Laura Lee
MPH Candidate
The University of Iowa
Mentor: Dr. Gregory Gray
Preceptor: Dr. Robert Gibbons
The Armed Forces Research Institute of Medical Sciences

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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

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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)
 Designing a log number system for specimen collection and processing
Planning for village enrollment

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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

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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

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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

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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

• 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

• H5N1 outbreaks in many Asian countries since late 2003
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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

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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
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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.

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Enrolling subjects
 Sera and questionnaires collected
Weekly home & annual follow-up visits
 Report any Influenza-Like Illnesses (ILI)
 Village health workers
Investigation of ILI
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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

KPP
Bangkok
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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

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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
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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)

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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
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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

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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
 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

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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

 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

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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
 Informed local staff about specifics about the study and relayed concerns of the PI

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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
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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

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All-Nets
 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.

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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

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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