DoD-GEIS

[kent nickell]

Some excerpts from DoD-GEIS Influenza Programs, Strengthening Global Surveillance and Response (2008)

(( This review was done by a committee from the Institute of Medicine (IOM) primarily to review how the programs were functioning after an influx of $39 million dollars allocated by Congress as part of the 2006 National Defense Authorization Act. The IOM was established in 1970 by the National Academy of Sciences to secure the
services of appropriate professionals in the examination of policy matters pertaining to the health of the public.))

""In 1996, the Executive Office of the President of the United States issued a Presidential Decision Directive declaring that national and international capabilities for infectious disease surveillance, prevention, and response were insufficient to protect the health of US citizens from emerging infectious diseases and called on US federal agencies to remedy the situation. The Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS), established in 1997, represents the DoD's response to that Presidential Decision Directive. GEIS's focus is primarily on sentinel surveillance of indigenous and expatriate populations for certain infectious disease targets, including influenza. For many decades the DoD has maintained a series of overseas medical research facilities in Asia, Africa, and Latin America that have been well poised to participate in the detection of emerging infectious disease threats. Collectively, these DoD facilities constitute an extraordianry array of surveillance assets.

In 2006, through the National Defense Authorization Act, Congress provided a $39 million supplement to GEIS, specifically to expand surveillance and response capabilities with respect to the threat of pandemic influenza of avian virus origin. An IOM Comittee was assembled at the request of the DoD to evaluate how the GEIS pandemic influenza surveillance and response program utilized the supplemental funds, strengthened influenza surveillance efforts domestically and internationally, integrated DoD efforts with those of other Federal agencies, coordinated activities with host countries (and neighboring countries in regional efforts), and collaborated with the World Health Organization and other international agencies engaged in influenza pandemic preparedness. Toward this end, a Committee was assembled with expertise in influenza, epidemiology, public health laboratory management, virology, veterinary and human medicine, global health and military preventive medicine. The Committee made site visits to the DoD overseas medical research units where GEIS-supported projects are under way, as well as to key military medical laboratories within the United States involved in influenza surveillance. The findings of the Committee are summarized in this report, along with a series of recommendations.

The Committee found that the DoD's overseas medical research units constitute an impressive network that has laudably utilized the supplemental funding to strengthen influenza surveillance, in addition to continuing their historically primary research activities. Perhaps the Committee's most overarching recommendation is that DoD-GEIS
headquarters should be formally charged with providing overall managerial and technical oversight (quality assurance, safety, etc.) and interagency communication for the multi-service influenza and respiratory disease surveillance program and the revised coordination structure. Part of this should be a codified chain of accountability to include timely reporting of findings. If the full set of recommendations are acted upon, the Committee is confident that the DoD-GEIS's key role in global surveillance will be further strengthened and its effectivensss enhanced.""

""Institutionalizing influenza surveillance in host countries and within the populations of these host countries provides DoD-GEIS laboatories with opportunities to assist host governments in using the data to prioritize future surveillance activities. Expanding the scope of data collection and analysis to look beyond H5N1 and developoing surveillance activities that are amenable to other emerging diseases would greatly benefit overall public health capacity.""

""For several weeks in October 1918 the influenza pandemic was causing 5,000 to 6,000 deaths each week in the US Army""

The book has separate chapters dealing with the lab systems in Indonesia, Thailand, Egypt, Kenya, Peru, San Diego and San Antonio.

The recommendations largely revolve around increasing lab capacity and expertise and surge capacity and in increasing coordination within the lab system (Army, Navy and Air Force) and between DoD-GEIS and other US partners including HHS, CDC, the NIH, FDA, USDA, the Department of State, the US Agency for International Development, the Department of Homeland Security and other relevant US government efforts as well as various international oganizations.

""National Stategy for Pandemic Influenza Implementation Plan Roles and Responsibilities

The Secretary of Homeland Security will be responsible for coordination of the federal response as provided by the National Strategy for Pandemic Inflluenza (Strategy), and will support the Secretary of Health and Human Services' coordination of overall public health and medical emergency response efforts.

The Secretary of Health and Human Services will be responsible for the overall coordination of the public health and medical emergency response during a pandemic.

