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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. May - August 2007

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prospective studies of avian influenza transmission in asia

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

abstract
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
interventions activities
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
collaborating research centers
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

armed forces research institute of medical sciences afrims
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

afrims mission objectives
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

kamphaeng phet afrims virology research unit kavru
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
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
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/map.html

study objectives hypothesis
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.
study components
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
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

field site selection
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
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
log number system
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
results lessons
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
recommendations
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
communication skills
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
analytical assessment skills
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
cultural competency skills
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.
acknowledgements
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
references
References
  • 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
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