Outcome of a One-Week Intensive Training Workshop for Veterinary Diagnostic Laboratory Workers in Liberia

ADVANCE ONLINE ARTICLE Outcome of a One-Week Intensive Training Workshop for Veterinary Diagnostic Laboratory Workers in Liberia Julie A. Williamson n Susan J. Tornquist ABSTRACT There is a huge unmet need for veterinary diagnostic laboratory services in developing nations such as Liberia. One way of bridging the service gap is for visiting experts to provide veterinary laboratory training to technicians in a central location in a short-course format. An intensive 1-week training workshop was organized for 18 student and faculty participants from the College of Agriculture and Integrated Development Studies (CAIDS) at Cuttington University in rural central Liberia. The training was designed and delivered by the non-governmental organization Veterinarians Without Borders US and funded through a Farmer-to-Farmer grant provided by the United States Agency for International Development. Although at the start of training none of the students had any veterinary laboratory experience, by the end of the course over 80% of the students were able to discuss appropriate care and use of a microscope and name at least three important components of laboratory record keeping; over 60% were able to describe how to make and stain a blood smear and how to perform a passive fecal flotation; and over 30% were able to describe what a packed cell volume is and how it is measured and name at least three criteria for classifying bacteria. The intensive training workshop greatly improved the knowledge of trainees about veterinary diagnostic laboratory techniques. The training provided initial skills to students and faculty who are awaiting the arrival of additional grant-funded laboratory equipment to continue their training. Key words: laboratory science, veterinary diagnostics, short course, outcomes assessment, global issues in veterinary education INTRODUCTION Liberia s civil wars, spanning from 1989 to 2003, severely disrupted animal agriculture in the country. Livestock quality and numbers are still less than pre-conflict levels due to the lack of quality breeding stock, the inadequate knowledge of appropriate animal husbandry, the random importation and movement of animals without proper biosecurity precautions, and the outbreaks of infectious diseases, including contagious bovine and caprine pleuropneumonia, foot and mouth disease, Newcastle disease, avian influenza, and peste des petits ruminants. In its attempt to rebuild the country, the government of Liberia has identified animal agriculture as a priority area for improvement due to its potential positive impact on human nutrition, health, and livelihoods. Reliable, timely access to veterinary diagnostic laboratory services is critical to the recognition and control of animal disease and subsequent success in animal restocking efforts. At present, Liberia has a single veterinary diagnostic laboratory, the Fendell National Veterinary Laboratory, located in the capital city of Monrovia. This laboratory has trained technicians in disease diagnostics, but the government of Liberia s budget limitations have resulted in a lack of reagents, intermittent electric current availability, and doubts about the government s ability to continue support of the laboratory. The development of additional veterinary laboratory facilities and the improvement of practitioner-to-laboratory linkages is critical to improve the delivery of animal health services, break cycles of animal disease, and protect public health. In 1994, the Agreement on the Application of Sanitary and Phytosanitary Measures was adopted as part of the Uruguay Round of Multilateral Trade Negotiations General Agreement on Tariffs and Trade. The agreement provided guidelines to member countries to enhance and regulate trade while maintaining protection against human, animal, and plant disease. The agreement advocates the use of standards from the World Organization for Animal Health (OIE), which has developed an official animaldisease status recognition for member countries. Countries such as Liberia that lack OIE disease status certification have a significantly impaired ability to trade internationally. If Liberia gained veterinary diagnostic expertise and infrastructure for trans-boundary disease control, attaining OIE certification could be possible, further boosting the country s development of its agricultural economy. One proposed method for bridging the service gap is to provide veterinary laboratory training to technicians in a central location in an intensive short-course format. doi: 10.3138/jvme.0413-061R JVME 2013; advance online article 1

