GEIS Program
Projects FY03-04
Antimicrobial
resistance enteric pathogens
Prediction of malaria transmission with GIS
Surveillance
for zoonotic and vector-borne diseases
Surveillance of drug resistant malaria in
Asia
Study of febrile illnesses in Sangkhlaburi,
Thailand
AFRIMS-Thai MoPH zoonotic disease surveillance
Southeast Asia laboratories infrastructure
support
Sero-prevalence
of endemic infectious diseases in Thailand
Royal
Thai Army Surveillance and Outbreak Network
Molecular
Epidemiology of HIV-1
Influenza
surveillance in SE Asia
Febrile
disease surveillance, Nepal
Institutional Data Management System
GEIS Program
Accomplishments for FY03
- AFRIMS continues
to be very active in training and support of numerous infectious
disease labs throughout Asia to include laboratories, hospitals,
and ministries of health in Vietnam, Cambodia, Thailand, Maldives,
Bangladesh, India, Nepal, and Uzbekistan. Training is either
hosted at AFRIMS, or conducted at the collaborator’s home
site using the equipment and expertise on hand. Both possess
unique and distinct advantages.
Surveillance
of antimicrobial resistance enteric pathogens in indigenous
population and travelers in Thailand, Vietnam and Nepal
2000-2004
Description: Stool samples are systematically sampled from patients
with diarrhea from study sites and identified by various means.
Antimicrobial resistance testing is performed on isolated organisms
and results are compared to assymptomatic controls, temporal
changes in resistance and virulence factors.
Status:
- The Department
of Enteric Diseases continues world-class research in the
diagnosis of causative agents of diarrhea and monitoring antibiotic
resistance. Enterics continues operations at field sites in
Nepal, Vietnam, Thailand, and Laos, and also receiving specimens
from China, Pakistan, and Indonesia through the International
Vaccine Institute. Major findings include:
- Campylobacter
remains one of the most common pathogens identified
in the non-immunes with diarrhea (CG, travelers in Nepal
and Bumrungrad), ranging from 13-38% as well as in Thai
children (19-23%).
- Shigella
prevalence is very low (0-3%) in Thailand either in
travelers (CG and Bumrungrad), Shigella is found in
Nepal (13%). S. sonnei is the most common serotype
isolated.
 Salmonella
was frequently isolated from cases with diarrhea in
Thailand as well as in asymptomatic controls but was
not frequently found among travelers with diarrhea and
controls in Nepal.- ETEC
is one of the common causative agents for travelers’
diarrhea in Nepal, isolated from 12%. Identification
rate of ETEC in Thailand is about 3-6% while none of
ETEC was identified during this Cobra Gold exercise.
- In
Thailand, ciprofloxacin resistant Campylobacter
was high during CG exercise (90%), in Bangkok (78-88%)
and upcountry sites (75%). Resistant rate was a little
lower in Nepal at 70%. Macrolides are still effective
for Campylobacter in every site although resistance
was detected in 5-9% of the isolates in Bangkok.
- Newly
detected ciprofloxacin-resistant Salmonella
(4%) in Bumrungrad hospital. Cobra Gold Salmonella
isolates have been 100% ciprofloxacin sensitive.
- In
general, ciprofloxacin is an effective antibiotic for
common enteric pathogens (Shigella, Salmonella, ETEC)
except for Campylobacter isolates.
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Remote
sensing-based geographic information system to predict malaria
transmission risk in villages in North-Western Thailand
2001-2004
Description: GIS Remote sensing used to identify larval breeding
habitats of mosquito vectors of malaria. Goal is to develop
a model that can be used to predict potential outbreaks and
target malaria control efforts thus increasing efficiency of
resources.
Collaborators: AFRIMS Department of Entomology
Links: http://www.kit.nl/biomedical_research/html/gis.asp
Status:
- The Department
of Entomology is continually improving remote sensing-based
GIS applications for surveillance of malaria in Thailand and
defining the environmental determinants of the malaria vectors.
