Transcript namru3 apora apr2015

NAMRU-3
Cairo, Egypt
LCDR Nehkonti Adams, MC USN
Officer In Charge, Ghana Detachment
Naval Medical Research Unit 3 (NAMRU-3) Mission
Study, monitor, and detect emerging and re-emerging
disease threats of military and public health importance;
develop mitigation strategies against these threats in
partnership with host nations and international and U.S.
agencies in CENTCOM, EUCOM, and AFRICOM areas of
responsibility.
NAMRU-3 Ethos
“It is to these aims and ideals – the increase
of medical knowledge and the fostering of
good will – that I dedicate US Naval Medical
Research Unit No. 3”
CDR Robert A Philips, dedicatory address 27 Oct 1948
(as quoted in Snodgrass 2003)
NAMRU-3 Cairo facility
NAMRU-3 Activities
NAMRU-3 Virology Department
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Military to Military Influenza Surveillance
– Currently engaged with Burkina Faso, Cote D'Ivoire and Togo Armed forces to build the
capacity for influenza surveillance.
– This project involves multiple arms of surveillance such as, acute respiratory infection,
seasonal influenza, influenza-like illness, severe acute respiratory infections and zoonotic
influenza surveillance including avian influenza.
– Activities include, but are not limited to, training on the proper use of related equipment,
training on surveillance methods and procedures, obtaining governmental permissions,
recruitment of local staff, ensuring of adherence to safety and biosafety procedures and
collection and processing of study specimens.
– One to five- year plan includes:
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Enhancing surveillance efficiencies at current disease sentinel sites, through periodic refresher training
of lab and epidemiology personnel on both the civilian and military side
Expanding to other sentinel sites within each partner country will be considered only after efficiencies
are maximized at current sites
Expanding the respiratory diagnostic breadth at the reference laboratories of partner countries to
include other respiratory pathogens with PHEIC potential
Establishing and sustaining sequencing capability (a key surveillance and epidemiological tool for early
warning to a PHEIC) in our partner countries
NAMRU-3 Detachment Accra, Ghana
Republic of Ghana
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Population-25.9 million
Climate-tropical, temperature range (22-42C)
Economy- GDP $1,858 per capita (2014)
Endemic diseases
– Malaria (>2.3 million cases/year report to public health
facilities)
– HIV prevalence 1.3% (2013)
– Most common NTDs : lymphatic filariasis, schistosomiasis,
buruli ulcer, yaws, leprosy, cutaneous leishmaniasis
• Outbreaks
– 2014 cholera outbreak - >30,000 cases
Ghana Detachment Background
• LCDR Braden Hale 1998 - Dose-ranging trial of Tafenoquine for weekly
malaria prophylaxis, Navrongo
• CAPT Bill Rogers 1999
– Research Fellow of Parasitology Department-NMIMR (Noguchi)
– $5 million NIH grant to establish malaria vaccine testing sites
– 2001 establishment of detachment in US Embassy
– 2005 renewal of NIH contract ($12million, seven – year)
• Officers In Charge of expanded Noguchi detachment:
– LCDR Greg Raczniak 2005-2008
– LCDR Karl Kronnman 2008-2011
– CDR Christopher Duplessis 2011-2013
– LCDR Nehkonti Adams 2013-current
Ghana Detachment Manning
• Total manning: 14 as of Feb 2015
– Two NSDD-38 approved positions
• Officer in Charge –infectious disease physician
• Research Scientist – medical entomologist ETA Mar-Apr 2015
– Twelve non-military staff
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5 locally employed via Embassy
4 lab technicians employed via contract
1 data manager employed via contract
1 monitoring and evaluation technician employed via
contract
• 1 admin assistant employed via contract
Ghana Detachment Assets
• Space
– Two adjoining rooms obtained in 2007 by
agreement with Noguchi, Memorial Institute for
Medical Research (NMIMR).
• Lab capabilities and Instrumentation
– Bacterial culture
– ELISA and conventional PCR
– Access to a BSL-3 laboratory, insectary and
molecular suite
– Storage container (CONEX Box)
NAMRU-3 Ghana Detachment
Accomplishments 2014
 Assisted with a nationwide training on influenza surveillance
 Provided training on ethics in human subject research
 Conducted national avian and swine sampling exercise
 Influenza testing on 340 returning Hajj pilgrims
 Influenza surveillance capacity building in Togo
 Presentation at The West African Conference on Research,
Diagnostics, Epidemic Preparedness and Response to Lassa Fever
and other Viral Hemorrhagic Fevers held in Benin City, Nigeria
NAMRU-3 Disease Surveillance in Ghana
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Sexually Transmitted Infections
surveillance
Military to Military Influenza
surveillance
Non-malarial Acute Febrile
Illness surveillance
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Integrated Human Animal
Vector surveillance
• Cutaneous Leishmaniasis
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Integrated Hospital-Based
Infectious Diseases Surveillance
Characterizing Gonorrhea and Chlamydia Prevalence and
Gonorrhea Resistance Profiles in Military Populations
Problem: Emergence and spread of multi-drug resistant
Neisseria gonorrhea is a major health issue globally
Objectives:
• Identify disease burden among patients at three sites
• Elucidate circulating strains of N. gonorrhea
• Determine antibiotic resistant profiles
Study Progress:
• >700 subjects enrolled, 30 multidrug resistant isolates
recovered, >35% pre-presentation antibiotic use
STI/AFI Training at Military Clinics
Takoradi/Sekondi
Military-to-Military Influenza Surveillance
Problem: There are several respiratory pathogens with the ability to cause a
pandemic. Pandemic planning to include established surveillance around the
world is paramount. Militaries are especially susceptible to outbreaks of
respiratory pathogens.
Primary Objective: To establish and maintain influenza surveillance at military
bases in Ghana.
Clinical sites: Five Medical Reception Stations (MRS) and 1 Military Hospital and
10 civilian sites.
Ghana NIC: WHO reference laboratory for H5N1
Activities:
• Weekly and semiannual reports on surveillance data are shared with the CDC
and WHO
• Annual troop education and avian sampling exercise carried out in all the
major barracks.
Mil-Mil Investigation: Acute Febrile Illness
(AFI) Characterization
Problem: Acute Febrile Illness (AFI) is a common presentation to
health care facilities globally including Ghana. The clinical presentation
of most febrile illnesses are nonspecific. Most cases are empirically
treated for malaria. This contributes to under-diagnosis and lack of
epidemiological knowledge of other infectious etiologies of fever.
Primary objective: To improve surveillance and laboratory capacity for
diagnosis of non-malarial etiologies of AFI.
Clinical sites: 37 Military Hospital and 3 clinics in Sekondi-Takoradi
Pathogens of interest:
• Malaria
• Coxiella burnetti
• Rickettsia spp
• Leptospira interrogans
• Salmonella typhi
• Dengue
• Chikungunya
• West Nile Virus
• Hantavirus
• Henipaviruses
Integrated Human- Animal-Vector- Surveillance
(IHAVS)
Problem: a high percentage of etiology of fevers are unknown in Africa. A percentage
of these cases are attributed to zoonotic diseases.
Objective: To establish a surveillance system for evaluation of a panel of vector-borne
and zoonotic pathogens in a population where there is high density co-mingling
activities of humans and animals.
Progress: Initial surveillance activities was conducted in Kumasi Abattoir among
humans (abattoir employees), slaughtered animals and trapped vectors. There is
ongoing sample collection at another abattoir in Greater Accra Region.
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108 abattoir workers were enrolled; Blood samples were collected from 149 cattle, 149 goats and
130 sheep.
Collected specimens identified evidence of Rift Valley Fever, West Nile Fever, Dengue Fever, CrimeanCongo Hemorrhagic Fever, Hepatitis E virus, Coxiella Burnetti, Leptospira spp.
Etiology of cutaneous leishmaniasis in Volta
Region of Ghana
Problem: Leishmaniasis is a disease with significant global impact
affecting more than 88 countries in the world. There is a lack of POC
test in endemic areas.
Primary objective: To optimize and prospectively evaluate a deployable pointof-care field diagnostic test for cutaneous leishmaniais. The diagnostic test
will utilize recombinase polymerase amplification coupled with lateral flow
test strip to detect leishmaniasis.
Partners: NAMRU-6 ,University of Texas Medical Branch, NMIMR
Clinical sites: Ghana-Ho and Peru-Madre de Dios
Integrated Hospital Based Infectious Disease surveillance (IHBIDS)
Primary Objective: To identify the number of hospitilized and outpatient cases due to acute
respiratory illness (ARI), acute diarrheal illness (ADI) and acute febrile illness (AFI) in four
referral hospitals in Ghana.
Progress: Syndromic Surveillance system established in August 2009 at 4 referral hosp. (Tema
General Hosp., 37 MH, Tamale Teaching Hosp., and Korle-Bu Teach. Hosp.)
• 3,163 patients enrolled in the study
• ARI:
– 7% were Influenza A positive, out of which 4% are Flu A subtypes H3 (4%) and 3% of pH1N1
strains circulating
– 2% Influenza B positives identified.
• AFI:
– Pathogens identified thus far are: Dengue Fever, Yellow Fever, Chikungunya, West Nile Fever,
Brucella, Salmonella, Leptospira, Q-Fever, Rickettsia.
• ADI:
– Viral Pathogens Identified: Rotavirus (24%), Noroviruses (6%), astrovirus (5%) and adenovirus
(5%).
– Parasitic Pathogens identified: Giardia (2%) and Crysporidium (3%).
Integrated Hospital Based Infectious Disease surveillance
(IHBIDS)
• Capacity building:
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ARI surveillance transitioned as
non-research into the local
surveillance system at 37 MH
and Tamale Teaching Hospital
Relationship between antibody recognition by Plasmodium
falciparum pre-erythrocytic vaccine candidate antigens and
clinical parasitological protection against malaria
Problem: Malaria remains one of the important tropical infectious diseases in sub-Saharan
Africa. Global estimates of the burden due to malaria showed that in 2013, about 198 million
cases and 584,000 deaths were recorded The development of an effective malaria vaccine
remains a global health priority. Less than 0.5% of the 5300 proteins expressed by P. falciparum
genome during the multistage parasite lifecycle has been evaluated as vaccine candidates.
Primary Objective: To test the hypothesis that naturally induced humoral immunity to novel P.
falciparum sporozoite surface antigens currently being explored as malaria vaccine candidates is
associated with protection from infection and or clinical disease in malaria endemic areas.
Approach: We propose to screen eight antigens for antibody responses using archived banks of
plasma from longitudinal specimens acquired at monthly intervals (irrespective of infection) in a
cohort of 1 – 5 year old children who were followed up for one year.
The results obtained will contribute to the final down selection of new vaccine candidates for
further clinical development.
Malaria Drug Resistance Studies
NMIMR
A SYBR Green 1-based in vitro test of susceptibility of Ghanaian Plasmodium falciparum
clinical isolates to a panel of antimalarial drugs.
Primary objective: To use SYBR Green 1 fluorescent-based in vitro drug sensitivity assay to assess the
susceptibility of clinical isolates of P. falciparum to a panel of 12 antimalarial drugs in three distinct ecoepidemiological zones in Ghana.
Approach: The P. falciparum isolates were obtained from children visiting health facilities in sentinel
sites located in Hohoe, Navrongo and Cape Coast municipalities.
Results: The study concluded that Ghanaian P. falciparum isolates have become susceptible to
chloroquine but may be losing its sensitivity to artesunate.
Characterization of Molecular Markers of Drug Resistance in Plasmodium
falciparum from Ten Regions of Ghana over a 3-year period.
Primary objective: To investigate the Plasmodium falciparum multidrug resistance gene (pfmdr1) copy
number, mutations and the chloroquine resistance transporter gene (pfcrt) mutations in Ghanaian isolates
collected in seven years to detect the trends in prevalence of mutations.
Results: The study found a decreasing trend in the prevalence of chloroquine resistance markers after
change of treatment policy. This presents the possibility for future introduction of chloroquine as
prophylaxis for malaria risk groups such as children and pregnant women in Ghana.
Vector Biology Focus, AFRICOM
Evaluation of spatial repellent (SR) products under semi-field conditions in Liberia and profiling hybrid
molecular form of Anopheles gambiae in Ghana.
Primary objective: To evaluate commercial and advanced developed spatial repellant products in
semi-field conditions for the control of mosquito disease vectors in Liberia.
