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GEIS at Naval Medical Research Unit 3, Egypt

Naval Medical Research Unit 3 (NAMRU-3), is the largest U.S. military medical research facility operating overseas and one of the largest medical research laboratories in the North Africa-Middle East region. The laboratory traces its origins back to 1942, when American scientists and technicians began working with Egyptian physicians at the Abassia Fever Hospital, Cairo, Egypt, under the auspices of the U.S. Typhus Commission, established by President Franklin D.Roosevelt.

After World War II, the Egyptian government invited the U.S. Navy to continue collaborative studies of endemic tropical and subtropical diseases with Egyptian scientists. NAMRU-3 was formally established in 1946, and the laboratory has been in continuous operation ever since, despite periods of political tension and a 7-year lapse in U.S.-Egyptian relations (from 1967 to 1973). For a short period, NAMRU-3 had a satellite facility in Ethiopia (which operated for a time as NAMRU-5), but the facility was closed because of political difficulties. NAMRU-3 is hosted by the Egyptian Ministry of Health and Population (MOHP) and has worked closely with the MOHP and the Abbasia Fever Hospital for over 50 years.

Though NAMRU-3 has historically been dedicated to a research mission, infectious disease surveillance and response activities were conducted at NAMRU-3 before the introduction of GEIS. GEIS has supported surveillance projects at NAMRU-3 since 1998 (NAMRU-3, 2000a). GEIS support for NAMRU-3 surveillance projects totaled $1,000,000 in fiscal year 2000 (GEIS, 2000b) and is expected to total $1,075,000 in fiscal year 2001 (GEIS, 2000c).

A subcommittee of the Institute of Medicine (IOM) Committee to



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 5 GEIS at Naval Medical Research Unit 3, Egypt Naval Medical Research Unit 3 (NAMRU-3), is the largest U.S. military medical research facility operating overseas and one of the largest medical research laboratories in the North Africa-Middle East region. The laboratory traces its origins back to 1942, when American scientists and technicians began working with Egyptian physicians at the Abassia Fever Hospital, Cairo, Egypt, under the auspices of the U.S. Typhus Commission, established by President Franklin D.Roosevelt. After World War II, the Egyptian government invited the U.S. Navy to continue collaborative studies of endemic tropical and subtropical diseases with Egyptian scientists. NAMRU-3 was formally established in 1946, and the laboratory has been in continuous operation ever since, despite periods of political tension and a 7-year lapse in U.S.-Egyptian relations (from 1967 to 1973). For a short period, NAMRU-3 had a satellite facility in Ethiopia (which operated for a time as NAMRU-5), but the facility was closed because of political difficulties. NAMRU-3 is hosted by the Egyptian Ministry of Health and Population (MOHP) and has worked closely with the MOHP and the Abbasia Fever Hospital for over 50 years. Though NAMRU-3 has historically been dedicated to a research mission, infectious disease surveillance and response activities were conducted at NAMRU-3 before the introduction of GEIS. GEIS has supported surveillance projects at NAMRU-3 since 1998 (NAMRU-3, 2000a). GEIS support for NAMRU-3 surveillance projects totaled $1,000,000 in fiscal year 2000 (GEIS, 2000b) and is expected to total $1,075,000 in fiscal year 2001 (GEIS, 2000c). A subcommittee of the Institute of Medicine (IOM) Committee to

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Review the Department of Defense Global Emerging Infections Surveillance and Response System visited NAMRU-3 from October 8 to 14, 2000. The subcommittee consisted of committee members Kathleen Gensheimer, James Hospedales, and Guénaël Rodier. A list of the people who the subcommittee met with and the itinerary that was followed can be found at the end of this chapter. LABORATORY NAMRU-3 has extensive laboratory capacities, particularly in virology but also in bacteriology and parasitology. NAMRU-3 also maintains extensive insectary and animal research facilities. The animal research facility is accredited by the Association for Assessment and Accreditation of Laboratory Animal Care-International (GEIS, 2000f). NAMRU-3 headquarters are housed within 68,000 square feet of laboratory space, 25,000 square feet of office space, 9,200 square feet of warehouse and supply storage space, and 2,750 square feet of biosafety level 3 biocontaminant space in Cairo, Egypt (GEIS, 2000f). Field sites are maintained in Abu Homos (for the study of enteric pathogens) and Qus and Armut (for the study of febrile illnesses), Egypt. Conclusions The value of NAMRU-3 laboratory capacities is widely acknowledged by all public health partners, such as the MOHP. NAMRU-3 facilities play an essential role in supporting operational research in infectious diseases and infectious disease surveillance in Egypt and in the region. Such capabilities constitute the basis for the close partnership and working relations between NAMRU-3 and the Egyptian MOHP, the World Health Organization (WHO) Regional Office for the Eastern Mediterranean (EMRO), and the U.S. Agency for International Development (USAID). The laboratory capacity is clearly sufficient to support the mission of the Global Emerging Infections Surveillance and Response System (GEIS). STAFFING NAMRU-3 is organized into administrative and research departments. Virology Research, Disease Surveillance, Enteric Disease Research, and Vector Biology Research Programs are maintained within NAMRU-3’s Research Sciences Department (RSD). GEIS is coordinated by the director of the RSD. GEIS plays a major role in supporting the newly created NAMRU-3 Disease Surveillance Program (supported with a combination of GEIS and USAID funds) and significantly contributes to the Virology

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Research Program and the Enteric Diseases Research Program. GEIS provides little or no support for the Vector Biology Research Program. At the time of the IOM subcommittee’s visit, NAMRU-3 staff included 40 military assignees; among them were 20 professional, uniformed services personnel (17 U.S. Navy, 2 U.S. Army, and 1 U.S. Public Health Service, Centers for Disease Control and Prevention [CDC] personnel). In addition, NAMRU-3 employs a staff of approximately 141 foreign service nationals (FSNs). The deputy director of RSD is an FSN with long-term service with NAMRU-3 and plays a key role in the continuity and institutional memory of NAMRU-3 and in maintaining relationships with collaborators, particularly the Egyptian MOHP. No full-time employee works exclusively on GEIS projects. All department heads have significant involvement in programs other than GEIS. At the time of the subcommittee visit, layoffs of FSN employees were anticipated before the end of 2000. Layoffs were to occur as the result of financial limitations and a decision to outsource more services. These anticipated layoffs resulted in some concern among staff that NAMRU-3 may not be able maintain operations at current levels. Conclusions NAMRU-3 hosts a dedicated, skilled scientific team that can fulfill the objectives of GEIS. Staff relationships appeared to be supportive and mutually reinforcing. At present, GEIS is efficiently administered by the director of the RSD, but there is no overall oversight of GEIS by individuals or organizational units with expertise in epidemiology. GEIS at NAMRU-3 would benefit from a full-time, on-site coordinator possessing, at a minimum, applied epidemiology and public health experience. Although a high level of commitment to GEIS was observed and GEIS has been given strong support from the CDC assignee who directs the Disease Surveillance Program, the organizational structure of the RSD does not formally put the Disease Surveillance Program in a position to coordinate surveillance activities and data or to foster collaboration between projects and among programs. A shortage of military public health personnel with a sufficient background in applied epidemiology and disease surveillance also appeared to be of concern. In particular, there did not appear to be a full understanding of the public health implications of the GEIS mission, including the need to strengthen the capacities of countries in the region. A strength of GEIS at NAMRU-3 is the presence of FSN staff who play a key role not only in the management and technical support of GEIS but also in the integration of the program with other in-country infectious disease surveillance activities and in the improvement of ties with NAMRU-3’s partners in public health activities. Because of their potential

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review for long-term service, the involvement of FSNs with the efforts of NAMRU-3 is integral to the full implementation and continuity of the GEIS mission. Continuity in the senior management of NAMRU-3 is also important to the fulfillment of the GEIS mission. Although retention of military personnel is probably not a concern unique to NAMRU-3, the potential for military staff turnover to disrupt the GEIS mission poses a very real concern. TECHNOLOGY AND INFORMATION MANAGEMENT A tour of the NAMRU-3 facility in Cairo revealed considerable technical capacity, including access to the Internet (to be further improved), e-mail, library facilities, and a local area network. A visit to the Abu Homos study site on the Nile delta (Enteric Diseases Research Program) showed good information technology (IT) facilities, whereas sites at Armut in Upper Egypt (cohort and sentinel studies carried out by the Disease Surveillance Program) showed more limited IT facilities. NAMRU-3 maintains two different laboratory information systems. A “homegrown,” ACCESS (database)-based specimen registration system (the LISA system) has been developed to catalog all but virology specimens. The LISA system is a stand-alone system and does not extend to the computerization of testing in the various laboratories, nor does it support the reporting of results or the analysis of aggregate data patterns and trends. The second system, a virology system, was not reviewed but is understood to be a Paradox (database)-based, separate system for accessioning of virology specimens. As for the LISA system, this system does not extend to the computerization of testing in the various laboratories or report results. An overall plan to integrate NAMRU-3 information facilities, including IT-related hardware and software, communications activities, information feedback activities, and dissemination efforts, does not exist. NAMRU-3 surveillance-related information is disseminated through quarterly reports and an annual report sent to the MOHP. At the program level, it is not clear how the information on emerging patterns and trends in the region is shared with the GEIS Central Hub or with other GEIS sites, other than through publications in various international scientific journals and through annual reports. Conclusions The IT environment at NAMRU-3 is sufficient to support the achievement of GEIS information objectives. The LISA system supports the NAMRU-3 GEIS priority of archiving selected specimens and epidemiological data for future investigations. This environment would benefit

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review from an overall information plan, including the integration of information systems, and the development of systematic means of expeditiously communicating surveillance information to short- and long-term users (e.g., a NAMRU-3 website dedicated to surveillance). SURVEILLANCE Surveillance activities were conducted by NAMRU-3 before the advent of GEIS. The GEIS focus on infectious diseases surveillance and response was added in fiscal year 1997 to the existing NAMRU-3 operating structure, which was historically dedicated to laboratory- and field-based infectious disease research. A GEIS implementation plan that takes advantage of existing projects has been developed for fiscal years 2000 to 2004. GEIS at NAMRU-3 is organized around five core areas or goals that include the following (GEIS, 1999a, 2000b; NAMRU-3, 2000a): enhanced surveillance for priority infectious diseases in Egypt; regional surveillance for selected diseases in Middle Eastern, Eastern European, Western Asian, and African countries; surveillance for infectious diseases in U.S. multinational forces and observers; surveillance and response to outbreaks in the WHO EMRO; and archiving of selected specimens and epidemiological data for future investigations. These goals are linked to the priorities defined by the GEIS Central Hub in the following four pillar areas: influenza surveillance, drug-resistant malaria surveillance, surveillance for diseases caused by drug-resistant enteric pathogens, and acute febrile illness surveillance. The four RSD programs have worked together to define the activities described above. Their GEIS project applications and progress reports are submitted to the GEIS Central Hub on an annual basis. Enhanced Surveillance for Priority Infectious Diseases in Egypt NAMRU-3 has developed protocols funded by GEIS to incorporate the pillars noted above. In particular, NAMRU-3 is developing a capacity for surveillance for a number of clinical syndromes including acute undifferentiated febrile illnesses, meningitis-encephalitis, viral hemorrhagic fevers, influenza, and dysentery. Since 1998, GEIS has supported projects to further develop efforts related to the surveillance of patients with meningitis-encephalitis in a network of infectious disease hospitals (“fever hospitals”) in Egypt. Laboratory training and supplies have been provided in selected hospitals to upgrade clinical and microbiological capa-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review bilities. Clinical specimens are sent to NAMRU-3 for virological workups and other testing. Currently, surveillance is being conducted in 12 sites in 10 of 28 Egyptian governorates; and the scope of work has broadened to include patients with other in-country priority diseases such as typhoid fever, brucellosis, and viral hepatitis. With GEIS funding, the Virology Research Program and the Disease Surveillance Program are working together to identify the causes of meningitis and encephalitis and to evaluate patients with acute febrile illness in selected governorates. The Enteric Diseases Research Program and the Disease Surveillance Program are collaborating on a project to implement surveillance for dysentery and severe diarrhea in selected populations. NAMRU-3 has also developed considerable capacity to conduct population-based surveillance (e.g., children with diarrhea in the Abu Homos field site and patients with acute fever of unknown origin in Upper Egypt). NAMRU-3 has participated in a number of additional activities related to disease surveillance in Egypt. In 1998, the Egyptian MOHP formed a surveillance working group consisting of the MOHP Central Laboratory and the CDC Field Epidemiology Training Program (FETP), the WHO Regional Office, the U.S. Agency for International Development (USAID), and NAMRU-3. The primary goals and objectives of this working group were to develop a capacity for surveillance of infectious diseases in Egypt. In 1999, the WHO Regional Office convened an expert panel to review the activities of existing communicable disease surveillance programs in Egypt (e.g., programs for the surveillance of polio, tuberculosis, and human immunodeficiency virus [HIV] infection/AIDS) and proposed an action plan to strengthen the national surveillance and response system. The expert panel, in which NAMRU-3 played a key role, made a number of recommendations regarding the strengthening of communicable disease surveillance in Egypt (NAMRU-3, 2000b). USAID and the government of Egypt are the primary providers of funding to support the implementation of the action plan advised by the panel. This allows NAMRU-3 to target funds from GEIS mainly toward regional surveillance and response activities, although GEIS remains essential in providing technical support in Egypt. Regional Surveillance for Selected Diseases in Middle Eastern, Eastern European, Western Asian, and African Countries A variety of surveillance-related projects are conducted in the region; in Egypt, Yemen, Syria, Djibouti, Turkey, Ghana, and Hungary, for instance. NAMRU-3 conducts focused surveillance and operational research activities in the region for influenza (Egypt and Syria and planned in

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Djibouti), dengue (initiated in Djibouti and Yemen), and antimalarial drug resistance (planned in Yemen and Ghana). Surveillance for Infectious Diseases in Military Populations Serological studies of cohorts of U.S. multinational forces and observers (MFOs) in the Sinai have been and are still conducted by NAMRU-3. These studies have documented significant rates of incidence of West Nile encephalitis virus and sandfly fever virus infections. Surveillance for influenza among MFO troops is also conducted. In Turkey, a project has investigated gastroenteritis in locally deployed U.S. military personnel. Surveillance and Response to Outbreaks in the WHO EMRO See the section Response later in this chapter. Archiving of Selected Specimens and Epidemiological Data for Future Investigations See the section Technology and Information Management earlier in this chapter. Conclusions In addition to infectious disease research in the field, NAMRU-3 activities now formally encompass infectious disease surveillance and response, including the provision of support for national public health infectious disease surveillance infrastructure. The introduction of GEIS has brought to NAMRU-3 a broader framework and additional resources. These resources allow NAMRU-3 to better assess and respond to infectious disease threats within the region in partnership with WHO and with relevant countries and relevant institutions. Establishing GEIS within the research framework of NAMRU-3 (funded by the Military Infectious Disease Research Program [MIDRP]) benefits both MIDRP and GEIS in a synergistic fashion: GEIS benefits from the scientific and technical facilities, staff expertise, established research efforts, and working relationships already in existence. In return, GEIS strengthens and builds partnerships and provides surveillance information useful to guide the development of future MIDRP-funded research projects, maximizing the benefits to the U.S. military as well as to Egypt and the surrounding region. The GEIS framework and the links between projects that it provides have enhanced many NAMRU-3 research protocols. Although NAMRU-3 is successfully taking advantage of the skill and experience of its staff, as

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review well as the technical and political opportunities available within the region, closer coordination of the various GEIS projects at NAMRU-3 and increased capacity in epidemiology would benefit GEIS. Overall, NAMRU-3 is in a unique position to provide essential surveillance information related to infectious disease threats in Egypt and the region, including information on acute respiratory infections, arbovirus infections, viral hepatitis, and enteric diseases. Projects provide essential data regarding long-term trends in the antibiotic resistance of enteric pathogens and the incidence of diseases caused by arboviruses. Studies of military populations, together with information obtained from in-country and regional surveillance activities, work to provide a comprehensive picture of the potential infectious disease threats facing U.S. military forces. Regional infectious disease surveillance efforts also expand NAMRU-3’s working relationships and partnerships within and outside of Egypt. The subcommittee questions whether the current annual review and funding process allows sufficient time for surveillance project maturation and planning between reviews. Annual review appears to rush the proposal preparation process and can culminate in the making of decisions about the merits of projects on the basis of incomplete information. RESPONSE CAPACITY Epidemics of known or emerging infectious diseases occur regularly in the region. Requests for assistance from the Egyptian MOHP or the WHO are directed to NAMRU-3’s commanding officer, who determines the degree to which NAMRU-3 can assist. The mission of GEIS and the GEIS funding apparatus are used to facilitate timely responses to epidemics. NAMRU-3 can rapidly bring epidemiological and laboratory expertise to the field when epidemics occur and can also offer technical support to confirm diagnoses and to provide advice to the authorities that request it. NAMRU-3’s administrative, medical, logistical, and scientific capabilities have all been called into play in assessing and managing epidemics in the region. In addition, the partnerships that NAMRU-3 has established with the Egyptian MOHP, other countries, and EMRO provide prompt clearances by the countries involved so that personnel and equipment can be brought to the field in a timely manner. In recent years, NAMRU-3 has provided technical support to several epidemic investigations, including the following: acute gastroenteritis among U.S. Department of Defense (DoD) forces at Incirlik, Turkey, 1999; cluster of unexplained deaths among infants in Gharbia governorate, Egypt, 1999 (methanol intoxication);