Analyzing environmental determinants with satellite data is
used to validate analyses of satellite data with in situ (ground
truth) data and develop a predictive capability. Results are
then verified with field studies and leads to targeted interdiction
of malaria breeding sites.
Surveillance
for Zoonotic and Vector-Borne Diseases with the potential to
cause Epidemic Outbreaks in human populations in Southeast Asia
2001-2004
Description: Rodents collection from several sites in Thailand
and test for emerging diseases to include scrub typhus, arena
viruses, TBE complex viruses, and Bartonella
Collaborators: University of Texas, Galveston, USAMRIID, CDC,
Fort Collins, and AFRIMS
Links: Arena virus http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4931a1.htm
Status:
- Entomology conducted
surveillance for zoonotic and vector-borne diseases that have
the potential to cause epidemic outbreaks in human populations
in Southeast Asia. They have continued their work with in
the Maldives to help their MoH deal with a new-onset scrub
typhus endemicity.
Surveillance
for Drug Resistant Malaria in Asia
2001-2004
Description: Continued surveillance activities throughout Southeast
Asia (Bangladesh, Myanmar, Thailand and Vietnam) for threat
assessment of multi-drug resistant malaria, and began work in
the Terai of Nepal. No emergence of artemesinin resistance has
been detected, but evidence that mefloquine resistance has spread
across Myanmar and into Bangladesh. Surveillance is active in
Thailand, Vietnam, Bangladesh, Burma, Nepal, Sri Lanka, Bhutan.
Collaborators: Thai Ministry of Public Health, Dr. Steven Meshnick
(NIH R01 grant).
Status:
- AFRIMS Department
of Immunology and Medicine continues to provide and expand
the most comprehensive surveillance program in Asia for emerging
drug resistant malaria and has made great progress in the
development of new tools for the detection of drug resistant
malaria.
- Our
in vitro data from Bangladesh suggest that chloroquine
(the official first line treatment for uncomplicated
falciparum malaria in Bangladesh) resistance may have
reached a similar level as in the western border regions
of Thailand. In vitro mefloquine resistance is more
common than previously expected in Bangladesh but the
degree of resistance is still considerably below that
of the Thai-Myanmar border.
- The
new HRP2 drug sensitivity assay proved to be highly
sensitive, quick and simple to establish and perform.
It provides a simple, semi-automated, non-isotopic drug
sensitivity assay for field use that undoubtedly has
the potential to replace traditional assays, which are
either particularly time-consuming, not sensitive enough
to be used in the field, or requiring radioisotopes.
This method and supporting data analysis software is
being made available free of charge to interested public
health laboratories on the internet with GEIS support,
and can be reviewed at http://malaria.farch.net.
- First
in vivo data from Bangladesh suggest that even the second
line treatment for uncomplicated falciparum malaria
(3 days of quinine plus Fansidar) may be less than 80%
effective.
- AFRIMS
has identified linkage between in vitro mefloquine resistance
and point mutations on the Plasmodium falciparum
multi-drug resistant 1 (pfmdr1) gene. The association
as measured by odds ratio, is highly statistically significant
and has never been reported before. The association
between gene amplification and mefloquine resistance
was also demonstrated in this study.
- In
contrast with some other reports, AFRIMS detects no
improvement of mefloquine resistance in the western
border regions of Thailand.
- No
artemisinin resistant P. falciparum isolates
have been found among the wild isolates from this region
collected by AFRIMS.
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Study
of Febrile Illnesses in Sangkhlaburi, Thailand
2000-2004
Description: Continued a multi-year effort to establish infectious
etiologies to undifferentiated fevers along the Thai-Myanmar
border. Over 500 persons enrolled to date. Leptospirosis appears
to be a frequent, but previously unrecognized cause of morbidity
and mortality. Our data has led to a change to local health
treatments. Animal surveillance activities are used as confirmation
of suspected disease risk.
