7
GEIS Central Hub and Military Health System Activities

The expanded charge of the Institute of Medicine’s (IOM’s) Committee to Review the Department of Defense (DoD) Global Emerging Infections Surveillance and Response System states that “the committee will review how well Global Emerging Infections Surveillance and Response System (GEIS) program goals, objectives, and activities are being carried out domestically, namely, within the military health system and the GEIS Central Hub.”

The range of GEIS activities addressed within the infrastructure of the military health system (MHS) do not constitute a domestic program per se but are conceptually linked to GEIS as a whole as part of a system of global emerging infectious disease surveillance. As a triservice program, GEIS has taken an approach that pursues gaps in the MHS’s capability to identify and address emerging infectious diseases and works to remedy those gaps by building infrastructure, facilitating and supporting response capabilities, providing training and education, and strengthening surveillance capabilities. GEIS resources have been allocated within the MHS to support an array of activities—some new, others already in existence—at many DoD facilities. Together, GEIS laboratory improvement and surveillance activities are intended to “ensure that DoD health care providers have improved access to quality assured, specialized laboratory tests and that those test results are captured for both patient care and public health purposes” (GEIS, 2000b, p. 12).

Within the MHS, many public health surveillance resources are already available. The Army’s Center for Health Promotion and Preventive Medicine (CHPPM) maintains a system of databases, the Defense Medical



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 7 GEIS Central Hub and Military Health System Activities The expanded charge of the Institute of Medicine’s (IOM’s) Committee to Review the Department of Defense (DoD) Global Emerging Infections Surveillance and Response System states that “the committee will review how well Global Emerging Infections Surveillance and Response System (GEIS) program goals, objectives, and activities are being carried out domestically, namely, within the military health system and the GEIS Central Hub.” The range of GEIS activities addressed within the infrastructure of the military health system (MHS) do not constitute a domestic program per se but are conceptually linked to GEIS as a whole as part of a system of global emerging infectious disease surveillance. As a triservice program, GEIS has taken an approach that pursues gaps in the MHS’s capability to identify and address emerging infectious diseases and works to remedy those gaps by building infrastructure, facilitating and supporting response capabilities, providing training and education, and strengthening surveillance capabilities. GEIS resources have been allocated within the MHS to support an array of activities—some new, others already in existence—at many DoD facilities. Together, GEIS laboratory improvement and surveillance activities are intended to “ensure that DoD health care providers have improved access to quality assured, specialized laboratory tests and that those test results are captured for both patient care and public health purposes” (GEIS, 2000b, p. 12). Within the MHS, many public health surveillance resources are already available. The Army’s Center for Health Promotion and Preventive Medicine (CHPPM) maintains a system of databases, the Defense Medical

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Surveillance System (DMSS), that provides “up-to-date and historical data on diseases and medical events (e.g., hospitalizations, ambulatory visits, reportable diseases, HIV [human immunodeficiency virus] tests, acute respiratory diseases, and health risk appraisals) and longitudinal data on personnel and deployments” (AMSA, 2001) dating back to 1990 (AMSA, 2001; IOM, 1999). The DoD also maintains a serum repository, linked to the DMSS, that contains more than 20 million specimens (AMSA, 2001). In addition to reporting data to CHPPM,1 the Navy and the Air Force also maintain distinct surveillance systems, namely, the Naval Disease Reporting System, the Shipboard Non-Tactical ADP (automated data processor) Automated Medical System, and the Air Force Reportable Events Surveillance System (AFRESS). These systems constitute surveillance resources that GEIS seeks to enhance and to make use of in furthering its emerging infectious disease surveillance goals. To better understand the nature of the domestic and global emerging infections surveillance activities of the DoD, committee members made a site visit to San Diego, California, in January 2001. There the committee visited the Naval Health Research Center (NHRC), as well as the Navy Environmental and Preventive Medicine Unit 5 (NEPMU-5) and the U.S. Naval Hospital, San Diego. Additional information regarding GEIS domestic projects, program management, and collaborative relationships was gathered at a meeting in Washington, D.C., in March 2001. During this meeting, a site visit was made to the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID). Meeting agendas and lists of people met can be found at the end of this chapter. To provide the most comprehensive review of a diverse collection of activities possible, this review relies heavily on presented and written material and differs in format from the overseas research laboratory review segments of this report. DESCRIPTION OF GEIS CENTRAL HUB AND MHS ACTIVITIES In the GEIS fiscal year 2000 annual report, GEIS activities are identified as occurring in “three primary settings: the military health system (MHS), the five DoD overseas medical units, and various training, leadership, and capacity building partnerships with regional CINCs [commanders in chief, unified combatant commands] and other governmental and international agencies” (GEIS, 2000b, p. 7). GEIS operations at the overseas laboratories are considered in detail elsewhere in this report, leaving two areas of GEIS focus to be addressed 1   To date, reporting is incomplete (U.S. Air Force and U.S. Navy comments at presentation to committee, March 2001).