The Secretary of Defense will be responsible for protecting American interests at home and abroad.

The Secretary of Transportation will be responsible for coordination of the transportation sector.

The Secretary of Agriculture will be responsible for overall coordination of veterinary response to a domestic animal outbreak of a pandemic virus or virus with pandemic potential and ongoing surveillance for influenza in domestic animals and animal products.

The Secretary of the Treasury will be responsible for monitoring and evaluating the economic impacts of the pandemic and will help formulate the economic policy response and advise on the likely economic impacts of containment efforts.""

""Military forces in a number of developing countries work closely with their ministries of health to help to strengthen their infectious disease surveillance and control programs. In turn, a number of activities performed by the DoD overseas laboratories are done so in collaboration with the host-country military, and two of these five laboratories are hosted by the foreign militaries: the Peruvian Navy hosts NMRCD in Lima and the Royal Thai Army (RTA) hosts AFRIMS in Bangkok. Examples of their collaborative efforts include a unit-based surveillance system developed by RTA and AFRIMS to improve infectious disease surveillance in remote areas of Thailand along the country's borders with Cambodia and the Lao People's Democratic Republic and also an electronic disease surveillance system, Alerta, developed by the Peruvian Navy and NMRCD. Before the development of this system, the Peruvian Navy had relied on a time-consuming paper-based reporting system. (Chretien JP, et al 2007. The importance of militaries from developing countries in global infectious disease surveillance. Bulletin of the World Health Organization 85(3): 174-180)""



Committee members:

Myron M. Levine MD, DTPH (Chair) Professor and Director, Simon and Bessie Grollman Distinguished Professor, Center for Vaccine Development, University of Maryland School of Medicine

Carol Cardona, DVM, PhD Associate Veterinarian, Associate Specialist in Cooperative Extension, Veterinary Medicine Extension, University of California, Davis

Walter Dowdle, PhD The Task Force for Child Survival and Development

Timothy Germann, PhD Technical Staff Member, Applied Science & Methods Development Group, Los Alamos National Laboratory

Mary Gilchrist, PhD Director, Bureau of Laboratory Sciences, State Laboratory Institute, Department of Public Health, The Commonwealth of Massachusetts

James M. Hughes MD Director, Program in Global Infectious Disease, Center for Global Safe Water, School of Medicine and Rollins School of Public Health, Emory University

K. Mills McNeill, PhD MD Director, Public Health Laboratory, Mississippi State Department of Health

Peter Palese, PhD Professor and Chair Department of Microbiology, Mount Sinai School of Medicine

Kennedy Francis Shortridge, PhD, DSc Emeritus Professor, The University of Hong Kong and Honorary Professor, Department of Microbiolgy, The University of Hong Kong, Hong Kong SAR, China, Honorary Professor, Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand

James Tibenderana, MBCHB, MPhil, PhD Drug Policy Change Specialist/Epidemiologist Malaria Consortium, Uganda


Board Liaison

Philip K. Russell, MD (Board on Global Health Liaison) Former Director, Office of Research and Development Coordination, Office of the Assistant Secretary for Public Health Emergency Preparedness, US Department of Health and Human Services

[kent nickell]

Re: DoD-GEIS

more excerpts from the above book...

Collaboration

DoD-GEIS staff also participate in two HHS-coordinated influenza-related groups. The first is a quarterly meeting with both the influenza division and the Office of Global Health at HHS. DoD-GEIS's participation in this group allows for ongoing feedback regarding influenza and AI/PI surveillance and control activities.

DoD-GEIS and representatives from other DoD Offices are also members of the HHS Pandemic and Seasonal Influenza Risk Management Group. This group has met monthly since its creation in September 2006. Representatives from HHS, NIH, the US Department of Agriculture, the FDA, the State Department, and CDC participate in this meeting and its related topic-driven focus area groups. Surveillance of pandemic influenza is one of the many focus areas of this group, along with research and development, animal models, manufacturing capacity, regulatory and legal issues, and stockpile issues. Currently two of the three working groups, vaccine prioritization and influenza diagnostics, have DoD representation.