Courses of this type are common in the developing world and may be funded by local or national governments or non-governmental organizations. 1 3 The impact of short courses on veterinary paraprofessionals in developing nations is not fully known, although limited studies of such courses have found an overall positive impact on the activities of trainees. 4,5 The success of short intensive training courses in preparedness for highly pathogenic avian influenza led investigators to conclude that the same approach could be used to develop educational materials for other diseases that pose a threat to animal agriculture. 6 The United States Department of Defense also reports success using a 2-week Surveillance Food Laboratory Technician course to train technicians in laboratory methodologies and procedures. 7 The purpose of this study was to test the application of such short courses to veterinary laboratory skills training in a developing world setting while concurrently strengthening foundations for the advancement of livestock health in Liberia. MATERIALS AND METHODS An intensive 1-week training workshop was developed for students and faculty from the College of Agriculture andintegrateddevelopmentstudies(caids)atcuttington University at the request of the Dean and faculty. The location of the University was considered optimal for the workshop due to its proximity to large livestock populations in rural central Liberia. The workshop was designed and delivered by the non-governmental organization Veterinarians Without Borders US through a Farmer-to-Farmer grant provided by the United States Agency for International Development. The course was delivered by three veterinarians and one veterinary student for an intensive trainer to trainee ratio of 1:4.5. At the end of the course, students were individually orally examined to evaluate the knowledge they gained through the course. Assessment was conducted via one-on-one oral examination, with each trainee interviewed from a standard list of questions that equally covered the whole curriculum. Each student received a certificate of completion and filled out an evaluation of the workshop. RESULTS Eighteen student and faculty participants most likely to benefit from the workshop were chosen by administrators at CAIDS. These 18 participants included 15 males and 3 females. Eleven were students, four were CAIDS faculty or administrators, and three were members of the local animal agricultural community. The CAIDS students were selected for their strong academic background, stated interest in animal agriculture as it relates to the development of Liberia, and likelihood of continuing their education in laboratory science. The participation of CAIDS faculty and administrators served as training the trainers, which provided greater impact because better trained educators will improve the education of future students. Members of the local animal agricultural community were selected to provide industry input and practical experience as well as to build relationships between the educational community and local practitioners. While the participants had varying degrees of education and experience in basic sciences, agriculture, and animal health, none had any experience in laboratory science. The goal of the training was to provide initial skills and background in laboratory techniques to students before the arrival of grant-funded laboratory equipment for additional training. Course participants were taught through a combination of classroom, hands-on, and field exercises designed to provide a working knowledge of good laboratory practices and safety, personal protective equipment, sample collection and handling, care and use of microscopes and other laboratory equipment, basic microbiology and parasitology, and specific laboratory techniques including making and analyzing blood smears, performing fecal flotation, and measuring packed cell volume and total solids. The full curriculum including the instructors remarks on each topic are summarized in Table 1. At the conclusion of the course, trainees were asked questions designed to gage how well the course had met its training objectives. To conserve time, no trainee was asked every one of the six questions. Each question was answered by 61 72% of the participants. To be scored as correct, the student had to answer the question correctly and completely on the first attempt. This oral examination showed that 82% of respondents were able to describe the correct use and maintenance of a microscope and discuss important aspects of laboratory record keeping and basic concepts in laboratory science. The majority of respondents also demonstrated an understanding of how to perform basic laboratory procedures such as making and staining a blood smear (64% of respondents) and performing a passive fecal flotation (69%). A smaller proportion of respondents were able to describe what a packed cell volume was and how to measure it (33%) and name at least three criteria for classifying bacteria (38%). These questions were considered to be more challenging because they required respondents to recognize and understand red blood cells as a component of hematology and specific traits of bacteria as an aspect of microbiology