2 nd ASEAN China International Bioinformatics Workshop April

2 nd ASEAN China International Bioinformatics Workshop, April 2008 Collaborative Opportunities on Bioinformatics in the Diagnosis of Infectious Diseases: Our Preparedness in Battle Against Avian Influenza？ Albert Cheung Hoi Yu, Ph. D. Professor Infectious Disease Center, Peking University Professor and Vice-director Neuroscience Research Institute, Peking University Chairman and CEO Hai Kang Life Corporation Limited Beijing Hai Kang DNA Chips Limited achy@hsc. pku. edu. cn

Avian Influenza (AI) – A Global Threat !

Influenza Pandemic Preparedness Plan Surveillance–in man & animals Stockpiling and logistics Emergency responses Public health Community Public communication Coordination and command

Phases of Alert WHO Inter-pandemic Phase Very similar IV New virus in animals, no human cases Higher risk of human cases No or very limited human-to-human transmission 3 Evidence of increased human-to-human transmission 4 III Human infection with no human-tohuman transmission 2 Pandemic Alert New virus isolated in humans but triggered no immune response OR immune response triggered but no symptoms 1 Evidence of significant human-to-human transmission Pandemic Efficient and sustained human-to-human transmission Degree of Response Low risk of human cases New virus causes human cases China Preparatory Stage II Human-to-human Transmission I Efficient and sustained human-to-human transmission OR WHO announcement of outbreak 5 6 Pandemic

Strategy of AI Control In China National Ministry of Public Health [ With Provincial Departments of Health, Local Health Bureaus ] Provide medical expert teams to support diagnosis / treatment 3. Reporting of confirmed diagnostic result 4. Communication, feedbacks & proposed response National CDC National Medical Expert Team Direct & Real-time access to medical records through online reporting system 2. Reporting / Delivery of sample for diagnosis & confirmation Provincial Medical Expert Team Cooperation : Diagnosis and Treatment Provincial CDC 1. Reporting of suspected cases Suspected AI Case identified in Local Hospital [by Local Medical Expert Team and Local CDC]

Surveillance of AI in Animals During outbreak: Detection and report of infection by farmers and volunteer, based on clinical criteria (5% deaths in flock), to activate pre-emptive culling, confirmed by lab. (cloacal swab – viral isolation) After outbreak: µ Maintenance of clinical-based surveillance with lab. testing to confirm freedom from disease in control zone around infected area for 21 days, then 5 months (OIE) µ Proactive countrywide community survey to detect and destroy infected flocks, then twice a year

Surveillance of AI in Humans Detection and report of all pneumonia & flulike illnesses with history of exposure to sick/dead poultry or of contact with pneumonia cases… Nasopharyngeal swab of all cases sent for rapid flu test, and conventional test for H 5 N 1. Investigations of all reported cases by trained epidemiology teams. Daily situation monitoring, daily update on website.

Pandemic Planning Diagnostic Pyramid

AIV Family Tree

Evolving Viruses • H 5 N 1 viruses in 1997, 2003, 2004 and 2005 are genetically and antigenically different • Different virus clades encountered in countries of the region: • Clade 1 (Lao, Thailand, Vietnam, Cambodia, China) • Clade 2 -subclade 3 (China, Thailand, Cambodia, Vietnam) • Clade 2 -subclade 1 (Indonesia) • Sequence variation should be considered in diagnostic development

The Battle Against Infectious Disease To defeat an infectious disease, you must control its transmission from infected people to healthy ones. The critical issues are planning, surveillance, and getting an early warning. It was important to find ways to rapidly tell people that they are not infected.

AI in China

Outbreaks of AI in Poultry and Human Cases in Thailand Jan-May 2004 Jun-April 2005 May 2005 - Dec 05 Confirmed case Suspect case Area of outbreak in poultry Source: BOE, MOPH

Lab Conditions • No temperature control nor heating– temp in lab was about 10 o. C • Walls and floors did not have appropriate covering (tiles and bumpy lino) • Electricity supply not guaranteed (no generator); interruptions experienced during testing • No freezer below about 8 o. C

Challenges for Diagnostics from Global Public Health Perspective As accurate as necessary – to ensure WHO's public health responsibilities fulfilled As quick as possible – to detect the emergence of new variants of human pandemic potential – to trigger outbreak response, investigation and rapid containment whenever needed As simple as possible – the majority of diagnostic labs in the world does not have advanced lab settings – many crucial diagnosis conducted under huge pressure

Symptoms • Respiratory distress syndrome Virus Current Detection Methods Ag / Ab-based method • X-ray evidence of lung damage Microbiological evidence of virus (virus isolation) • Fever Conventional PCR Real time-PCR Users NASBA • Where? New Method • Who? User-friendly? Modified Enhanced real time-PCR • Affordable? Infection

Amplification Technology of NASBA Isothermal amplification technique comparable results within different test units Simplified operation process reduced contamination, higher reproducibility PCR’s false positive result

NASBA Protocol Step 1. Reagent mixing Step 2. Isothermal incubation (can be replaced by a heat block) Step 3. Probe hybridization Step 4. Signal detection by ELISA reader

NASBA System Adapt to regular instrument

Participation of NASBA-EOC Detection in the Influenza Surveillance Program Commissioned by the National AIV Task Force n NASBA-EOC: Takes part in the project implemented by National AIV task force n Surveillance of avian influenza virus (generic and subtype H 5), human influenza virus, parainfluenza virus, and other selective pneumonia-causing pathogens in Beijing population n Beijing Hai Kang DNA Chips Limited provides NASBA AIV / H 5 test kits for the surveillance program

National Task Force for Human AIV Training on AIV diagnosis using the NASBA EOC method to the National AIV task force members in Beijing, China

Multiplex NASBA!

Molecular Pneumonia Detection Systems n Project awarded by the China Ministry of Science and Technology (a “ 863” project) n We collaborated various hospitals in Beijing including hospitals affiliated Peking University, Chao Yang Hospital, You An Hospital and Di Tan Hospital of Capital Medical University n Development of multiplex NASBA, ERT-PCR and other detection system/ technology for various pneumoniacausing pathogens (including SARS, AIV, influenza, etc. ) n Development of a Lab-On-A-Chip (LOAC) system

Was it possible to establish rapid and accurate tests for Infectious diseases in an outbreak situation?

Difficulties in Getting Good Diagnostic Kit Validated! • Adequate clinical samples • Well characterized samples are indispensable for the development and evaluation of diagnostic test • Appropriate and adequate specimens • Good quality • Adequate clinical information • Appropriate labeling and storage • Good data management

Development of Sustainable and Integrated Management System 1. Development of knowledge management mechanism during the inter – pandemic period 2. Development of knowledge management mechanism during pandemic 3. Establishment of a system for coordination and communication among various organizations during pandemic 4. Coordination with foreign and international organizations 5. Monitoring and evaluation

Major success factors for AI control Strong leadership and support of the Government Close co-operation between public health and animal health authorities, and among partners in multi – sectors Proactive risk communication to the public and strong public involvement Extensive international collaborations, especially with WHO, OIE, FAO, APEC, ASEAN-China-Korea-Japan, … Existing infrastructure (surveillance, laboratories, disease control, hospital infection, trained personnel)

The influenza epidemic of 1918 killed 20 million in just 18 months. With 25 million Americans alone infected during the influenza epidemic, it was hard to provide care for everyone. The Red Cross, seen here with masks over the faces of the nurses, often worked around the clock. Source: Courtesy of the National Library Museum.

CNN - “Businesses brace for pandemic” 3 November 2005