experience
Absolutely! It was an amazing experience, from networking and collaborating on an international scale with the most amazing and interesting people to experiencing the culture. I felt a real sense of achievement seeing how I can personally make a difference. It is hard work, working long hours with little breaks in sometimes difficult conditions, but the end result was worth any hardship. My favourite challenge was when I first opened the incubator to find lots of small ants favouring the Trypticase Soy agarplates. At first I didn’t think much of it, but when I looked at the plates carefully I saw tiny ant footsteps left by the insects that had walked on a cholera plate just after it had been inoculated. The ants had walked across the plate, dragging the bacteria with it (Picture 7). It is possible that perhaps there is a vector influence with the spread of some diseases that we wouldn’t normally consider!
By Marie Anne Chattaway
**Pictures taken by Marie Anne Chattaway, HPA.