that had been discussed during the course. For nearly every student, these were completely novel concepts at the beginning of the workshop. Assessment results are listed in Table 2. Anonymously collected student surveys revealed that overall, the trainees were very pleased with the course. Students reported that the best parts of the course were the practical exercises and lessons on diseases and microscopes. The students least favorite parts of the course were related to course administration and facilities, including that food and transportation were not provided and that the electricity was intermittent on certain days of the course. Students stated that they believed the biggest needs for training in Liberia were for additional laboratory training and education in treatment of animal disease. When asked how to improve the course, participants suggested extending the duration of the course, creating a training center at Cuttington University to provide long-term training, and providing additional laboratory equipment and/or compensation to trainees. All of 2 JVME 2013; advance online article doi: 10.3138/jvme.0413-061R

Table 1: Veterinary laboratory course curriculum and instructor evaluation Topic Welcome and introduction Introduction to microscopy Practical exercise: use of a microscope Rabies Good laboratory practices Sample collection and handling External parasitism Basic microbiology Internal parasitism Practical exercise: internal parasitism Hematology Practical exercise: performing PCV and TS testing Hematologic parasites Practical exercise: making and staining blood smears Treatment of internal parasites Blood collection techniques Microbiological sample collection Practical exercise: examining blood smears Microbiology: agents and classification Microbiology: bacterial stains Details Formal opening facilitated by CAIDS, including the welcome to Veterinarians Without Borders Discussion of parts of a microscope and microscope care and maintenance Hands-on exercise in carrying a microscope, adjusting eye pieces, putting on/removing slides, and adjusting focus Discussion of the agent, pathogenesis, and signs of suspect cases and the appropriate response Discussion of proper labeling, record keeping, controls, and personal protective equipment Discussion of how and when to collect samples for analysis and what type of blood tube(s) to use Discussion of agents, signs, and diagnosis via skin scraping (Samples obtained from students animals were all negative for external parasites. Having fresh skin scrapings with mites instead of relying on printed materials and pictures of positive scrapings would have been ideal.) Lesson on basics of disease-causing agents: bacteria, viruses, protozoa, and fungi Discussion of agents and techniques for identification Exercise in which participants brought in fecal samples from their animals and learned how to perform a passive fecal flotation (Parasites were identified in nearly all of the provided samples, including coccidia [chicken], strongyles [small ruminant], and roundworms [canine]. Having positive samples enhanced this portion of the training, and other egg types were demonstrated using printed materials and pictures.) Discussion of blood function, components, and testing Exercise in which participants used sample blood drawn by course trainers to measure PCV/TS (Although it seemed as though students understood PCV/TS testing, the evaluation at the end of the course revealed that some students confused testing a PCV/TS with making a blood smear.) Discussion of parasites such as Trypanosomes, Babesia, and Anaplasma (Photographs were used in teaching this topic because throughout the course, no blood parasites were found in the samples used for teaching.) Exercise following a short lesson in which participants made and stained blood smears using previously collected blood and Wright s stain Discussion of the use of common anthelmintics for livestock, fowl, and companion animal species Discussion of where and how to collect blood with demonstration of bleeding piglets Discussion of collection and handling of samples intended for microbiological testing Examination of blood smears previously stained by students (This exercise was complicated by loss of electricity, which forced the microscopes to be operated with a small generator. To reduce fluctuations in electrical current, high-quality voltage regulators and microscopes that are 110/220V rated should be used in subsequent courses.) Discussion of identification techniques for microorganisms in the laboratory Discussion and demonstration of Gram and Wright s staining of bacteria for identification purposes doi: 10.3138/jvme.0413-061R JVME 2013; advance online article 3