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review here: activities conducted within the infrastructure of the MHS, and activities conducted in an effort to build partnerships or provide humanitarian assistance (GEIS, 2000b). In addition to these GEIS programmatic activities, the GEIS Central Hub also engages in activities to manage GEIS as a whole. Core funding for GEIS has been budgeted by using program 8 (P-8) funds—which are operational funds as opposed to research funds. Supplementary funding is also received from unified combatant commands. Through the year 2001, approximately 65 percent of GEIS funds went to support the overseas research laboratories. The remaining funds were divided between the Central Hub, the MHS, and USAMRIID (Kelley, 2001a), as summarized in Tables 7-1 to 7-3. GEIS Surveillance-Related Activities General Public Health Laboratory Improvement and Laboratory-Based Surveillance Directory of Laboratory Services and Virtual Public Health Laboratory In September 1999, GEIS and the Armed Forces Institute of Pathology (AFIP) sponsored a Military Public Health Laboratory Symposium and Workshop, the proceedings of which were published in a supplement to the journal Military Medicine (July 2000). The symposium was attended by representatives of academia and members of the public and private sectors. In the course of this symposium, a workshop group convened and considered, as two distinct concepts, the needs and requirements for the development of a DoD Directory of Public Health Laboratory Services and a Virtual Public Health Laboratory (VPHL), respectively (Bolton and Gaydos, 2000). The DoD Directory of Public Health Laboratory Services was envisioned as a means of making a directory of public health laboratory services for infectious agents available to DoD medical facilities, a resource that the DoD lacks (Bolton and Gaydos, 2000; Gaydos, 2001b). The workshop group contended that clinical, research, environmental, occupational, and veterinary laboratory capacities are not well known to those working outside of each laboratory (Bolton and Gaydos, 2000). As a result, the workshop group states, time can be lost and excessive costs can be incurred when physicians and laboratory personnel make uninformed decisions about where to send specimens for testing (Bolton and Gaydos, 2000; Gaydos, 2001a). Identification of a testing site can be particularly difficult for rare or emerging infectious diseases, as frequently only one laboratory is capable of performing tests (Ascher, 2000). The directory concept also embraces the idea of capturing test results (through the Composite Health Care System [CHCS]) for epidemiological study.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review TABLE 7-1 GEIS Surveillance-Related Activities Element Project or Activity General public health laboratory improvement and laboratory-based surveillance Virtual Public Health Laboratory Enhancement of laboratory diagnostic capacity CHCS implementation Respiratory disease surveillance and capacity building For example, adenovirus, influenza viruses A and B, Streptococcus pyogenes, invasive Streptococcus pneumoniae For example, influenza virus (DoD Laboratory-Based Influenza Surveillance Program) Mortality surveillance Triservice mortality surveillance Surveillance for and response to sexually transmitted diseases and antibiotic resistance Gonococcal Isolate Surveillance Project Antimicrobial resistance surveillance pilot project Development of a geographic information system for surveillance of sexually transmitted and other diseases Health indicator surveillance ESSENCE (syndromic surveillance for emerging infectious diseases and bioterrorism events in National Capital Area) Syndromic surveillance for shipboard deployed forces

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Lead Agents and Primary Collaborators GEIS Funding, FY 2000 Budgeted GEIS Funding, FY 2001a Project Status AFIP $60,000 $320,000b Prototype USAMRIID $125,000c $135,000c Ongoing Tricare Management Activity $15,000 $55,000 CHCS II in development NHRC $650,000 $705,000 Funded projects under way AFIERA $508,000 $590,000 Ongoing AFIP CHPPM $100,000 $105,000b Additional component in development Central Hub in collaboration with CDC, WHO, and domestic and overseas military sites   $20,000 Beginning at sentinel site in Hawaii, expansion planned Central Hub in collaboration with Army and Air Force medical centers; CRDA between GEIS, WRAIR, and MRL Pharmaceuticals, Inc. $64,000 $60,000 Beginning at sentinel site in Hawaii, expansion planned Collaboration with USAMRIID and Madigan $100,000 $25,000 One-year pilot beginning in FY 2001; if successful, continued indefinitely Central Hub, CHPPM $35,000 $25,000 Ongoing NEHC $104,000 $60,000 Ongoing

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Element Project or Activity Malaria and other public health threats in Republic of Korea Korea malaria/febrile illness surveillance Other Central Hub-managed GEIS projects Remote sensing Antimalarial drug surveillance Surveillance for viral respiratory pathogens and causes of severe acute febrile illnesses in Uganda Miscellaneous Outbreaks/requested activities (e.g., surveillance for West Nile virus) NOTE: FY, fiscal year; CHCS (II), Composite Health Care System (II); AFIP, Armed Forces Institute of Pathology; USAMRIID, U.S. Army Medical Research Institute of Infectious Diseases; NHRC, Naval Health Research Center; AFIERA, Air Force Institute for Environmental Safety and Occupational Health Risk Analysis; ESSENCE, Electronic Surveillance System for the Early Notification of Community-Based Epidemics; CHPPM, Center for Health Promotion and Preventive Medicine, U.S. Army; CDC, U.S. Centers for Disease Control and Prevention; WHO, World Health Organization; CRDA, cooperative research and development agreement; WRAIR, Walter Reed Army Institute of Research; NEHC, Navy Environmental Health Center; MEDCOM, Medical Command; NASA, National Aeronautics and Space Administration; USAMRU-K, U.S. Army Medical Research Unit, Kenya. The larger VPHL concept—virtual in the sense that it would involve the strengthening and formalization of links between existing laboratories, within and outside of the DoD, not the creation of new facilities— was considered a means of improving lines of communication and coordination, authority, and responsibility within the DoD laboratory system. The VPHL concept incorporates the directory of laboratory services, but it also calls for the strengthening and formation of interlaboratory agreements. The VPHL concept also includes provisions for the collection and archiving of specimens (Bolton and Gaydos, 2000). The workshop group from the Military Public Health Laboratory Symposium and Workshop emphatically recommended that a World Wide Web-based DoD Directory of Public Health Laboratory Services be

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Lead Agents and Primary Collaborators GEIS Funding, FY 2000 Budgeted GEIS Funding, FY 2001a Project Status 18th MEDCOM $100,000 $75,000 Ongoing Collaboration with NASA $10,000 $40,000 Under way Collaboration with WRAIR and WHO 0 $60,000 Ongoing Collaboration with AFIERA, WRAIR, WHO, Uganda Viral Research Institute, USAMRU-K, Rakai Project 0 $60,000 Under development Collaborations as needed or directed $40,000 $47,600 Projects conducted as needed aPreliminary budget estimates as of August 8, 2000. Figures are subject to change throughout the fiscal year and are provided only to give the reader a general sense of the scope and scale of GEIS project activity. These figures should not be interpreted as exact expenditures. bEstimated figures per S.Gubenia, Department of Defense Global Emerging Infections Surveillance and Response System, June 21, 2001. cDirect GEIS funding. Additional GEIS funds are provided indirectly through the laboratories for the processing of specimens and other services. SOURCES: GEIS, 2000a,b,c; Kelley, 2001b. developed. The workshop group advised that responsibility for operating, evaluating, and updating the directory should rest with AFIP, in coordination with GEIS. Rather than supporting the separate development of the directory and VPHL concepts, the workshop group viewed the directory as the first step in the realization of VPHL goals. The workshop group also suggested that some of the perceived weaknesses in the laboratory system could be addressed through alternative means, such as pursuit of formal agreements (i.e., with the U.S. Centers for Disease Control and Prevention [CDC]). The recommendations of the workshop group were subsequently endorsed by the Armed Forces Epidemiology Board (AFEB) (AFEB, 2000). A prototype of the DoD Directory of Public Health Laboratory Ser-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review TABLE 7-2 GEIS Training and Development Activities Element Project or Activity Agent GEIS Funding, FY 2000 Budgeted GEIS Funding, FY 2001a Status Training and capacity building Overseas Medical Research Laboratory Orientation Training Program Central Hub $50,000 $100,000 Ongoing   Peruvian Laboratory-Based Public Health Surveillance Projectb Central Hub, Institute Nacional de Salud $105,000 Unknown Ongoing   Caribbean Laboratory-Based Public Health Surveillance Projectb Central Hub, WRAIR, CAREC     Ongoing   U.S. Army Health Facilities Planning Agency Support to the Caribbean Epidemiology Centerb Central Hub, HFPA, CAREC     Ongoing Systems research, development, and integration (infrastructure development) GEIS website (GEISWeb) Central Hub $75,000   Ongoing NOTE: FY, fiscal year; WRAIR, Walter Reed Army Institute of Research; CAREC, Caribbean Epidemiology Center; HFPA, Health Facilities Planning Agency. aPreliminary budget estimates as of August 8, 2000. Figures are subject to change throughout the fiscal year and are provided only to give the reader a general sense of the scope and scale of GEIS project activity. These figures should not be interpreted as exact expenditures. bSupported with funds supplied by the Overseas, Humanitarian, Disaster, and Civil Aid (OHDACA) program. SOURCES: GEIS, 2000a,b,c; Kelley, 2001b.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review TABLE 7-3 GEIS Management Activities Element Project or Activity Agent GEIS Funding, FY 2000 Budgeted GEIS Funding, FY 2001a Status Management Develop, coordinate, and monitor execution of strategic plan           Review annual proposals for funding and prioritize support           Coordinate distribution of funds           Review and publish annual reports from GEIS funded agencies           Assist with obtaining supplementary resources           Represent GEIS to higher headquarters and other federal, international, and local agencies           Facilitate CINC-supported civic assistance projects           Manage public and professional awareness initiatives           Foster solutions to emerging infections problems through sponsorship of professional forums           TOTAL Central Hub $715,000 $715,000 Ongoing NOTE: FY, fiscal year; CINC, commander in chief, unified combatant command. aPreliminary budget estimates as of August 8, 2000. Figures are subject to change throughout the fiscal year and are provided only to give the reader a general sense of the scope and scale of GEIS activity. SOURCES: GEIS, 2000b,c; Kelley, 2001b.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review vices was presented to the IOM committee at its meeting in March 2001. The “first-step” product is to offer a World Wide Web-based listing of participating laboratories, available laboratory tests, charges for tests (if any), points of contact within participating laboratories, specimen submission procedures, and reporting procedures (Kalasinsky, 2001). With planned additions, the directory will move to increasingly encompass the VPHL concept and is to offer regular updates (monthly), realistic turnaround times for tests, toxicology results, patient records, or test results (in a secure, access-limited area), and access to the frozen specimen repository (Kalasinsky, 2001). No plans are in place to make the directory available to non-DoD users. Ultimately, however, non-DoD laboratories are also envisioned as playing a role in VPHL (Bolton and Gaydos, 2000). Potential partners in what is to evolve to become VPHL include the following (Kelley, 2001a): clinical treatment facility laboratories; the Walter Reed Army Institute of Research (WRAIR), USAMRIID, and DoD overseas laboratories; Brooks Air Force Base (Project Gargle); NHRC laboratory; CHPPM laboratories; TAML [theater area medical laboratories] and other advanced forward laboratories; DoD veterinary pathology laboratories; AFIP; CDC and selected state health department laboratories; and academic institutions. Enhancement of Laboratory Capacity USAMRIID serves as a reference center for the isolation and identification of infectious disease agents requiring handling at biosafety level 3 and above. USAMRIID serves as a DoD and World Health Organization (WHO) reference center for the testing of human specimens for unusual infectious disease agents. GEIS supports the USAMRIID infrastructure as a means of maintaining capacity for emerging infectious disease surveillance and response. This support is provided on the basis of the assertion that a broad, operationally oriented DoD reference laboratory for the isolation and identification of unusual etiologic agents and the diagnosis of infectious diseases requiring high levels of containment is in the interest of GEIS (GEIS, 2000b). GEIS at USAMRIID contributes to surveillance capabilities by producing, testing, and stockpiling critical diagnostic reagents to support surveillance and epidemic investigations of global emerging infections. In fiscal year 2000, USAMRIID needed and produced reagents for the detection of infection due to hantavirus, tick-borne encephalitis viruses, dengue virus,

