Albert Cheung Hoi Yu, Ph.D.Albert Cheung Hoi Yu, Ph.D.

ProfessorInfectious Disease Center, Peking University

Professor and Vice-directorNeuroscience Research Institute, Peking University

Chairman and CEO Hai Kang Life Corporation Limited

Beijing Hai Kang DNA Chips Limited

achy@hsc.pku.edu.cn

Collaborative Opportunities on Bioinformatics in theDiagnosis of Infectious Diseases:

Our Preparedness in Battle Against Our Preparedness in Battle Against Avian InfluenzaAvian Influenza ？？

2nd ASEAN China International Bioinformatics Workshop, April 2008

Avian Influenza (AI) – A Global Threat !

Surveillance–in man & animals Stockpiling and logistics Emergency responses

Public health Community

Public communication Coordination and command

Influenza Pandemic Preparedness Plan

Phases of AlertPhases of AlertWHO ChinaVery similar

6Efficient and sustained

human-to-humantransmission

Pandemic

5Evidence of significant

human-to-humantransmission

4Evidence of increased

human-to-humantransmission

3No or very limitedhuman-to-human

transmission

PandemicAlert

New virus causes human cases

2Higher risk of human cases

1Low risk of

human cases

Inter-pandemicPhase

New virus inanimals, no

human cases

Pandemic

Efficient and sustained human-to-human transmission OR

WHO announcement of outbreak

I

Human-to-humanTransmissionII

Human infection with no human-to-

human transmissionIII

Preparatory Stage

New virus isolated in humans but triggered no immune response OR immune response

triggered but no symptoms

IV

Degree of R

esponse

Strategy of Strategy of AI AI Control In ChinaControl In ChinaNational Ministry of Public Health

[ With Provincial Departments of Health, Local Health Bureaus ]

Provincial Medical Expert Team

Provincial CDC

Suspected AI Case identified in Local Hospital [by Local Medical Expert Team and Local CDC]

1. Reporting of suspected cases

2. Reporting /

Delivery of sample for diagnosis & confirmation

National Medical Expert Team

4.Communication, feedbacks & proposed response

Direct & Real-time access to medical records through online reporting system

Provide medical expert teams to support diagnosis / treatment National CDC

3. Reporting of confirmed diagnostic result

Cooperation : Diagnosis and Treatment

Surveillance of AI in AnimalsDuring 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

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 cases sent for rapid flu test, and conventional test for H5N1. Investigations of all reported cases by trained epidemiology teams. Daily situation monitoring, daily update on website .

Surveillance of AI in Humans

Pandemic Planning Diagnostic Pyramid

AIV Family Tree

• 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

Evolving Viruses

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.

The Battle Against Infectious Disease

AI in China

Source: BOE, MOPH

Confirmed case

Suspect case

Area of outbreak in poultry

Jan-May 2004 Jun-April 2005

Outbreaks of AI in Poultry and Human Cases in Thailand

May 2005- Dec 05

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

Challenges for Diagnosticsfrom 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

Current Detection Current Detection MethodsMethods

Ag / Ab-based method

Microbiological evidence of virus (virus isolation)

Conventional PCR

Real time-PCR

NASBA

New MethodNew Method

Modified Enhanced real time-PCR

SymptomsSymptoms

• Respiratory distress syndrome

• X-ray evidence of lung damage

• Fever

VirusVirus

InfectionInfection

UsersUsers

•Where?

•Who? User-friendly?

•Affordable?

Isothermal amplification technique

comparable results within different test units

Simplified operation process

reduced contamination, higher reproducibility

PCR’s false positive result

Amplification Technology of NASBA

Step 3. Probe hybridization

Step 1. Reagent mixing

Step 4. Signal detection by ELISA reader

Step 2. Isothermal incubation (can be replaced by a heat block)

NASBA Protocol

Adapt to regular instrument

NASBA System

Participation of NASBA-EOC Detection in theParticipation of NASBA-EOC Detection in theInfluenza Surveillance Program Influenza Surveillance Program

Commissioned by the National AIV Task ForceCommissioned 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

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 SystemsMolecular 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

Was it possible to establish rapid and accurate tests for

Infectious diseases in an outbreak situation?

• 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

Difficulties in Getting Good Diagnostic Kit Validated!

Development of Sustainable and Integrated Management System

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

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

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)

Major success factors for AI control

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