Table 1: Continued Topic Practical exercise: Gram staining Practical exercise: microscopy Cytology Epidemiology and biosecurity Student evaluations of course Post-training assessment of participants Closing ceremony and awards Details Exercise in which students used cotton-tipped applicators to swab an area of their choice, made a slide, and performed a Gram stain to identify the presence of bacteria Exercise in which students practiced techniques learned earlier in the week, such as passive fecal flotation, PCV/TS, blood smears, and Gram and Wright s stains (Trainers needed to work with students one-on-one for this exercise to ensure that students were identifying cells and structures correctly. Double-headed teaching microscopes would have been helpful for this portion of the course.) Discussion of cytology as a method of identifying body cells and microorganisms Discussion of how disease is spread and how to control disease A survey on the course completed by students Individual oral assessment of trainees Closing ceremony run by CAIDS CAIDS ¼ College of Agriculture and Integrated Development Studies; PCV ¼ packed cell volume; TS ¼ total solids Table 2: Results of the oral assessment following the veterinary laboratory training course Question Number of students who answered correctly Number of students who answered incorrectly % correct Describe the correct use and maintenance of a microscope 9 2 82 Give three important aspects of laboratory record keeping (e.g., recording animal ID, species, and date; recording results; and using a pen) 9 2 82 Describe the procedure used to perform a passive fecal flotation 9 4 69 Describe how to make and stain a blood smear 7 4 64 Name three ways to classify bacteria (e.g., size, shape, 5 8 38 and Gram stain) Explain what a PCV is and how it is measured 4 8 33 PCV ¼ packed cell volume the surveyed students stated that they would be interested in additional training in veterinary laboratory services. Survey results including the most common student comments are compiled in Table 3. DISCUSSION This intensive training workshop was delivered to CAIDS students, faculty, and administrators, as well as members of the local animal agricultural community in recognition of the importance of involving diverse stakeholders in the promotion of animal and human health at the population level. Diversity in trainees background knowledge, talent, and skills improved peer learning and interaction but also created a challenge for educators as they had to address questions from students at varied levels of understanding. The intensive trainer-to-trainee ratio allowed the educators to address student questions at levels appropriate for each individual s comprehension, without creating confusion among students with less background knowledge. Delivery of the workshop faced challenges associated with erratic availability of power for microscopes and PowerPoint. This problem, common in the developing world, was ultimately solved by obtaining a private generator for use when the University s generators failed. In 4 JVME 2013; advance online article doi: 10.3138/jvme.0413-061R

Table 3: Results of the veterinary laboratory training course evaluation Question Possible answers % of students Topics covered were pertinent. Yes 100 No 0 Classroom teaching was helpful. Yes 100 No 0 Interactive exercises were helpful. Yes 100 No 0 What was the best aspect of the course? Practical exercises 36 Learning about diseases and treatments 21 Microscopic examination to determine cause of disease 14 Learning about microscopes 14 What was the worst aspect of the course? No food provided 36 Lack of steady electricity 21 No transportation provided 21 What is the greatest need for additional Continued laboratory training 36 training in Liberia? Training in animal treatment 36 Do you have other comments about the course? The course was interesting/helpful 21 The duration of the course should be extended 14 A centre at the College to train students and serve 14 the community should be created Compensation/laboratory equipment should be provided 14 Training to help develop animal production skills should be continued 14 addition, an alliance was formed with the local hospital to allow students to utilize hospital laboratory space on the final day of the course. This cooperation of local health workers with the animal health community was an encouraging development in One Health (the collaboration among multiple branches of medicine) and provided hope for a potential partnership that had previously been absent in the region. Despite the challenges it faced, the workshop successfully provided entry-level skills and knowledge about veterinary diagnostic laboratory techniques to students and faculty without previous experience in laboratory science. After the 5-day introductory course in veterinary laboratory techniques, the level of knowledge gained by the participants represents an encouraging success. An anticipated long-term benefit to course participants is a better understanding of animal disease fundamentals, including microbiology, parasitology, epidemiology, biosecurity, and personal protective equipment, which is expected to improve participants care of their own animals while limiting their risk of exposure to zoonotic disease. In addition, for many participants this training sparked an interest in continuing their education in the area of laboratory science. Finally, course participants are expected to benefit from better relationships among educators, students, and community stakeholders that improve communication and cooperation regarding animal health issues. The success of this course can be partially attributed to a well-designed curriculum that provided extensive hands-on experience and a favorable ratio of teachers to trainees. All of the participants were very enthusiastic throughout the training, focusing on the new topics and asking questions about laboratory science and animal health. The fact that every participant requested further training in laboratory techniques and animal or veterinary science indicates that the course was viewed very favorably by participants. The data from this study support the utility of this type of intensive short course to train laboratory workers in rural Liberia. Limitations of this study include the assessment of knowledge immediately after the workshop. This method of assessment verifies that the knowledge was delivered but does not measure retention or assess how trainees will utilize the knowledge gained from the training. Additional studies are needed to determine the long-term doi: 10.3138/jvme.0413-061R JVME 2013; advance online article 5

impact of short intensive training courses in laboratory science. Ultimately, it is expected that follow-up training would be necessary to maintain knowledge over a long period. A long-term improvement in the veterinary laboratory capacity in Liberia is dependent upon continued educational programs, delivery and maintenance of equipment and supplies, and a sustainable source of diagnostic samples. Non-governmental organizations such as Veterinarians Without Borders US have led efforts to train community animal-health workers in the central region of Liberia since 2010. These community animal-health workers have been trained in proper collection and shipment of diagnostic samples and are expected to provide diagnostic samples once a functional laboratory in central Liberia is established. However, some degree of governmental or outside source funding will be likely necessary to maintain the facility until local community animal-health workers and livestock producers experience firsthand the value of veterinary diagnostic testing and become willing to pay appropriately for these services. ACKNOWLEDGMENTS This training workshop was designed and delivered by the non-governmental organization Veterinarians Without Borders US and funded through a Farmer-to-Farmer grant provided by the United States Agency for International Development. REFERENCES 1 Elinav H, Kalter HD, Caviedes L, et al. Training laboratory technicians from the Ethiopian periphery in the MODS technique enables rapid and low-cost diagnosis of Mycobacterium tuberculosis infection. Am J Trop Med Hyg. 2012;86(4):683 9. http://dx.doi.org/ 10.4269/ajtmh.2012.11-0516. Medline:22492154 2 Eke RA, Enwereji EE. Diagnosis of malaria by community health workers in Nigeria. East Afr J Public Health. 2009;6(1):15 6. http://dx.doi.org/10.4314/ eajph.v6i1.45736. Medline:20000057 3 Gosling R, Walraven G, Manneh F, et al. Training health workers to assess anaemia with the WHO haemoglobin colour scale. Trop Med Int Health. 2000;5(3):214 21. http://dx.doi.org/10.1046/j.1365-3156.2000.00533.x. Medline:10747285 4 Fechter-Leggett ED, Like B, Vigneau DL, et al. Education of veterinary medical and other public health providers: linking interventions with health outcomes. J Vet Med Educ. 2011;38(2):171 83. http://dx.doi.org/10.3138/ jvme.38.2.171. Medline:22023926 5 Waiswa C, Kabasa JD. Experiences with an in-training community service model in the control of zoonotic sleeping sickness in Uganda. J Vet Med Educ. 2010;37(3):276 81. http://dx.doi.org/10.3138/ jvme.37.3.276. Medline:20847337 6 Beltran-Alcrudo D, Bunn DA, Sandrock CE, et al. Avian flu school: a training approach to prepare for H5N1 highly pathogenic avian influenza. Public Health Rep. 2008;123(3):323 32. Medline:19006974 7 Mitchell SL, McCline KT, Hanfelt MM. Veterinary surveillance laboratories: developing the training program. US Army Med Dep J. 2010;Oct Dec:22 4. Medline:21181671 AUTHOR INFORMATION Julie A. Williamson, DVM, is Assistant Professor of Clinical Skills, Ross University School of Veterinary Medicine, 630 Route 1, North Brunswick, NJ 08902 USA. She also serves as a Director of Veterinarians Without Borders US. E-mail: jwilliamson@rossvet.edu.kn. Susan J. Tornquist, DVM, MS, PhD, Dip. ACVP, is Professor of Clinical Pathology and Associate Dean for Student and Academic Affairs, Oregon State University College of Veterinary Medicine, 700 SW 30th Street, Corvallis, OR 97331 USA. E-mail: susan.tornquist@oregonstate.edu. 6 JVME 2013; advance online article doi: 10.3138/jvme.0413-061R