Epidemiology of Infectious Diseases Course

Document Sample
Epidemiology of Infectious Diseases Course Powered By Docstoc
					         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
   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
   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

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
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

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
                                         World Health Organization
   AI in Southeast Asia
 • H5N1 outbreaks in many Asian
   countries since late 2003
    • Among poultry (5): Bangladesh,
      Indonesia, India, Myanmar, and
    • Human cases (2): Indonesia and
 • 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/
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,
   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
                      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
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
   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
   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
   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
   I had the rare opportunity to interact and work with many
    public health professionals from various international
   I observed at first hand how the PH professionals were
    dealing with current challenges of emerging global PH
   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
   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
       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
       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
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.
   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
   University of Iowa, 2006- Center for Emerging Infectious Diseases.
   Council on Linkages Between Academia and Public Health Practice.
   The World Health Organization. Avian Influenza fact sheet.
   The Armed Forces of Research Institute of Medical Sciences.

Shared By: