Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System

A Program Review

Philip S.Brachman, Heather C.O’Maonaigh, and Richard N.Miller, Editors

Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System

Medical Follow-Up Agency

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System A Program Review Philip S.Brachman, Heather C.O’Maonaigh, and Richard N.Miller, Editors Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System Medical Follow-Up Agency INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by Contract No. DAM17-00-P-0412. The views presented in this report are those of the Institute of Medicine Committee to Review the Department of Defense Global Emerging Infections Surveillance Response System and are not necessarily those of the funding agencies. International Standard Book Number 0-309-07635-8 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area), or visit the NAP’s home page at www.nap.edu. The full text of this report is available at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm.A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I.Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm.A.Wulf are chairman and vice chairman, respectively, of the National Research Council.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review COMMITTEE TO REVIEW THE DEPARTMENT OF DEFENSE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM PHILIP S.BRACHMAN (Chair), Professor, Department of International Health, Rollins School of Public Health, Emory University, Atlanta, Georgia RUTH L.BERKELMAN, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia DONALD S.BURKE, Professor, Department of International Health and Director of the Center for Immunization Research, Johns Hopkins School of Public Health, Baltimore, Maryland KATHLEEN F.GENSHEIMER, State Epidemiologist, Bureau of Health, Maine Department of Human Services, Augusta, Maine C.JAMES HOSPEDALES, Director, Caribbean Epidemiology Center, Pan American Health Organization, World Health Organization, Port of Spain, Trinidad, West Indies ANN MARIE KIMBALL, Professor, Health Services and Epidemiology, Adjunct in Medicine, University of Washington, Seattle, Washington GUÉNAËL R.RODIER, Director, Department of Communicable Disease Surveillance and Response, World Health Organization, Geneva, Switzerland RONALD K.ST. JOHN, Executive Director, Center for Emergency Preparedness and Response, Health Canada, Ottawa, Ontario, Canada Project Staff RICHARD N.MILLER, Study Director HEATHER C.O’MAONAIGH, Program Officer PAMELA RAMEY-McCRAY, Administrative Assistant ANDREA COHEN, Financial Associate

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Preface The U.S. Department of Defense (DoD) has historically defined its interest in infectious diseases almost exclusively in terms of “battle-stopper” illnesses—those resulting in acute effects that can directly affect military operations. Although this approach remains central to the U.S. military’s infectious disease doctrine, development of the DoD Global Emerging Infections Surveillance and Response System (GEIS) is part of an important transition in the way that the threat of infectious diseases— and, more specifically, the threat of emerging infectious diseases—is perceived and addressed by the U.S. military. Emerging infectious disease surveillance is sustained globally through a network of activities maintained through the collective efforts of numerous governmental and nongovernmental agencies. It is through the contributions of many partners that surveillance for emerging infectious diseases is possible. The DoD possesses valuable resources that can be brought to bear in this effort. It maintains an extensive, diverse array of laboratory facilities, both within the United States and overseas. These DoD laboratories can perform routine diagnostic testing, but they also possess rare, sometimes unique, diagnostic capabilities. DoD overseas laboratories are located throughout the world in areas where the potential for the emergence of infectious diseases is high. Often, laboratories operate in regions where alternative laboratory resources are sparse or nonexistent (e.g., sub-Saharan Africa). No other organization or government in the world maintains such extensive or capable laboratory facilities and staffing internationally. DoD laboratory facilities represent medical re-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review search, public health, and diplomatic resources that serve U.S. military, U.S. civilian, and global interests alike. For more than a decade, formal DoD participation in emerging infectious disease surveillance has been encouraged by many in the U.S. public health community and within the DoD. In 1996, Presidential Decision Directive NSTC-7 (NSTC is the National Science and Technology Council of the Executive Office of the President) transformed these recommendations into a mandate. Thereafter, the National Intelligence Council declared emerging infectious diseases to be a threat to the national security of the United States, underscoring the importance of DoD participation in disease surveillance efforts. This role is not an altogether new one, as the DoD has been conducting various infectious disease surveillance projects (e.g., for influenza) for many years. Accommodation of its expanded role has led the DoD to implement GEIS. The committee recognizes this effort as a responsive and effective step toward addressing the problem of emerging infectious diseases. We would like to thank the staff of the DoD laboratories, both domestic and overseas, and the staff of the GEIS Central Hub for the time and effort that they have invested in sharing with us information about the GEIS operations that they support. This review effort was very much a collegial one, and the report benefited from the openness of all those who provided us with documentation, presentations, and conversations. This study was also enriched by the insights that GEIS collaborators and associates provided regarding their views of GEIS from the outside looking in. Lists of the laboratory staff and GEIS collaborators and associates who shared their time with the committee can be found at the ends of Chapters 2 through 7 of this report. Any omissions are strictly the result of oversight. The support provided by Institute of Medicine staff was instrumental in keeping this study moving apace. We extend our thanks to Richard Miller, Heather O’Maonaigh, and Pamela Ramey-McCray of the Institute of Medicine’s Medical Follow-Up Agency and to National Academies Travel staff, particularly Ann-Marie Walko, for their assistance. This study also benefited from the attention of Andrea Cohen, financial associate; Michael Hayes, consulting editor; and Linda Kilroy, contracting officer. Medical Follow-Up Agency staff members Phillip Bailey, Salem Fisseha, Lois Joellenbeck, and Karen Kazmerzak also helped along the way. In addition, we are grateful to GEIS Central Hub staff members, particularly Joel Gaydos, Steve Gubenia, Patrick Kelley, Jennifer Rubenstein, and James Writer for their tireless assistance in preparing and compiling background documents and for helping to plan and negotiate the logistics of site visits. Likewise, we offer special thanks to Roxana Lescano, Lucy Rubio, and Trueman Sharp, Naval Medical Research Center Detachment,

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Peru; Andrew Corwin and John Sisson, Naval Medical Research Unit 2, Indonesia; Gaye Ruble, Armed Forces Research Institute of Medical Sciences, Thailand; Cole Church, Naval Medical Research Unit 3, Egypt; Ronald Rosenberg, U.S. Army Medical Research Unit, Kenya; and Leslie Henry, Naval Health Research Center, San Diego, for their help in putting site visits together. This report is a testament to the hard work, patience, and resolve of many. We extend to all involved our appreciation and gratitude. Philip S.Brachman (Committee Chair) Ruth L.Berkelman Donald S.Burke Kathleen F.Gensheimer C.James Hospedales Ann Marie Kimball Guénaël R.Rodier Ronald K.St. John

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: JAMES BANTA, Adjunct Professor, International Public Health, International Health Policy, The George Washington University Medical Center KENNETH BART, Director, Graduate School of Public Health, San Diego State University DAVID BRANDLING-BENNETT, Deputy Director, Pan American Health Organization SCOTT HALSTEAD, Adjunct Professor, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences ROBERT HOLZMAN, Professor of Clinical & Environmental Medicine, New York University School of Medicine JOSHUA LEDERBERG, Raymond and Beverly Sackler Foundation Scholar, The Rockefeller University

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review     Collaborations,   39     Recommendations,   42     People Met and Interviewed,   44     Itinerary,   45 3   GEIS AT NAVAL MEDICAL RESEARCH UNIT 2, INDONESIA   47     Laboratory,   48     Staffing,   50     Technology and Information Management,   51     Surveillance,   52     Response Capacity,   56     Collaborations,   57     Recommendations,   58     People Met and Interviewed,   61     Itinerary,   62 4   GEIS AT THE ARMED FORCES RESEARCH INSTITUTE OF MEDICAL SCIENCES (AFRIMS), THAILAND   65     Laboratory,   66     Staffing,   67     Technology and Information Management,   69     Surveillance,   69     Response Capacity,   74     Collaborations,   74     Recommendations,   77     People Met and Interviewed,   79     Itinerary,   80 5   GEIS AT NAVAL MEDICAL RESEARCH UNIT 3, EGYPT   83     Laboratory,   84     Staffing,   84     Technology and Information Management,   86     Surveillance,   87     Response Capacity,   90     Collaborations,   91     Recommendations,   93     People Met and Interviewed,   96     Itinerary,   96 6   GEIS AT U.S. ARMY MEDICAL RESEARCH UNIT, KENYA   99     Laboratory,   100     Staffing,   102     Technology and Information Management,   104

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review     Surveillance,   105     Response Capacity,   109     Collaborations,   111     Recommendations,   115     People Met and Interviewed,   119     Itinerary,   119 7   GEIS CENTRAL HUB AND MILITARY HEALTH SYSTEM ACTIVITIES   121     Description of GEIS Central Hub and MHS Activities,   122     Conclusions,   146     Recommendations,   150     Agendas,   153     GEIS Central Hub and Military Health System Activities Review: Meeting Participants, Guests, and Other Contributors,   155 8   SUMMARY CONCLUSIONS AND RECOMMENDATIONS   159     Summary Conclusions,   159     Summary Recommendations,   170     REFERENCES   177     APPENDIX: COMMITTEE MEMBER AND STAFF BIOGRAPHICAL SUMMARIES   187