Collaborators: AFRIMS Departments of Virology, Vet Med and Entomology
Status:
- The Department
of Immunology and Medicine’s Febrile Illness study at the
Kwai River Christian Hospital in Sangklaburi, Thailand has
found:
- Fever
with respiratory symptoms and non-specific findings
are the most commonly encountered syndromes in the test
area. In the absence of sophisticated laboratory testing
capability, antimicrobial therapy remains largely empiric.
- Malaria
is a common cause for fever in patients presenting with
fever. By syndrome, malaria most commonly presents a
fever without specific symptoms or fever with splenomegaly.
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AFRIMS-Thai
MoPH development of Zoonotic Disease Surveillance System in
Thailand
2002-2004
Description: Coordination and collection of data from Bureau
of Epidemiology MOPH and Department of Livestock Development
MOA with analysis performed by Bureau of Epidemiology and reports
for AFRIMS and MOPH
Status: Execution stage
Collaborators: MOPH, AFRIMS-GEIS, Ministry of Agriculture
Description: AFRIMS GEIS in alliance with the Thai Ministry
of Public Health has established a pilot zoonotic disease surveillance
program that will be web-based and facilitate the reporting
of human and animal disease between the public health and livestock
communities. A national level-working group has been established
and met several times during FY03. The working group selected
the zoonotic diseases of interest to be monitored; selected
one province (Kohnkaen) in the North-eastern region for a one
year pilot study to demonstrate the feasibility and usefulness
of the program; assessed the needs of the province to determine
the capacity, equipment, and mechanism of communication within
and between the MoPH and DLD; and has contracted with a programmer
to develop an internet-based software program and homepage.
The program will expand this coming year to at least one more
province in a different geographic region of the country.
Collaborators: Thai Ministry of Public Health
Infrastructure
support to Southeast Asia laboratories & FUO surveillance/study
in Nepal and in conjunction with EWARS
2001-2004
Description: Provide reagent and supply support to several labs
in South East Asia (e.g. VBDRTC, ICDDR-B) Sustainability is
improved by ongoing support activities to include training and
other QA/QC activities. Collaborative FUO Surveillance and Etiology
Study conducted in Nepal with EWARS.
Collaborators: AFRIMS Department of Virology, VBDRTC, ICDDR-B
Links: http://www.icddrb.org
http://www.ehproject.org/live/old_whats_new/August2002.htm
Status:
- AFRIMS Department
of Virology preliminary reports to show that Leptospirosis
is prevalent in Nepal. Continued laboratory infrastructure
support, supply of reagents, and training to numerous infectious
diseases is provided to labs throughout Asia to include Vietnam,
Cambodia, Thailand, Bangladesh (ICDDRB), India, Nepal, and
Uzbekistan. Several weeks of training were provided both at
AFRIMS and on-site. These contributions to regional infrastructure
provide incalculable returns in medical intelligence, disease
detection and disease control/prevention activities.
Prevalence
of antibodies to infectious diseases of public health importance
among recruits in the Royal Thai Army
2002-2004
Description: Testing of archived recruit sera for sero-prevalence
of infectious diseases to include dengue, scrub typhus, leptospirosis,
flaviviruses, and others; include GIS mapping of results.
Status:
- The cross-sectional
seroprevalence of HIV infection in all RTA conscripts has
been determined by AFRIMS since 1991 (approximately 65,000
conscripts per year). This represents a random sample of all
20-year-old males from every province in the country. AFRIMS
GEIS program has taken over the responsibility for the data
entry and storage archiving and plans to expand testing for
antibodies of infectious disease interest to include scrub
typhus, leptospirosis, and vaccine preventable diseases.