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Venezuelan equine encephalomyelitis virus, West Nile virus, St. Louis encephalitis virus, Crimean Congo hemorrhagic fever virus, Marburg virus, anthrax, brucellosis, tularemia, and other infectious diseases and infectious disease agents (GEIS, 2000b). These reagents were widely distributed within the DoD and in some cases to civilian collaborators. USAMRIID also undertook the production of non-cross-reactive diagnostic reagents for West Nile virus as part of the DoD response to a request from the CDC for assistance with surveillance for West Nile virus. USAMRIID also plays a role in the training of both DoD and civilian personnel in the performance of diagnostic techniques and procedures, as needed (GEIS, 2000b). In addition to the funds directly provided to USAMRIID by GEIS for capacity-building purposes, USAMRIID also receives support from GEIS indirectly through laboratories that seek USAMRIID services for, for instance, entomological studies and confirmation of diagnoses. CHCS GEIS has set aside funds to support the development of capabilities within CHCS II, the successor to CHCS, a clinical information system project that began in the early 1980s. The DoD’s CHCS consists of databases maintained at medical treatment facilities worldwide. These databases contain information on the results of laboratory test results and pharmacy data. However, these databases are not linked together as part of a cohesive system. To overcome limitations associated with this disconnect, a linked system, CHCS II, is in development and will be used to support laboratory-based surveillance activities (GEIS, 2000b; IOM, 1999). At present, DoD laboratories, as opposed to health care providers, are not required to report notifiable infections to DoD authorities, although they are required report the occurrence of such infections to civilian public health authorities (Frommelt, 2000; Brady and Frommelt, 2000; IOM, 1999). However, at the Military Public Health Laboratory Symposium and Workshop held in September 1999, the workshop group recommended that all requests for testing made as part of the DoD Directory of Public Health Laboratory Services be entered into the DoD’s laboratory information system, the CHCS (or CHCS II), to create an audit trail for test requests, to make results quickly available to those with system access, and to promote proper archiving of data (Bolton and Gaydos, 2000). GEIS envisions that such a mechanism of rapid laboratory-based reporting through CHCS will also enable the tracking of the incidence of important infections and antibiotic resistance, the goal being the prompt detection of all cases that warrant a public health response (GEIS, 1998). Respiratory Disease Surveillance and Capacity Building GEIS MHS respiratory disease surveillance efforts are primarily fo-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review gram represents an important step in achieving GEIS training goals. However, this program, which focuses on the short-term placement of trainees at overseas laboratories, does not fully realize the potential of GEIS to contribute to the training of researchers and public health professionals (DoD personnel and others). Ad hoc training activities are already conducted at many laboratories overseas and within the MHS. By helping to coordinate and promote existing training resources, GEIS may be of benefit to many. GEIS may also wish to consider expanding the Overseas Medical Research Laboratory Orientation Training Program concept, as well as developing additional training programs. For example, programs that would allow MHS public health laboratory personnel4 to receive epidemic response training at overseas laboratories, programs that place personnel at MHS facilities for specialized laboratory training, and programs that foster increased collaboration with the CDC’s Field Epidemiology Training Program (a part of the Training in Epidemiology and Public Health Intervention Network [TEPHINET]) are potential training endeavors that may benefit from and be of benefit to GEIS. GEIS makes use of other DoD public health surveillance systems, such as DMSS, AFRESS, and others in pursuit of its goals. GEIS also supports the development and implementation of new surveillance systems and techniques, in keeping with its systems research goal. For instance, development of the ESSENCE bioterrorism surveillance system, development of an emerging infectious disease alert component for the new DoD mortality surveillance system, support of the exploratory use of GIS and remote-sensing techniques for surveillance purposes (e.g., surveillance for STDs at Madigan Army Hospital and remote-sensing collaborations with NASA), and many other projects exemplify GEIS’s commitment to using new and diverse methods to create a DoD surveillance system that is sensitive to emerging infectious diseases. Many of these efforts show great promise. It is important, however, that GEIS investment in the development of new systems and techniques follows from a clearly established and widely understood need and that large-scale implementation of new systems or techniques follows a thorough evaluation. Competing or redundant systems can adversely affect surveillance and response efforts by consuming valuable resources and by cluttering reporting channels. The transition that GEIS has made from a concept on paper to a functioning, productive program is in no small way a testament to the indus- 4   USAMRIID staff representatives, for instance, expressed to the committee an interest in pursuing a training partnership, through GEIS, with the overseas laboratories.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review try and ingenuity of Central Hub management. Now that the program has gotten a solid start, it is appropriate to consider whether the program management approaches that helped GEIS take its infant steps are the same approaches that will serve GEIS well in the future. In particular, the Central Hub has, to date, been opportunistically focused on identifying and filling critical gaps in DoD infectious disease surveillance and response capabilities and establishing a base of projects in support of GEIS goals. In doing so, GEIS has amassed an array of projects that, although all valuable in their own right, do not fit together smoothly as part of a cohesive, conspicuous GEIS whole. Coordination and communication, essential program elements and key roles of the Central Hub (Bancroft and Schlagel, 1997; CISET, 1997; GEIS, 1998), are not sufficiently addressed at present. MHS-based projects can better contribute to GEIS if they are more tightly integrated with each other and are geared toward supporting and complementing surveillance activities conducted in overseas laboratories. MHS laboratories possess valuable diagnostic capabilities and reservoirs of staff expertise. These resources are not put to their highest and best use if their work for GEIS consists primarily of conducting isolated projects. GEIS would benefit from refinement of the group of MHS-based projects that it funds. The development of a group of core projects that make integrated use of consortium resources, that are sustainable over a lengthy or indefinite time period, and that have the flexibility to address changing surveillance and response needs is preferable to the provision of support for a large number of projects that are relatively narrow in scope, short in duration, and circumspect in their implementation. Scaling back the breadth of GEIS involvement in the MHS may be necessary to develop a group of activities that provide GEIS with improved continuity, congruity, and visibility. The GEIS project review process may need to be revised to accommodate this approach. At present, Central Hub involvement in the management of projects that it does not directly conduct seems confined largely to the annual review process. For GEIS to function as a program, active management is important. It is important that the management provided by the Central Hub include consistent interaction with staff directing GEIS projects to monitor project progress, identify potential new collaborative activities, and identify needs for assistance. The role of the Central Hub, first and foremost, is to serve as the focal point for GEIS coordination and communication. It is important that other Central Hub activities do not conflict with these tasks. It is also important that the Central Hub plays an active role in communicating GEIS-generated information within the GEIS consortium, within the DoD, to public health partners, and to the public. Current