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review cluster of unexplained illness with skin lesions, Egypt, 2000 (accidental exposure to radiation); epidemic of Rift Valley fever in Yemen, 2000. The NAMRU-3 response to this epidemic was quite apparent at the time of the subcommittee visit to Cairo. The support provided by NAMRU-3 at the request of EMRO during this investigation included the establishment of a field laboratory in less than 1 week and the rapid design and implementation of an epidemiological investigation of both humans and animals. Importantly, this was the first report of Rift Valley fever outside Africa. NAMRU-3’s unique capacity to rapidly investigate and respond to emerging infections in the region was clearly demonstrated, despite the tense political situation (related to the October attack on the USS Cole at Aden, Yemen). Although the investigators were from a U.S. military organization, they did not experience any significant security problems, undoubtedly because NAMRU-3 is primarily perceived in the region as a well-respected scientific institution rather than a military establishment. Conclusions NAMRU-3’s capabilities to respond to epidemics of potential public health or military significance are unsurpassed in the region in terms of laboratory diagnosis, field investigation, and collaboration (e.g., with the Egyptian MOHP and the WHO). The mission of GEIS and the GEIS funding apparatus have greatly facilitated timely responses to epidemics. The GEIS program has enhanced and strengthened the unique regional capacity of NAMRU-3. NAMRU-3 efforts in response to the Rift Valley fever epidemic were an impressive example of NAMRU-3’s response capability. COLLABORATIONS Public health partners are receiving NAMRU-3 support in the following areas: isolation and identification of “exotic” or emerging viruses in the region; rapid deployment of field diagnostic capacity in support of outbreak investigations; production of diagnostic reagents (e.g., specific antigens) not commercially available; collection, transportation, and storage of vast quantities and varieties of clinical specimens, including maintenance of a unique regional serum bank; and strengthening of the overall laboratory capacity in the region, par-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review ticularly in Egypt, through training and quality control programs, usually associated with specific NAMRU-3 research or surveillance projects. NAMRU-3 has many partners, including the Egyptian MOHP, governmental agencies of other countries in the region, other DoD departments, and a range of technical and financial partners such as the WHO, the CDC, and USAID. Partner agencies visited by the subcommittee spoke highly of the work and responsiveness of the laboratory and offered strong support for NAMRU-3’s activities. The subcommittee also heard from staff at NAMRU-3 and from NAMRU-3’s partners that the introduction of GEIS has expanded NAMRU-3’s mandate and range of partners. Before GEIS, NAMRU-3 had no explicit mission to strengthen the capacity of the MOHP. Joint planning and programming are well established with the MOHP. Within the MOHP, key partners include the FETP, the Central Laboratory, the fever hospitals, and field sites such as those that the subcommittee visited in Abu Homos. Staff and partners alike reported being very pleased at the development of GEIS, noting that it had increased the relevance of the work of the laboratory both to the country and to the surrounding region. The U.S. Embassy’s deputy chief of mission praised the work of NAMRU-3 in Egypt, noting that the NAMRU-3 partnership with the MOHP takes many forms, including training and staff development and the provision of equipment and supplies for laboratory-based surveillance efforts, most of which are being funded by USAID. In all visits to MOHP facilities, concern was expressed about the need for and the sustainability of a strong surveillance effort for infectious diseases and the need for the Egyptian MOHP to accept responsibility for maintaining and expanding the current surveillance activities. NAMRU-3 staff also mentioned that input from experts (a review team or similar source) regarding the development of Egyptian public health laboratory capacity and surveillance activities would be useful and might be something that GEIS could help procure. NAMRU-3 also has collaborative relationships with other countries under EMRO’s purview, such as Yemen, Sudan, Djibouti, and Turkey. The EMRO director of communicable diseases also spoke highly of NAMRU-3 and its proactive approach to strengthening the surveillance and response systems within the region. NAMRU-3 is a WHO Collaborating Center for HIV, for cholera, and for emerging infectious diseases. Among financial partners, the USAID mission in Egypt also praised the work and approach of NAMRU-3 and reported confidence in expanding its partnership with NAMRU-3 to implement key surveillance-related projects in Egypt. Information sharing relationships between NAMRU-3 and its partners appear strong, but seem person-based and circumstance dependent.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review The assignment of a CDC public health professional to NAMRU-3 makes CDC a key technical partner of NAMRU-3. Other DoD entities, such as the U.S. Army Medical Research Institute of Infectious Diseases and other military laboratories operating overseas, are also essential partners with NAMRU-3. However, it was not completely clear to the IOM subcommittee how communication and coordination with the GEIS Central Hub and other GEIS sites is realized. Conclusions NAMRU-3 has been very successful in developing and maintaining a range of local, national, regional, and international partnerships. In particular, the GEIS mission has increased the possibilities for capacity building with the Egyptian MOHP in support of improved surveillance and response. NAMRU-3 support to the Central Laboratory, enhanced by GEIS, has been crucial in the last few years in building new laboratory capacity in Egypt. GEIS could also provide supervision for the training of in-country laboratory workers for a limited time to improve communicable disease surveillance in the country. This training will, in turn, support the GEIS mission at NAMRU-3. It is important that the capacity-building efforts of NAMRU-3 be directed to the development of systems that can be sustained by the Egyptian government. The level of appreciation and confidence expressed by partners regarding NAMRU-3 were noteworthy. NAMRU-3 is viewed by its various stakeholders as an asset for infectious disease research in the field and is deemed important to the region. GEIS is now seen as a means of applying some of the pertinent research and surveillance findings to public health practice in Egypt and in the surrounding region. GEIS at NAMRU-3 thus serves as a cornerstone for the promotion of infectious disease surveillance in the region. This positions NAMRU-3 well for the development of new partnerships, including those needed to generate additional financial and political resources. It should be acknowledged that these successful partnership may sometimes bring competing priorities to the table. These competing priorities can be dealt with only by reiterating and promoting the GEIS core surveillance goals to these partners at every opportunity. RECOMMENDATIONS • GEIS activities at NAMRU-3 are of critical importance to the program as a whole. The committee encourages the DoD to plan for GEIS activities at NAMRU-3 on a long-term basis. NAMRU-3 provides an important resource for both research and surveillance missions. Demand for