Secondary objective: To determine the need for SR products with regional military partners and
establish product testing capabilities in the region.
Progress: We have established a laboratory strain of Anopheles gambiae M/S hybrid molecular
form by crossing M form mosquitoes with S form at Noguchi Memorial Institute for Medical
Research (NMIMR) insectary located in Accra, Ghana.
“Push/Pull”
Primary objective: To develop an integrated Push-pull system which will be used to test various
repellents and attractants for their ability to push or pull blood feeding insects from one area to
another.
Progress: Two fifty meter tunnels for treatment and control have been constructed and several
cycles of testing have been completed.
Lassa Fever
Problem: Ghana has had several imported cases of Lassa Fever in their peacekeeping forces deployed to Liberia
and Sierra Leone. In recent years there has been two cases of laboratory confirmed Lassa Fever in patients
who did not have a significant travel history.
Primary objective: To assess the prevalence of Lassa virus in the rodent reservoir, Matomys, in high risk areas
of Ghana.
Progress: NAMRU-3 GD captured and necropsied rodents for arenavirus and other rodent-borne pathogen
screening based on a predicted Lassa virus risk map (Fichet-Calvet and Rodgers 2009). Rodent tissues and
human sera were collected from ten villages throughout the country.
Results:
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Only two of the 764 rodents belonging to Mus (Nannomys) species tested positive for arenaviruses.
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Using an in-house enzyme-immunoassay (ELISA), human serum showed evidence of arenavirus antibodies
in 34 samples (5%). Antibodies to Puumala and Dobrava serotypes and Leptospira were also detected in
11%, 12% and 21%, respectively, with commercial kits.
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Our findings support the idea that Lassa virus is not widely prevalent in Ghana, and the M. natalensis
reservoir is not as common as in more highly endemic countries.
Lassa Fever Outbreak, Liberia August 2013
– Location: Bong and Lofa County, Liberia
– Partners: US Military (personnel from Operation Onward
Liberty (OOL)) and Armed Forces Liberia (AFL)
– NAMRU-3 created a transport SOP and case report form
for Lassa fever testing
– Provided environmental inspection and infection control
training
West African Ebola Outbreak
• LCDR Nehkonti Adams, OIC of the NAMRU-3 Ghana detachment
was called upon
– by Chief Medical Officer of Operation Onward Liberty for educational
materials to provide to troops deployed to Liberia.
– to serve on Ghana Health Service (GHS) Ebola National Technical
Coordinating Committee (NTCC) as a member of the Case
Management subcommittee.
– to lead an Interagency Ebola Team comprised of members from
NAMRU-3, CDC, USAID West Africa, USAID Ghana, and various other
DoD agencies to coordinate WHO, Government of Ghana, local NGOs,
foreign donors, UNMEER and USG aid agencies preparedness.
– to participate and provide technical expertise in an Ebola simulation
exercise at Kotoka International Airport with WHO, Ghana Health
Services and Noguchi Memorial institute for Medical Research.
Pending Engagements in West Africa
in Wake of 2014 Ebola Outbreak
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Liberia
– Liberia Institute for Biomedical Research (LIBR)
• Expand surveillance and pathogen discovery projects in the context of USAID, CDC, other DoD
footprint.
• Develop laboratory and outbreak response capability at LIBR
– Lofa County
• Hemorrhagic fever and arbovirus surveillance
– Bong County
• Acute infectious causes of neurologic diseases
– Nimba County
• Xenosurveillance
– Collect and analyze blood fed mosquitoes in and around the frontier/trade route town of
Ganta on the main road linking Liberia to Guinea and Cote d’Ivoire
– Utilizing novel vector surveillance protocol, link human and animal febrile illness to
pathogens found in blood meals of collected mosquitos.
– Correlate arboviruses and other pathogens in collected blood fed mosquitos with
infected human population.
Pending Engagements in West Africa
in Wake of 2014 Ebola Outbreak
• Nigeria – Calabar Institute of Tropical Disease and
Prevention (CITDP), University of Calabar, Cross River State
– Capacity building and malaria vector surveillance including
insecticide resistance
Outbreak Response Pillars
• Early Detection
– Disease surveillance that provides accurate and
complete information on the nature of the disease,
location, population, etc.
• Early and Efficient Response
• Recovery