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Prospective Studies of Avian Influenza Transmission in Asia Laura Lee MPH Candidate The University of Iowa Mentor: Dr. Gregory Gray Preceptor: Dr. Robert Gibbons The Armed Forces Research Institute of Medical Sciences Abstract May - August 2007 Worked as a local study coordinator at the KAVRU, Kamphaeng Phet, Thailand Prospective Studies of Avian Influenza Transmission in Asia PI: Dr. Gregory Gray Follow 1600 adults with exposure to poultry in Cambodia and Thailand for the evidence of avian influenza infection for over three years Collaboration with the United States Department of Defense overseas laboratories and Ministry of Health officials in Thailand and Cambodia Interventions/Activities Assisting a local staff obtain an Institutional Review Board (IRB) approval from the Thai Ministry of Health (MOH) Selecting field sites by compiling and updating demographic and animal-related data from local public health offices and villages Assisting in writing a Standard of Operating Procedures (SOP) Designing a log number system for specimen collection and processing Planning for village enrollment Collaborating Research Centers The Center for Emerging Infectious Disease (CEID) Research center in the College of Public Health at the University of Iowa, Iowa City, Iowa Focuses in researching emerging infectious diseases with special interest in emerging respiratory viruses such as adenoviruses, human metapneumovirus, and influenza U.S. Naval Medical Research Unit No. 2 (NAMRU-2) Department of Defense overseas laboratory located in Jakarta, Indonesia Its primary mission is to study infectious diseases of military importance in Asia A satellite laboratory in Phnom Penh, Cambodia http://www.public-health.uiowa.edu/CEID Armed Forces Research Institute of Medical Sciences (AFRIMS) Located in Bangkok, Thailand Established in 1958 to study cholera epidemic in Thailand Current research interests include vector-borne diseases, malaria, emerging infections, and enteric diseases of military importance in Asia Over 40 field sites and research laboratories in Southeast Asia Funded by the US Department of Defense www.afrims.org AFRIMS - Mission & Objectives Monitor and assess potential disease threats - especially emerging infectious diseases Evaluate new drugs and vaccines for prophylaxis and treatment of militarily important infectious diseases Develop and test new forward-deployable rapid diagnostic methods Investigate and test new control measures against infectious disease vectors to interrupt disease transmission Define the epidemiology of militarily-important diseases endemic to tropical regions Advise the Commander-in-Chief (CINC), Pacific Command and the U.S. Ambassador, Thailand on tropical disease threats Develop infrastructure and continue proactive training, development and technology transfer to Thai medical research for Thai control and responsibility www.afrims.org Kamphaeng Phet-AFRIMS Virology Research Unit (KAVRU) One of AFRIMS’ satellite research laboratory Has been involved with vaccine developments and field testing of new vaccines Current project: Prospective Study of Dengue Virus Transmission and Disease in Primary School and Village Children in KPP (2003-07) As of 2007, finished collecting 4-year-surveillance data Planning a vaccine trial involving 2000 school children Avian Influenza (“bird flu”) • AI is an infectious disease of birds caused by type A strain of the influenza virus, which causes a wide range of symptoms in birds • AI do not normally infect humans. Highly pathogenic strains such as H5N1 may cause severe respiratory illness in humans • Most of human cases have occurred among those in close contact with infected birds or objects contaminated with their feces • However, a virus may mutate and be easily transmissible between humans leading an influenza pandemic World Health Organization AI in Southeast Asia • H5N1 outbreaks in many Asian countries since late 2003 • Among poultry (5): Bangladesh, Indonesia, India, Myanmar, and Thailand • Human cases (2): Indonesia and Thailand • 25 human cases in Thailand* • 17 cases have been fatal • Most cases occurring in 2004 • Last reported case in Sept 2006 • A need for good epidemiological collection and surveillance system *As of November 12, 2007, WHO http://www.pbs.org/wnet/wideangle/ shows/vietnam/map.html Study Objectives/Hypothesis Design: A three-year prospective study of H5N1 transmission among 1600 adults with exposure to poultry in Asia: 800 subjects from KPP, Thailand and 800 subjects from Kampong Cham Province, Cambodia. Objectives: To monitor adults with poultry contact for evidence of H5N1 infection To determine risk factors for H5N1 infection among people with close poultry exposure To characterize H5N1 isolates associated with human infections Hypothesis: Prevalence and incidence of H5N1 infection will be higher for those with more hours of exposure to poultry per week than those with less hours. Study Components Enrolling subjects Sera and questionnaires collected Weekly home & annual follow-up visits Report any Influenza-Like Illnesses (ILI) Village health workers Investigation of ILI 24-hour on-call staff Serum & throat swabs collected Family study of influenza transmission Family members asked to participated Specimen processing KAVRU, CEID, Thai MOH Kamphaeng Phet