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Acronyms and Abbreviations ADP automated data processor AFEB Armed Forces Epidemiology Board AFI acute febrile illness AFIERA Air Force Institute for Environmental Safety and Occupational Health Risk Analysis AFIP Armed Forces Institute of Pathology AFRIMS Armed Forces Research Institute of Medical Sciences AMREF African Medical and Research Foundation AFRESS Air Force Reportable Events Surveillance System AIDS Acquired Immunodeficiency Syndrome BSL biosafety level CAREC Caribbean Epidemiology Center CDC Centers for Disease Control and Prevention (United States) CHCS/CHCS II Department of Defense Composite Health Care System (I and II) CHPPM Center for Health Promotion and Preventive Medicine CINC Commander-in-Chief, Unified Combatant Command

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review CISET Committee on International Science, Engineering, and Technology CRDA Cooperative Research and Development Agreement DoD Department of Defense (United States) DMS Department of Medical Services DMSS Defense Medical Surveillance System EID emerging infectious disease ELISA enzyme linked immunosorbent assay EMRO Eastern Mediterranean Regional Office, World Health Organization ENSO El Niño/Southern Oscillation EWORS Early Warning Outbreak Response System ESSENCE Electronic Surveillance System for Early Notification of Community-Based Epidemics FSN foreign service national FETP Field Epidemiology Training Program FLUNET WHO’s influenza surveillance system GEIS Global Emerging Infections Surveillance and Response System GIS geographic information system GISP Gonococcal Isolate Surveillance Project HIV Human Immunodeficiency Virus ILRI International Livestock Research Institute IOM Institute of Medicine IT information technology IS information systems INS Instituto Nacional de Salud (Peru) JICA Japanese International Cooperative Agency KEMRI Kenya Medical Research Institute LITS Laboratory Information Tracking System MDR-TB multi-drug-resistant tuberculosis MEDCOM Medical Command MFO U.S. Multinational Forces and Observers

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review MHS Military Health System MIDRP Military Infectious Disease Research Program MoH Ministry of Health MOHP Ministry of Health and Population (Egypt) MSF Médicins Sans Frontières; Doctors without Borders NAMRID Naval Medical Research Institute Detachment NAMRU-2 Naval Medical Research Unit 2 NAMRU-3 Naval Medical Research Unit 3 NASA National Aeronautics and Space Administration NDRS Naval Disease Reporting System NEHC Naval Environmental Health Center NEPMU Navy Environmental and Preventive Medicine Unit NHRC Naval Health Research Center NIAID National Institute of Allergy and Infectious Diseases NMRCD Naval Medical Research Center Detachment NGO nongovernmental organization NIH National Institutes of Health NSTC-7 National Science and Technology Council, Executive Office of the President, Presidential Decision Directive NSTC-7 NSDD National Security Decision Directive OGE Oficina General de Epidemiologia (Ministry of Health Office of Epidemiology, Peru) OSTP Office of Science and Technology Policy PACOM Pacific Command PAHO Pan American Health Organization PHLIS Public Health Laboratory Information System RSD Research Sciences Department SEATO Southeast Asia Treaty Organization SOUTHCOM Southern Command STD sexually transmitted disease TAML Theater Area Medical Laboratory TB tuberculosis TEPHINET Training in Epidemiology and Public Health Intervention Network TMA Tricare Management Area

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review USAID United States Agency for International Development USAID-VIGIA United States Agency for International Development-project Addressing Threats of Emerging and Re-emerging Infectious Diseases USAMRIID United States Army Medical Research Institute of Infectious Diseases USAMRU-K United States Army Medical Research Unit, Kenya U.S. CDC United States Centers for Disease Control and Prevention USUHS United States Uniformed Services University of the Health Sciences VEE Venezuelan Equine Encephalitis VIGIA Addressing Threats of Emerging and Re-Emerging Infectious Diseases project VPHL Virtual Public Health Laboratory VOIP Voice Over Internet Protocol VSAT very small apperature terminal WHO World Health Organization WRAIR Walter Reed Army Institute of Research

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review GEIS Maps Source: J.Writer, Department of Defense Global Emerging Infections Surveillance and Response System.

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