In addition to formalized working groups, DoD and other governmental agencies, including HHS, DHS, the State Department, and CDC, have exchanged full-time medical liaison officers to help provide situational awareness of ongoing missions and to implement initiatives of mutual interest.

The assignment of a full-time US military medical officer to WHO in Geneva, Switzerland, has bolstered coordination and integration of efforts between DoD-GEIS and WHO

Oversight and coordination of the CDC-DoD Working Group on Influenza and Emerging Infectious Diseases, which AI-PI EPP (Emergency Preparedness Plan) program office staff assumed in October 2006.


DoD-GEIS Headquarters Influenza Activities

In addition to managing projects being carried out by other DoD partners, DoD-GEIS headquarters works directly with the Johns Hopkins University Applied Physics Laboratory (JHU/APL) to manage and execute several influenza-related projects. Two of these projects funded with AI/PI supplemental funding are an evaluation of the Early Warning Surveillance/Response System (EWORS) and an expansion of the Pandemic Influenza Policy Model (PIPM).

The EWORS was developed by NAMRU-2 to detect disease outbreaks early throughout Indonesia without relying on slower and often nonexistent laboratory methods. EWORS is based on entering basic demographic and syndromic data such as patient age, sex, fever, diarrhea, breathing difficulty, cough, or vomiting. This data is downloaded at a central location and then presented geographically to determine clustering by location. The program is being used at other locations also and being evaluated for its usefullness and is also being enhanced.

PIPM is a modeling project initiated to provide information on influenza preparedness to military installations in order to allow them to plan for various pandemic scenarios. The expansion of the PIPM is expected to examine the effect of changing disease and operational parameters on a wider range of DoD installations and organizations including basic training installations, installations with high operational tempos or high logistical thoughput, and installations within large metropolitan areas. The model is expected to provide military medical and operational commanders and policy makers with the first fine-grained, military-specific simulation tool for testing pandemic influenza surveillance and response strategies.

[kent nickell]

Re: DoD-GEIS

from the above book....

Naval Medical Research Unit 2 Indonesia Avian and Pandemic Influenza Activities

The Naval Medical Research Unit No. 2 (NAMRU-2), originally established during World War II in Guam and later relocated, first to Taiwan and then to the Philipines, began operating a detachment in Jakarta, Indonesia, in 1970.

NAMRU-2 employs a staff of more than 120 foreign service nationals (FSNs). FSN staff includes laboratory technicians and contract support personnel with expertise in areas of management and administration.

In Cambodia and Laos, NAMRU-2 paid contractors to manage the AI/PI-related projects in these satellite laboratories. With the expansion of AI/PI activities in Cambodia, the NAMRU-2 laboratory in Phnom Penh had difficulty finding and hiring technical staff. Recognizing the importance of not competing for the limited local technical personnel, NAMRU-2 and collaborating scientists from the CDC employed an innovative method to solve this problem. They hired a nongovernmental organization to search for competent, experienced technicians in neighboring Asian countries and imported them to live and work in Phnom Penh. The high level of competence and enthusiasm of these skilled senior technicians from Thailand and the Philippines has made its mark on the project. In order build this capacity in Cambodia in the longer term, NAMRU-2 is also now supporting local training to increase the expertise in laboratories in the country.

GEIS is integrated with current, ongoing activities within Indonesia's public health infrastructure. Within-country relationships are largely person based and proximity driven, and strong partnerships have resulted over the years. NAMRU-2 DoD-GEIS staff seemed very well known and respected by the national health authorities. The Ministry of Health approves all projects funded by GEIS. DoD-GEIS activities are transparent to the Indonesian Ministry of Health, and most projects are jointly conducted. Using the 2006 AI/PI supplemental funding, NAMRU-2's avian and pandemic influenza surveillance program was expanded to incorporate both animal and human surveillance.

The Laos People's Democratic Republic has had no human ILI (Influenza-like illness) surveillance network to identify human cases. Beginning in 2007, in conjunction with the MoH and CDC, NAMRU-2 developed a network of surveillance hospitals and clinics to screen and identify cases of H5N1 infections.

At the National Center for Laboratory and Epidemiology (NCLE) in Vientiane specimens will be screened by a mutliplex system for pathogen identification. H5N1-positive specimens will be confirmed by real-time RT-PCR methodology.

