Collaborative Opportunities in Bioinformatics for Avian Influenza Diagnosis

1. Collaborative Opportunities on Bioinformatics in the Diagnosis of Infectious Diseases: Our Preparedness in Battle Against Avian Influenza？ 2nd ASEAN China International Bioinformatics Workshop, April 2008 Albert Cheung Hoi Yu, Ph.D.ProfessorInfectious Disease Center, Peking UniversityProfessor and Vice-directorNeuroscience Research Institute, Peking UniversityChairman and CEO Hai Kang Life Corporation LimitedBeijing Hai Kang DNA Chips Limitedachy@hsc.pku.edu.cn

2. Avian Influenza (AI) – A Global Threat !

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

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

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

6. 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: • 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) • Proactive countrywide community survey to detect and destroy infected flocks, then twice a year

7. Surveillance of AI in Humans • Detection and report of all pneumonia & flu-like illnesses with history of exposure to sick/dead poultry or of contact with pneumonia cases… • Nasopharyngeal swab of all casessent for rapid flu test, andconventional test for H5N1. • Investigations of all reported cases by trained epidemiology teams. • Daily situation monitoring, daily update on website .

8. Pandemic Planning Diagnostic Pyramid

9. AIV Family Tree

10. Evolving Viruses • H5N1 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

11. The Battle Against Infectious Disease To defeat an infectious disease, you mustcontrol its transmission from infectedpeople 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.

13. AI inChina

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

15. Lab Conditions • No temperature control nor heating– temp in lab was about 10oC • 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 8oC

16. 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 humanpandemic 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

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

18. 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

19. 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 Protocol

20. NASBA System Adapt to regular instrument

21. Participation of NASBA-EOC Detection in theInfluenza Surveillance Program Commissioned by the National AIV Task Force • NASBA-EOC: Takes part in the project implemented by National AIV task force • Surveillance of avian influenza virus (generic and subtype H5), human influenza virus, parainfluenza virus, and other selective pneumonia-causing pathogens in Beijing population • Beijing Hai Kang DNA Chips Limited provides NASBA AIV / H5 test kits for the surveillance program

22. 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

23. Multiplex NASBA!

24. Molecular Pneumonia Detection Systems • Project awarded by the China Ministry of Science and Technology (a “863” project) • 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 • Development of multiplex NASBA, ERT-PCR and other detection system/ technology for various pneumonia-causing pathogens (including SARS, AIV, influenza, etc.) • Development of a Lab-On-A-Chip (LOAC) system

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

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

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

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

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

30. ThankYou！ 谢谢！ CNN - “Businesses brace for pandemic” 3 November 2005