Prospective Studies of Avian Influenza Transmission in Asia

1
Prospective Studies ofAvian 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

2
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

3
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

4
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
5
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
6
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
7
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

8
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
9
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/ma
p.html
10
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.

11
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

12
Kamphaeng Phet Province (KPP)

• One of the 76 provinces in Thailand
• Mainly rural
• Total population 728,000
• 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

KPP
Bangkok
13
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)

14
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

15
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

16
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

17
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

18
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

19
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

20
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.

21
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

22
References

• University of Iowa, 2006- Center for Emerging
  Infectious Diseases. http//www.public-health.uio
  wa.edu/CEID
• Council on Linkages Between Academia and Public
  Health Practice. http//www.trainingfinder.org/co
  mpetencies/list_nolevels.htm
• The World Health Organization. Avian Influenza
  fact sheet. http//www.who.int/topics/avian_influe
  nza/en/
• The Armed Forces of Research Institute of Medical
  Sciences. www.afrims.org