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review and support of these missions should be balanced so that neither one is jeopardized. Recommendation: DoD commitment to GEIS at NAMRU-3 should be long term. • The current annual approval process does not allow optimal time for NAMRU-3 project planning or maturation. Furthermore, it is important that the GEIS Central Hub review and approval process for GEIS projects provides NAMRU-3 with follow-up guidance regarding project progress in a consistent and timely manner (see also Chapter 7). Recommendation: Consideration should be given to revising the current GEIS project application and review process. • The assignment of additional civilian epidemiologists (from CDC and other relevant institutions) or the assignment of DoD epidemiologists or public health specialists to NAMRU-3 is essential to fulfill GEIS objectives. Improved communication by the GEIS Central Hub of the mission of GEIS to NAMRU-3 is also needed. Providing existing staff with additional training in epidemiology, public health, and public health surveillance could also help meet the need for additional applied epidemiology expertise at NAMRU-3. Recommendation: Additional applied epidemiological input should be provided to guide the development and conduct of NAMRU-3 GEIS projects to fully realize program goals. Recommendation: Consideration should be given to obtaining a full-time, on-site manager possessing experience in applied epidemiology and public health for the GEIS program at NAMRU-3, or to providing more epidemiological and technical oversight responsibility to the manager of the Disease Surveillance Program, as the current NAMRU-3 organizational structure does not allow the Disease Surveillance Program to maximize collaboration and coordination of GEIS activities across the Research Sciences Department. • FSN staff can help meet staffing needs in areas, such as epidemiology, for which there is presently a shortage of qualified DoD personnel. FSNs also help to provide continuity between projects and in relationships with partner agencies. Recommendation: NAMRU-3 should ensure the long-term presence of FSN personnel to maximize the continuity of individual GEIS projects and provide the institutional memory and cultural sensitivity necessary for the success of GEIS. • NAMRU-3 has been very successful in developing and maintain-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review ing a range of local, national, regional, and international partnerships. Recommendation: NAMRU-3, in coordination with the GEIS Central Hub, should expand partnerships with and continue to raise funds through (as applicable) sources such as USAID (country offices and its Global Bureau), the CDC (including the FETP), the WHO, and other relevant agencies to the full extent possible to enhance in-country surveillance and response capacities. Recommendation: NAMRU-3 should continue to support the Egyptian MOHP in gradually strengthening the MOHP’s own capacity for surveillance across Egypt, with a particular focus on laboratory diagnostic capabilities. This support should also be extended to other countries in the region, resources permitting. • The sharing of information with partners in public health activities, particularly those positioned to take action in response to epidemics, should be timely and systematic. Recommendation: A comprehensive NAMRU-3 information plan that outlines the needs and mechanisms for the reporting of information to partners in public health activities and to the GEIS Central Hub should be developed and acted upon. Recommendation: NAMRU-3 should actively pursue with its in-country partners resolution of issues regarding ownership of surveillance data and issues regarding the clearance of data for dissemination. • The subcommittee recognizes that the GEIS pillar disease areas are important ones and that defining these targets helps to provide some standardization of GEIS activities across sites, but the pillar structure should be flexible enough to permit, on a case-by-case basis, local infectious diseases that are of global concern (e.g., tuberculosis) to be addressed as high priorities through GEIS. This serves to take full advantage of the epidemiological setting of the facility, builds national health defenses in the host country, and can be of long-term benefit to the health of many populations, including U.S. military personnel and civilians. Recommendation: Consideration should be given to refining the focus of GEIS at NAMRU-3 to better enable diseases outside of the pillar areas to be addressed. • Partnerships benefit from knowledge of the native language by senior staff. Partnerships are of increased importance to NAMRU-3 now that its research mission has been formally expanded to include GEIS activities, which necessitate increased interactions with partner agencies.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Staff familiarity and comfort with the local language can also improve rates of retention of personnel and assist in cultural acclimation. Recommendation: Senior staff at NAMRU-3 actively involved in GEIS projects should be conversant in the dominant language of the host country or should be encouraged to pursue, with the support of GEIS, language training, and should seek to become conversant to the extent possible. PEOPLE MET AND INTERVIEWED NAMRU-3 Staff Edward Antosek Cole Church Elizabeth A.Dykstra Robert W.Frenck, Jr. Ross Graham Frank J.Mahoney James Malone Moustafa M.Mansour NAMRU-3 Associates Heda Mansour, Abassia Fever Hospital Mark Anthony White, USAID Deputy Chief of Mission, U.S. Embassy Dr. Zoheir Halaj, WHO representative, Egypt Dr. Nasser, director, FETP Egypt ITINERARY October 8 0900–0930 Command brief 0930–1000 GEIS project overview 1000–1100 Disease surveillance program brief and tour 1100–1130 Enteric disease research program brief and tour 1130–1300 Lunch 1300–1400 Virology research program brief and tour 1400–1430 Vector biology research program brief and tour

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review October 9 0840–1300 Meetings: Central laboratory, Ministry of Health and Population World Health Organization, Country Representative Office Field Epidemiology Training Program Ministry of Health Eastern Mediterranean Regional Office, World Health Organization Deputy Chief of Mission, U.S. Embassy October 10 0840 Meetings with USAID personnel October 11   K.Gensheimer and J.Hospedales 0730 Depart hotel for Alexandria 0930–1030 Mahalla El-Kobra Fever Hospital 1200–1500 Abu Homos Clinic brief and site visit G.Rodier 0500 Depart hotel for Luxor 1030 Quena fever hospital (canceled for security reasons) 1300 Cohort study October 12   K.Gensheimer and J.Hospedales 0900 Alexandria Fever Hospital G.Rodier 0900 Armunt Fever Hospital (done under military escort) October 13   Follow-up discussion with NAMRU-3 staff Writing of subcommittee report October 14   Depart for Kenya

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