In addition, NAMRU-2 is funding the development of a Singapore location in order to attract potential research partners based in Singapore, establish a base for diagnostic and training operations, enhance logistical capabilities and operational agility for surveillance activities in Cambodia, Laos, and Indonesia, and serve as a strategic training unit, capable of providing training to NAMRU-2 regional partners.

In collaboration with the National Aeronautics and Space Administration, data from animal surveillance will be coordinated with satellite data to determine environmental correlates for transmission of AI.

NAMRU-2's ongoing collaboration with AFRIMS (The Armed Forces Research Institute of Medical Sciences in Bangkok, Thailand) allows for improved utilization of AI/PI resources as well as redundant coverage for each of the laboratories in the event of a crisis (political, geologic, etc.) that might close one and not the other during a pandemic.

Armed Forces Research Institute of Medical Sciences Thailand Avian and Pandemic Influenza Activities

AFRIMS was established in 1958 through an agreement between the governments of the United States and Thailand.

AFRIMS's situation in Thailand has required a complementary approach as the country has its own influenza virus surveillance program and its response to the introduction of AI has been substantial. The Thai laboratory, which is affiliated with the Ministry of Public Health (M0PH), has sophisticated methodology to serve the country and is backed up at 14 remote sites across the country, all of which are also equipped with rapid testing technologies. Its internet-based reporting system will eventually merge with another AFRIMS-supported project, linking MoPH and the Ministry of Agriculture and Cooperatives to allow sharing of data on zoonotic illnesses between ministries at the provincial and national levels. Therefore, AFRIMS's capacity for AI must be directed at less well resourced countries in the region and at supplying services that are complementary to those available in Thailand.

Within Thailand, AFRIMS is expanding influenza surveillance programs through its relationship with the Royal Thai Army. In these locations, previously unaddressed by the MoPH, AFRIMS's DoD-GEIS funding supports the capacities of ten military and two civilian hospitals to detect and report influenza primarily among refugee populations and non-Thai citizens along the western border with Myanmar. This work supplements the surveillance system of the MoPH in Thailand.

In the Philippines the purpose of the AFRIMS work is to develop an active influenza surveillance program in the Cebu Province (AFRIMS).

AFRIMS is playing an important role outside of Thailand as well, primarily through the Walter Reed/AFRIMS Research Unit Nepal (WARUN), WARUN was formally established in August 1995 and currently provides influenza diagnostic support and training to various entities in Nepal, such as the National Public Health Laboratory (NPHL), the Epidemiology and Disease Control Division (EDCD), and WHO Nepal.

An innovative capacity using mass tag spectroscopy to detect a wider range of respiratory pathogens, ranging from influenza to human metapneumovirus to mycoplasma, will be installed and evaluated in collaboration with a group at Columbia University. The viablility of this technology is very much dependent on sound spectroscopy support. This venture may yield new information about pathogens that are currently unrecognized but that affect nationals, refugees, and military personnel alike.

The Nepal MoPH affirmed its relationship with WARUN and AFRIMS but noted that it expects to receive funding from the World Bank to build its own BSL-3. More specifically, the World Bank is giving Nepal $18 million, 60 percent of which will be allotted to the veterinary efforts and 40 percent to the human programs. When the IOM team visited WHO, officials there proposed to develop a model public health laboratory system in Nepal, working with the Nepal MoPH and personnel from AFRIMS/WARUN. This would require significant human resources input.

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Re: DoD-GEIS

Naval Medical Research Unit 3 Egypt Avian and Pandemic Influenza Activities

US Naval Medical Research Unit No. 3 (NAMRU-3) is a US Navy research biosafety level 3 enhanced (BSL-3E) laboratory with extensive human and animal viral diagnostic capacity located in Cairo, Egypt.

NAMRU-3 was formally established by the US Secretary of the Navy in 1946.

DoD-GEIS support for NAMRU-3 influenza surveilllance and reponse project totaled $4 million in fiscal year 2006. Using these funds, NAMRU-3 expanded a number of its activities, such as conducting training on influenza diagnosis, helping to build national influenza laboratory capacity in Egypt and the region (including Afghanistan, Jordan, Libya, and Ghana).