Royal
Thai Army Infectious Disease Surveillance and Outbreak Network
2002-2004
Description: Completed planning process and initiated implementation
of a near real-time communication and surveillance of syndromic
diseases categories. This database for Royal Thai Army will
involve two collection systems one for ambulatory care and one
for hospital care. Development of hospital management information
systems in 37 Royal Thai Army hospitals is networked together
into a central data repository allowing for real-time queries
and monitoring for disease outbreaks. RTA Unit-based (ambulatory)
disease syndrome surveillance and response system in units deployed
along Thai-Cambodian border. Both sets of data will be pulled
into one central database by evolving methodology. Next a central
review and verification process will occur and appropriate response
initiated as required. Outbreak Investigation Network: Assistance
given to the RTA and others (e.g. USCINCPAC, Regional MoH's)
for infectious disease outbreak identification, response, and
reporting.
Collaborators: Royal Thai Army, Phra Mongklut Klao Hospital
Links: http://www.pmk.ac.th
Status:
- The Unit Based
Surveillance system is expanding to additional command this
year. The developers, the surveillance team, and the outbreak
response team possess the technical resources and motivation
required to develop an army-wide surveillance plan. Collaborating
with GEIS enables advanced execution of this plan and assures
availability of this important data source to the international
community through DoD-GEIS.
- The Hospital Based
Surveillance captures disease relevant data from inpatient
encounters. The distribution and representative mix of clientele
served combine to makes this surveillance network nearly textbook
perfect. The impact is best summed up by Dr. Puntidis who,
at the Asia-Pacific Military Medicine Conference, when describing
the plans for the network, described how their vision is “one
country, one system.”
- The willingness
of AFRIMS to rapidly and thoroughly respond to the needs of
regional ministries of health and militaries has enabled the
AFRIMS GEIS program to grow in reputation as the institute
to turn to when an infectious disease outbreak occurs. GEIS
has enabled AFRIMS to add to its reputation as a comprehensive
research facility to be viewed as a dynamic and responsive
institute in the field of international public health in the
Asian region.
AFRIMS Infectious
Disease Outbreak Response Network- Information Communication
Infrastructure Development
2002-2004
Description: Website development initiated to work as a conduit
to communicate GEIS information in a timely, appropriate method.
Establish a network of links to access other surveillance activities
to facilitate future collaborative activities. Eventual goal
is to update incorporating dynamic website content, searchable
databases and eventually relational databases.
Status: GEIS 1.0 website completed
Collaborators: Global Disease Surveillance Network
Links: http://www.geis.fhp.osd.mil/GEIS/GlobalNetwork/Globalnetwork.asp
Molecular
Epidemiology of the Circulating Strain of HIV-1
2003-2004
Description: Study of Molecular Epidemiology of the Circulating
Strain of HIV-1 CRF01_AE by Full Genome Sequencing.
Status: Specimen collection and processing
DOD Influenza Surveillance
2001-2004
Description: Project Gargle Influenza surveillance from BKK,
Nepal, and expanding to Cambodia and Vietnam is a random sample
collection study designed to provide valuable input to the following
years influenza vaccine.
Status: Ongoing
Collaborators: Project Gargle participants are global dispersed
Links: Influenza
Reports
GEIS Annual
Report Production
2001-2003
Description: Summary of all GEIS related activities at AFRIMS
for the past year.
Status: Completed
WHO Collaborating
Center application
2003-2004
Description: Development of a robust, viable network to detect,
verify, and respond to potential disease outbreaks is a valuable
and timely effort by the WHO. The Armed Forces Research Institute
of Medical Sciences in Bangkok, Thailand is well positioned
and motivated to share expertise with the global medical community
in the area of outbreak detection and verification. The technical
programme sponsoring the request for designation is the GEIS
program of AFRIMS. Rationale for seeking designation as a WHO
collaborating center are; 40 years history of successful research
and development of drug, vaccine and disease diagnostic materials
in addition to active participation with the Department of Defense
Global Emerging Disease Information System http://www.geis.fhp.osd.mil.
Status: Application completed under review at WHO Headquarters
Surveillance
Database Development:
Developing laboratory
information database management and archiving of AFRIMS specimens.
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