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Epidemiology of Infectious Diseases Course


									         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
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.

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