NAMRU-3 has often been called on by WHO or national ministries of health to participate in outbreak-response teams.

NAMRU-3 had spent a significant amount of funding and effort on consulting with, training, and equipping more than 20 laboratories in the US Central Command (CENTCOM) and US European Command (EUCOM) areas of responsibility. To this end NAMRU-3 has expanded influenza surveillance expertise and diagnostic capacity throughout the region, including the countries of Azerbaijan, Djibouti, Egypt, Ghana, Iran, Iraq, Jordan, Kazakhstan, Kenya, Kyrgyzstan, Lebanon, Libya, Morocco, Nigeria, Oman, Pakistan, Saudi Arabia, Sudan, Syria, Ukraine, and Uzbekistan.

After being requested to conduct an assessment of public health laboratory capacity in Libya, NAMRU-3 identified the laboratory site within the Center for Infectious Disease in Tripoli and oversaw the purchase of equipment and reagents. In preparation for the opening of this laboratory site, NAMRU-3 hosted four Ph.D scientists from Libya for a two-week hands-on training course on avian influenza diagnostics. This marked the first time NAMRU-3 has had Libyans training side-by-side with US and Egyptian scientists.

As a regional influenza reference laboratory, NAMRU-3 has the capacity to serve as a reference laboratory for all of the countries in the EMRO (Eastern Mediterranean Regional Office) region, confirming influenza testing for ministries of health in the region. NAMRU-3 also extends assistance to the central Asian republics, West Africa, and countries such as Ukraine, Bulgaria. Macedonia, and Azerbaijan.

NAMRU-3 also conducted a WHO avian influenza training course for approximately 200 clinicians, laboratorians, and public health officials in Kiev for the countries of Ukraine, Azerbaijan, Georgia, Belarus, and Uzbekistan.

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Re: DoD-GEIS

US Army Medical Research Unit Kenya Avian and Pandemic Influenza Activities

In 1969 the US Army Medical Research Unit Kenya (USAMRU-K), a special foreign activity of the Walter Reed Army Institute of Research in Washington, DC, was activated on a temporary basis at the request of the government of Kenya to study trypanosomiasis. USAMRU-K's operations were originally dedicated to and supported by applied medical research, and its invitation to operate in Kenya was based on that research mission. Its operations became permanent in 1973, and since that time research has been conducted on malaria, leishmaniasis, and arboviruses. More recently, USAMRU-K has been involved with both avian and pandemic influenza surveillance.

Using DoD-GEIS supplementary funding USAMRU-K built laboratory capacity at the Kenya Medical Research Institute (KEMRI) and began the processes of establishing similar influenza surveillance projects in Uganda and Cameroon.

Because of a lack of surveillance activities, little information is available about the disease characteristics of influenza in sub-Saharan Africa. At the time of the IOM visit, for example, it is unclear if there are seasonal outbreaks or what viruses are circulating in countries such as Kenya.

The DoD-GEIS influenza surveillance in Kenya aims to isolate and characterize influenza viruses circulating among human populations, to estimate the burden of influenza disease among Kenyan children and adults, and to identify other viral and bacterial agents causing acute respiratory illnesses. The DoD-GEIS supported national surveillance system complements influenza surveillance activities being carried out by the Emerging Infections Program of the CDC in conjunction with KEMRI. CDC surveillance is aimed at detecting more severe clinical forms of influenza among hospitalized patients, while the WRP (Walter Reed Project) surveillance is directed at detecting influenza among less severely ill ambulatory patients seen as outpatients.

Since little is known about the seasonality of influenza in tropical populations or about the importance of influenza as a cause of acute respiratory disease in relation to other viral and bacterial respiratory agents in children and adults, epidemiologists at the Kenyan MoH have been urging DoD-GEIS investigators to use the influenza surveillance as an opportunity to investigate in the same patients the co-occurrence of other viral and bacterial pathogens. Given the keen interest of the MoH in obtaining such etiologic data, the IOM team was supportive of nesting a study to detect an array of other viral and bacterial etiologies within the influenza surveillance activitites. Should such a modification to the protocol proceed, it would be advisable to also collect respiratory specimens from age-matched healthy controls without acute respiratory illness, as a number of known respiratory pathogens can be present in non-ill individuals who have subclinical infection. Quantifying the background of such subclinical infection for various pathogens would be invaluable in allowing the most comprehensive analysis and interpretation of the surveillance data for influenza as well as for other etiologies.