Province (KPP) One of the 76 provinces in Thailand Mainly rural Total population: 728,000 KPP Male: 362,000 Female: 366,000 Bangkok Region most affected by an outbreak of H5N1 in 2004-05 Extensive culling occurred to control the outbreak, which lead to significant depopulation of poultry Since, culling has been discouraged due to decreasing reports of large poultry die-offs Many have repopulated their poultry Caging of poultry encouraged yet poorly enforced Field Site Selection Source of information: Ministry of agriculture and Livestock office provided animal- related data Local public health offices provided specific info on housing layout and population demographics Selection criteria: Distance to healthcare facility Distance to KAVRU Density of poultry in sub-district Population Number of households Density of animals such as fighting-cocks, ducks, pigs, wild birds, and cats Recent outbreak of AI (2004 or 2005) Field Site Selection (cont.) Eight sites selected in the Meung District, KPP Accessibility All sites are within 35 km from the KAVRU Villages are within 10 min drive of a local PH office Villages are near a major road unless otherwise specified Exposure Moderate to high animal-animal cross-interaction and human-animal interaction Caging encouraged yet poorly enforced Some villages have many fighting-cock breeders Confirmed outbreak of AI in 2004-05 Log Number System A multi-site study that involved collecting multiple numbers and types of specimens Designed a log system for specimen collection/processing Each site assigned a site code that every label will start with Each subject assigned a unique number during enrollment During family ILI-investigation, the number assigned to each family member will contain matching cohort number Three family members with a subject number 089 at site T4 T408900 (cohort), T408901 (family #1), T408902 (family #2) A letter at the end will indicate type of specimen Results/Lessons I developed skills and knowledge to work well in a diverse public health setting and dealt with challenging situations involving an international study involving multiple sites Learned to effectively communicate both in writing and orally to accurately relay information to public health professionals I had the rare opportunity to interact and work with many public health professionals from various international organization. I observed at first hand how the PH professionals were dealing with current challenges of emerging global PH threat Recommendations Working closely with the Thai Ministry of Health (MOH) to obtain the IRB approval Before an enrollment can begin, Pilot testing questionnaires to a selected group of villagers Conducting a village-wide meetings to inform villagers and local PH officials about the aims of the study Creating a system for selecting houses so the research nurses will know exactly which houses to visit Hiring more staff A need of 24-hour on-call team for ILI investigation Laboratory technicians, and research nurses Communication Skills Participated in weekly teleconference calls with the PI and other collaborating researchers Wrote weekly reports to inform the PI of daily activities Kept in regular correspondence through emails Relayed scientific information between the local staff and other researchers Informed local staff about specifics about the study and relayed concerns of the PI Analytical/Assessment Skills Collected and updated information on animal-related and demographic data in order to select eight field sites Identified relevant and appropriate data and info source Visited villages and discussed the info with the local staff to attach meaning to the collected data Identified gaps and discrepancies in sources of the data Designing a log number system for specimen collection Assessed and analyze the main components of the study Worked closely with the statistician and the local administrative team to identify and fix the problems of the system Cultural Competency Skills All-Nets Three months of Thai tutoring lessons to learn about the culture and the language Working with the local staff Only foreigner in the laboratory Learned to communicate with the staff who were at different levels of English Consulted the local staff on site selection and log number system so that they also felt comfortable with the information and that the info applied to the local setting Participated in several activities outside the work in order to learn about their culture and to share mine. Playing sports, cooking, taking weekend trips, etc. Acknowledgements Dr. Gregory Gray and the staff; The Center for Emerging Infectious Disease (CEID) Drs. Robert Gibbons,In-Kyu Yoon, and the staff; The Armed Forces Research Institue of Medical Sciences (AFRIMS) Dr. Thomas Cook and Kristina Venzke; The Minority Health International Research Training (MHIRT) program The University of Iowa College of Public Health References University of Iowa, 2006- Center for Emerging Infectious Diseases. http://www.public-health.uiowa.edu/CEID Council on Linkages Between Academia and Public Health Practice. http://www.trainingfinder.org/competencies/list_nolevels.htm The World Health Organization. Avian Influenza fact sheet. http://www.who.int/topics/avian_influenza/en/ The Armed Forces of Research Institute of Medical Sciences. www.afrims.org
"Epidemiology of Infectious Diseases Course"