Transcript Epidemiology of Infectious Diseases Course 173:255

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
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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
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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)
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Designing a log number system for specimen collection
and processing
Planning for village enrollment
Collaborating Research Centers
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The Center for Emerging Infectious Disease (CEID)
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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)
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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)
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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
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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)
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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)
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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*
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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
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Design:
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Objectives:
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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.
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:
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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
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Enrolling subjects
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Weekly home & annual follow-up visits
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24-hour on-call staff
Serum & throat swabs collected
Family study of influenza transmission
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Report any Influenza-Like Illnesses (ILI)
Village health workers
Investigation of ILI
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Sera and questionnaires collected
Family members asked to participated
Specimen processing
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KAVRU, CEID, Thai MOH
Kamphaeng Phet Province (KPP)
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KPP
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One of the 76 provinces in Thailand
Mainly rural
Total population: 728,000
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Bangkok
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Male: 362,000
Female: 366,000
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
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Source of information:
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Ministry of agriculture and Livestock office provided animalrelated data
Local public health offices provided specific info on housing
layout and population demographics
Selection criteria:
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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.)
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Eight sites selected in the Meung District, KPP
Accessibility
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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
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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
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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
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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
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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
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Working closely with the Thai Ministry of Health
(MOH) to obtain the IRB approval
Before an enrollment can begin,
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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
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A need of 24-hour on-call team for ILI investigation
Laboratory technicians, and research nurses
Communication Skills
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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
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Informed local staff about specifics
about the study and relayed
concerns of the PI
Analytical/Assessment Skills
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Collected and updated information on animal-related
and demographic data in order to select eight field
sites
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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
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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
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All-Nets
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Three months of Thai tutoring lessons to learn about the
culture and the language
Working with the local staff
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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
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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
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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