1. Albert Cheung Hoi Yu, Ph.D. 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 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

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

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

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

5. Strategy of AI Control In China National 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

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. 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

8. Pandemic Planning Diagnostic Pyramid

9. AIV Family Tree

10. 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

11. 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

13. AI in China

14. 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

15. 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

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 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

17. 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 Symptoms Respiratory distress syndrome X-ray evidence of lung damage Fever Virus Infection Users Where? Who? User-friendly? Affordable?

18. 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

19. 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

20. Adapt to regular instrument NASBA System

21. Participation of NASBA-EOC Detection in the Influenza 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. 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!

27. 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

28.  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

29. 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.

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