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review efforts to disseminate information are noteworthy but insufficient. GEIS can help consortium members develop strategies to share information with public health partners that need the information to take timely action in response to an emerging infectious disease. The Central Hub can also encourage program identity and collaborative activities by routinely collecting GEIS-generated information from consortium members, synthesizing this information as needed, and providing reports back to consortium members and others in a timely fashion. Tools such as GEISWeb and the DoD Directory of Public Health Laboratory Services can help improve coordination and communication within GEIS and beyond (WHO, 2000a). The concept of a Directory of Public Health Laboratory Services in a system of distributed responsibilities such as the DoD makes good organizational sense. If constructed wisely,5 the DoD Directory of Public Health Laboratory Services and the broader concept of the Virtual Public Health Laboratory can help make DoD laboratory resources more accessible to GEIS sites and others, encouraging collaboration and use of the full spectrum of DoD laboratory capabilities in the conduct of GEIS projects. GEISWeb also plays a role in fostering communication and the dissemination of information regarding GEIS projects. It may be useful to use GEISWeb as a point of entry into the DoD Directory of Public Health Laboratory Services. These resources cannot, however, take the place of frequent interpersonal communications between Central Hub staff and GEIS project managers at the overseas laboratories and within the MHS. The committee recognizes that managing a program as diverse and diffuse as GEIS is no small task. It appears to the committee that the Central Hub is limited in its ability to effectively coordinate GEIS by a lack of administrative authority and management resources, including a lack of appropriate staffing (in number and in expertise) and a lack of a clear and consistent means of both receiving and providing scientific and management direction. RECOMMENDATIONS • The GEIS Central Hub needs to be provided with increased administrative authority and management resources to achieve its program management goals. Recommendation: Staffing within the Central Hub should be in- 5   For instance, if it is designed by experienced developers with a specific end product in mind, incorporates input from a clearly defined user group, is flexible enough to accommodate additional modules over time, and is accessible to as wide a user group as appropriate and possible.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review creased so that its communication and coordination responsibilities can be optimally addressed. Recommendation: The Central Hub should have available to it improved means of obtaining more and more frequent management guidance. Recommendation: The Central Hub should be given more management authority so that it can successfully meet its objectives. • The infrastructure of the MHS provides an important platform for the support of surveillance for emerging infectious diseases within the nondeployed U.S. military population and for support of the efforts of the overseas medical research laboratories. GEIS investment in MHS public health laboratory activities should focus on developing strong capabilities for identifying and responding to emerging infectious diseases and cultivating collaborative relationships among laboratories so that capabilities are optimally used. Recommendation: GEIS projects within the infrastructure of the MHS are important but should be more tightly integrated with each other and better coordinated with and supportive of activities conducted at the overseas laboratories. • The development of centers of laboratory excellence within the DoD (e.g., for influenza and respiratory diseases) encourages the availability of specialized capabilities and makes those specialized capabilities more visible within the DoD laboratory system. Additional centers of excellence for underaddressed disease target areas, such as diseases caused by enteric pathogens, should also be grown at appropriate facilities. Similarly, GEIS consortium members should be encouraged to become or to remain WHO Collaborating Centers (e.g., for Emerging Infectious Diseases), as this promotes capacity and recognition of that capacity. Recommendation: GEIS efforts to build MHS public health laboratory capacity to detect and respond to emerging infectious diseases should be clearly focused and should be increased. • The research and development that GEIS supports in the context of information technology and laboratory diagnostics should be limited to those areas for which other expertise and venues do not exist. Exploration of new surveillance techniques and methodologies, such as syndromic surveillance, are also important but should be scientifically validated before they become widely enmeshed in GEIS. Communications tools, such as GEISWeb and the Directory of Public Health Laboratory Services-Virtual Public Health Laboratory can be very valuable to GEIS and need to