In young pediatric patients the site visit team also suggested using RT-PCR to test stool specimens from patients with gastroenteritis in order to detect H5 influenza virus.

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Re: DoD-GEIS

Naval Medical Research Center Detachment Peru Avian and Pandemic Influenza Activities

The Naval Medical Research Center Detachment Peru (NMRCD), formerly known as The Naval Medical Research Institute Detachment, was established in Lima in 1983 through an agreement between the surgeons general of the Peruvian and US navies, with the concurrence of The US Department of State and the Peruvian Ministry of Foreign Affairs. The agreement established a cooperative medical research program to study infectious diseases of interest to both parties.

Peru's relative proximity to the continental United States and the frequent commerce and travel between North and South America give this unit an important role in infectious diseases surveillance, particularly as it relates to the biosecurity of the United States.

The mission of the detachment includes support for vaccine and drug development, evaluation of rapid diagnostics, and surveillance of emerging and re-emerging infectious diseases. The programs and collaborations of NMRCD extend through most of the countries of South and Central America.

NMRCD has a long-standing febrile syndrome surveillance protocol under DoD-GEIS. NMRCD's surveillance study, performed primarily with the General Office of Epidemiology in Lima and the National Institute of Health in Lima, is supported by approximately 10 additional collaborating institutions in Peru and the US. Currently about 64 clinics and hospitals (military and civilian) participate in febrile syndrome surveillance, and all can provide rapid diagnosis for influenza.

With the help of AI/PI funds this approach is now being extended to the Colombian Army, National Police, and Navy as well as to two Army sites in Ecuador. The influenza surveillance capabilities include isolation from nasopharyngeal swabs, PCR, and sequencing at NMRCD. Consideration is being given to expanding efforts to other countries such as Suriname.

NMRCD collaborates with many partners, including the CDC, MoH, USAID, PAHO (Pan American Health Organization), DGE (Directorate of General Epidemiology), and the Instituto Nacional de Salud (INS). Capacity building is central to the program.

Outbreak response has been central to NMRCD. NMRCD is well positioned to respond to influenza outbreaks, as evidenced from its experiences in 2006-2007 when it responded to outbreaks of plague, yellow fever, diarrhea, cyclospora, undifferentiated febrile syndrome, Venezuelan equine encephalitis, mumps, dengue, rabies, and influenza. The training unit has sponsored 33 iterations of the NMRCD outbreak investigation course. Over 1300 trainees from 14 countries have been trained over the past 5 years.

The number of sites from which NMRCD actively collects respiratory specimens has increased as well. Samples are collected form sites in 10 countries throughout South and Central America. Peru has the most active sites with 25; other sites are located in Argentina, Bolivia, Colombia, Ecuador, El Salvador, Honduras, Nicaragua, Paraguay, and Venezuela.

In addition to outbreak training, NMRCD has provided a number of courses in the conduct of research, bioethics, data analysis, and epidemiology. Students from many institutions based in the United States have been rotating regularly through NMRCD. These include USUHS, the University of Washington, the University of Iowa, Johns Hopkins University, Emory University, Tulane University, Kansas State University, and the State University of New York at Stony Brook.

The Ministry of Agriculture's laboratory, SENASA, has a mandate from the Food and Agricultural Organization and The World Organization for Animal Health to do animal surveillance for influenza, but resources to conduct this surveillance are quite limited. Independent collection of specimens by the INS influenza laboratory is compromised in a number of locations around Peru by issues surrounding the cold chain, the series of low-temperature facilities used for storing samples. These limitations have prompted the INS to focus on surveillance in intensive care units, whereas the NMRCD collects specimens primarily from primary care settings.

One of the main challenges for the Peruvian government influenza surveillance network is the cold chain needed to preserve specimens collected around the country. NMRCD has offered use of its ultra-low-temperature freezers around the country as well as assistance with biosafety issues.