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Armed Forces Research Institute of Medical Sciences Welcome from AFRIMS A joint medical research facility of the Royal Thai Army and the United States Army Medical Research and Development Command “…probably the most sophisticated diagnostic and research laboratory in all of Southeast Asia.” U.S. Institute of Medicine report on DoD-GEIS, 2001 Armed Forces Research Institute of Medical Sciences Major Research Initiatives at AFRIMS • • • • Japanese Vaccine Development in 1990s Dengue Vaccine Development – current HIV Vaccine Development – current Diarrhea Research and Surveillance of Drug Resistance • Malaria Drug Development (mefloquine, tetracycline, new artemisinins) and Surveillance of Drug Resistance • Mosquito and other Insect Biology • Emerging Diseases Surveillance and Response Armed Forces Research Institute of Medical Sciences Global Emerging Infectious Diseases Surveillance (GEIS) • What is an Emerging Disease? • a new disease, not previously described (e.g. SARS) • an underestimated disease (e.g. leptospirosis), • a re-emerging disease, often with increased drug resistance (MDR-TB or MDR-Pf) • The DoD-GEIS program at AFRIMS: • • • • • Febrile illness surveillance (Sangkhlaburi, Kamphaeng Phet, Nepal) Drug resistant malaria surveillance Drug resistant diarrheal pathogen surveillance Rapid sentinel surveillance at RTA hospitals Outbreak response Armed Forces Research Institute of Medical Sciences Summary of Presentations • Fever Study • • • • • Overview Specific causes of fever Clinical characterizations Leptospirosis Rickettsial Illnesses Dr. Scott Miller Dr. Mark Fukuda Nichapat U-Thaimongkol Dr. Ruth Ellis Dr. Scott Miller • Diarrhea Study • Malaria Drug Resistance • New Directions Dr. Ladaporn Bodhidatta Dr. Scott Miller Drs. Krisada Jongsakul & Mark Fukuda Armed Forces Research Institute of Medical Sciences Surveillance of Febrile Illnesses of Adults in Sangkhlaburi District 1999-2003 Department of Immunology and Medicine AFRIMS Dr. R. Scott Miller, M.D. Armed Forces Research Institute of Medical Sciences Background • AFRIMS started doing surveys for malaria prevalence and drug resistance patterns surveys in the Sangkhlaburi district in 1995 • Testing an antibiotic, azithromycin: • for prevention of malaria in 1996; • for treatment of PF with quinine in 2000-2001 • Started an relationship with Kwai River Christian Hospital • What is causing the other 70% of fevers at the hospital? Armed Forces Research Institute of Medical Sciences Objectives • To define the specific cause of undifferentiated febrile illnesses: • To identify specific rickettsial, arboviruses and zoonotic pathogens. • To identify the patterns of drug resistance of diarrheal pathogens and enteric fevers (typhoid) • Evaluate the prevalence of these illnesses by sero-surveys of the local populations • To evaluate test kits for rapid diagnosis of undifferentiated febrile illnesses as compared to standard diagnostics. • Study approved by Committee on Research in Humans Subjects, MOPH Armed Forces Research Institute of Medical Sciences Fever Study Methods • Identify volunteers from those presenting to with a fever or history of fever • Informed consent obtained • Blood drawn for: • • • • Malaria smear and rapid testing WBC, HCT and platelet count Renal and liver tests Serum for acute serology testing • Medical history and physical exam • Treatment by hospital staff or volunteers Armed Forces Research Institute of Medical Sciences Fever Study Methods • Return for follow-up visit at 3-4 weeks • And earlier visits as needed • Interim medical history and exam • Additional blood drawn for: • Repeat WBC, HCT and platelet count • Renal and liver tests, if initially abnormal • Serum for paired convalescent serology testing • Fever syndrome classified by clinical and laboratory features Armed Forces Research Institute of Medical Sciences Fever Syndrome Classification a). fever with upper respiratory disease b). fever with lower respiratory disease c). fever with meningitis, encephalitis, or neuropathy d). fever with gastrointestinal disease e). fever with renal disease f). fever with abnormal bleeding g). fever with liver disease h). fever with anemia, leukopenia or thrombocytopenia i). fever with hepatomegaly or splenomegaly (circle) j). fever with lymphadenopathy k). fever with arthritis (mono- or polyarticular) l). fever with rash m). fever with eschar n). fever with shock o). fever with non-specific symptoms p). isolated fever without systemic symptoms q). fever with other symptoms (specified) _______________ Armed Forces Research Institute of Medical Sciences Fever Study Village Seroprevalence Study • Cross-sectional surveys of adult volunteers • • • • End of dry season and rainy season (every 6 months) 1999-2001 (2 monsoon cycles) Serum collection and malaria smear Volunteers from three villages near KRCH (n=497) • • • • Viakadee (n=182) Mong Satur (n=175) Mong Satur Tai (n=140) Tested for exposure to: rickettsia, leptospirosis, and other animal diseases