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review be rigorously planned, and produced and maintained by developers possessing extensive expertise and experience. Recommendation: The development of new systems resources is an important goal of GEIS, but the needs and specifications for innovative surveillance systems should be clearly defined before they are undertaken, and caution should be used when implementing unproven systems on a large scale. • Current efforts to provide training and communications and laboratory resources to public health partners are producing tangible benefits, but insufficient coordination within GEIS detracts from the effectiveness and recognition of these efforts. Recommendation: Central Hub-managed international capacity-building projects should be better coordinated with DoD laboratory facilities overseas and within the MHS, as appropriate. • GEIS can contribute substantially to DoD training activities relevant to emerging infectious disease surveillance and response. The Overseas Medical Research Laboratory Orientation Training Program and other ad hoc training activities currently in place are noteworthy and important, but additional GEIS involvement in the training of research and public health professionals—including, but not limited to, DoD personnel—can make existing training activities more efficient, productive, and visible and can help encourage the development of additional training programs. Recommendation: Central Hub involvement in coordinating and supporting training activities relevant to emerging infectious disease surveillance and response should be increased. • The Central Hub needs to increase its efforts to provide centralized coordination and scientific direction for GEIS projects. Projects should be better coordinated among members of the GEIS consortium. Project progress would also benefit from more and more frequent scientific guidance. Recommendation: The GEIS Central Hub should Provide clear and specific guidance to laboratories regarding the goals of GEIS and the qualities that GEIS projects are expected to possess, actively assist laboratories in developing project plans, and provide periodic scientific guidance for projects under way, as needed. Provide a mechanism for project review that is structured, that is clearly and consistently defined, that allows adequate time for

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review project conduct between reviews, that results in timely feedback to the laboratories proposing projects, and that is carried out by a diverse panel of experts including Central Hub staff and others, such as senior DoD laboratory staff, Military Infectious Disease Research Program (MIDRP) staff, and other DoD and non-DoD representatives. Consistently interact with staff directing GEIS projects to monitor project progress, evolving potential for collaboration, and needs for assistance. • It is important that projects be directed by regionally appropriate overseas and MHS-based laboratories. Recommendation: Given personnel and other resource shortages, Central Hub conduct of surveillance projects is undesirable and should be minimized and avoided to the extent possible. • At present GEIS does not regularly produce or distribute an informational product that synthesizes data from its consortium members and that feeds the information back to its consortium members and other users in a timely manner. Recommendation: Improved means of centrally collecting, analyzing (as appropriate), and distributing surveillance data and other information in a timely manner should be developed and implemented. AGENDAS IOM and DoD-GEIS MHS Program Review San Diego, California January 9–10, 2001 Tuesday, January 9, 2001 0800–0815 Welcome/Introductory Remarks CAPT T.Contreras, NHRC Commanding Officer Dr. Berkelman, Acting Chair 0815–0845 Orientation to GEIS the MHS COL Kelley 0845–1000 Review of Air Force Central Hub Activities LTC Neville 1000–1015 Break 1015–1300 Review of NHRC Activities LCDR Ryan and CAPT Gray and Staff

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 1300–1345 Lunch at NHRC 1345–1415 Tour of NHRC GEIS CAPT Gray 1415–1500 Travel to NEPMU 1500–1525 Review of NEHC GEIS Activities CDR Murphy 1525–1545 Review of NEPMU GEIS Activities CDR Thornton 1545–1605 Tour of NEPMU CAPT Tueller 1605–1635 Travel to Naval Hospital, San Diego 1635–1710 Presentation on Antibiotic Resistance Surveillance CAPT Davis 1710–1800 Naval hospital laboratory and questions for and laboratory staff on laboratory-based surveillance for reportable infections and antibiotic resistance 1900 Dinner for presenters and IOM committee members Wednesday, January 10, 2001 (at NHRC) 0800–0845 ESSENCE, and Syndromic Surveillance MAJ Pavlin 0845–0910 Madigan STD Project COL Gunzenhauser 0910–0940 Korea Malaria Surveillance MAJ Pavlin and LTC Klein 0940–1010 Uganda Projects MAJ Pavlin 1010–1100 Follow-questions and discussions 1100 IOM committee members to return to hotel for working session Fifth Meeting of the Institute of Medicine Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System Washington, DC 66, 7, 8 March 2001 Tuesday, March 6, 2001: Site Visit, Ft. Detrick, Maryland 1330–1400 USAMRIID briefing COL Ted Cieslak and Dr. George Ludwig 6   Supplemental session, not all committee members present.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 1400–1445 USAMRIID diagnostics Dr. George Ludwig 1445–1530 Tour of USAMRIID COL Ted Cieslak 1530–1630 Discussion with MIDRP COL Charles Hoke 1630–1700 Discussion with MRMC Command Group COL John Glenn Wednesday, March 7, 2001 0800–0805 Welcome and introductions Dr. Philip Brachman 0805–0845 AFIP Virtual Public Health Laboratory Dr. Joel Gaydos and Dr. Victor Kalasinsky 0845–0915 AFIP Mortality Surveillance Project Dr. Joel Gaydos 0915–1030 Overview of Other DoD Surveillance COL Patrick Kelley 1030–1100 Collaborations with NASA LTC Kenneth Linthicum 1100–1200 Other Activities of GEIS Central Hub (OCONUS training, Humanitarian assistance, Website) Mr. James Writer 1200–1300 Catered lunch at IOM 1300–1400 Other activities of GEIS Central Hub continued (Management, External Relations) COL Patrick Kelley 1400–1500 Follow-up discussions with presenters and invited collaborators 1500–1700 Closed session 1700 Adjournment Thursday, March 8, 2001 0800–1500 IOM committee meets in closed session GEIS CENTRAL HUB AND MILITARY HEALTH SYSTEM ACTIVITIES REVIEW: MEETING PARTICIPANTS, GUESTS, AND OTHER CONTRIBUTORS Assaf Anyamba, Goddard Space Flight Center, NASA, Greenbelt, Maryland

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Carolyn Baker, Naval Health Research Center, San Diego, California Linda Canas, Diagnostic Virology, Brooks Air Force Base, San Antonio, Texas Theodore J.Cieslak, Operational Medicine Department, U.S. Army Medical Research Institute of Infectious Diseases, Ft. Detrick, Maryland T.Contreras, Naval Health Research Center, San Diego, California Jonathan Davis, Institute of Medicine, Washington, District of Columbia Susan R.Davis, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland Matthew DiFranco, collaborator, Naval Health Research Center respiratory disease surveillance projects, San Diego, California Benedict Diniega, Chemical and Biological Defense Health Affairs, U.S. Department of Defense, Washington, District of Columbia Maria Gabriela Fernandez-DiFranco, Naval Health Research Center, San Diego, California Joel Gaydos, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland Michele Ginsberg, San Diego County Health Department, San Diego, California John Frazier Glenn, Medical Research and Materiel Command, Ft. Detrick, Maryland Greg Gray, Naval Health Research Center, San Diego, California Jeffrey Gunzenhauser, Public Health Residency, Madigan Army Medical Center, Tacoma, Washington Tony Hawksworth, Naval Health Research Center, San Diego, California Charles Hoke, Military Infectious Disease Research Program, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland Marie Hudspeth, Naval Health Research Center, San Diego, California Victor F.Kalasinsky, Armed Forces Institute of Pathology, Washington, District of Columbia Patrick Kelley, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland Terry A.Klein, 18th Medical Command, Republic of Korea Kenneth Linthicum, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland George V.Ludwig, Applied Diagnostics Branch, U.S. Army Medical Research Institute of Infectious Diseases, Ft. Detrick, Maryland Victor Macintosh, Preventive Medicine Division, Air Force Medical Operations Agency Marrietta Malasig, Naval Health Research Center, San Diego, California AbuBakr Marzouk, Office of the Air Force Medical Examiner, Armed Forces Institute of Pathology, Washington, District of Columbia Michael McCarthy, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland Jamie McKeehan, Naval Health Research Center, San Diego, California Wilbur K.Milhous, Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland Melinda Moore, Office of International and Refugee Health, Office of Public Health and Science, Office of the Secretary, U.S. Department of Health and Human Services, Rockville, Maryland Brian P.Murphy, Preventive Medicine, Navy Environmental Health Center, Norfolk, Virginia James Neville, Force Health Protection and Surveillance Branch, Brooks Air Force Base, San Antonio, Texas Matt O’Shea, Naval Health Research Center, San Diego, California Lawrence Palinkas, Division of Family and Preventive Medicine, University of California, San Diego, California John S.Parker, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland Julie Pavlin, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland Saibal Poddar, Naval Health Research Center, San Diego, California Bob Potter, Office of the Air Force Medical Examiner, Armed Forces Institute of Pathology, Washington, District of Columbia Margaret Ryan, Naval Health Research Center, San Diego, California Paul Sato, Naval Health Research Center, San Diego, California Lori Senini, San Diego County Border Health, San Diego, California Dawn Taggett, Naval Health Research Center, San Diego, California Scott Thornton, Navy Evironmental and Preventive Medicine Unit Number 5, San Diego, California John Tueller, Navy Evironmental and Preventive Medicine Unit Number 5, San Diego, California

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review James Writer, Department of Defense Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Silver Spring, Maryland