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Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response
Review of the DoD-GEIS Influenza Programs
Strengthening Global Surveillance and Response
Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs
Board on Global Health
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
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.
This study was supported by Contract No. W81XWH-06-C-0381 (DoD-7741) between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-11010-5
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Additional copies of this report are available from the
National Academies Press,
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For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2008 by the National Academy of Sciences. All rights reserved.
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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.
Suggested citation: Institute of Medicine (IOM). 2008. Review of the DOD-GEIS influenza programs: Strengthening global surveillance and response. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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. Ralph J. Cicerone 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. Charles M. Vest 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. Harvey V. Fineberg 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. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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COMMITTEE FOR THE ASSESSMENT OF DOD-GEIS INFLUENZA SURVEILLANCE AND RESPONSE PROGRAMS
MYRON M. LEVINE, M.D., D.T.P.H. (Chair), Professor and Director, Simon and Bessie Grollman Distinguished Professor,
Center for Vaccine Development, University of Maryland School of Medicine
CAROL CARDONA, D.V.M., Ph.D., Associate Veterinarian, Associate Specialist in Cooperative Extension,
Veterinary Medicine Extension, University of California, Davis
WALTER DOWDLE, Ph.D.,
The Task Force for Child Survival and Development
TIMOTHY GERMANN, Ph.D., Technical Staff Member,
Applied Science & Methods Development Group, Los Alamos National Laboratory
MARY GILCHRIST, Ph.D., Director,
Bureau of Laboratory Sciences, State Laboratory Institute, Department of Public Health, The Commonwealth of Massachusetts
JAMES M. HUGHES, M.D., Director,
Program in Global Infectious Disease, Center for Global Safe Water, School of Medicine and Rollins School of Public Health, Emory University
K. MILLS McNEILL, Ph.D., M.D., Director,
Public Health Laboratory, Mississippi State Department of Health
PETER PALESE, Ph.D., Professor and Chair Department of Microbiology,
Mount Sinai School of Medicine
KENNEDY FRANCIS SHORTRIDGE, Ph.D., D.Sc., Emeritus Professor,
The University of Hong Kong and
Honorary Professor,
Department of Micobiology, The University of Hong Kong, Hong Kong SAR, China,
Honorary Professor,
Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand
JAMES TIBENDERANA, M.B.CH.B., M.Phil., Ph.D.,
Drug Policy Change Specialist/Epidemiologist Malaria Consortium, Uganda
Board Liaison
PHILIP K. RUSSELL, M.D.,
(Board on Global Health Liaison)
Former Director,
Office of Research and Development Coordination, Office of the Assistant Secretary for Public Health Emergency Preparedness, U.S. Department of Health and Human Services
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Project Staff
PATRICK W. KELLEY, M.D., Dr.P.H., Director,
Boards on Global Health and African Science Academy Development
RICK ERDTMANN, M.D., M.P.H., Director,
Boards on Military and Veterans Health and Medical Follow-up Agency
J. ALICE NIXON, M.A., Study Director
KIMBERLY WEINGARTEN, Research Assistant
ANGELA MENSAH, Senior Program Assistant (November 2006–April 2007)
EMILY S. MEYER, Intern (February 2007–May 2007)
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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:
Donald S. Burke, Graduate School of Public Health, University of Pittsburgh
Philip E. Coyle III, Science Strategies, LLC
Kathy Edwards, Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine
Benson Estambale, College of Health Sciences, University of Nairobi Institute of Tropical and Infectious Diseases,
Alison P. Galvani, Division of Epidemiology of Microbial Diseases, Yale University School of Medicine
Kathleen F. Gensheimer, Medical Epidemiology Section, Division of Infectious Diseases, Maine Department of Health and Human Service
Lance Jennings, Canterbury Heath Laboratories, Christchurch, New Zealand
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Daniel Lavanchy, Epidemic and Pandemic Alert and Response, Office for Alert and Response Operations, World Health Organization
Graeme Laver, Australian National University, Professor Emeritus
Mark Miller, Fogarty International Center, National Institutes of Health
Frederick A. Murphy, Galveston Department of Pathology, University of Texas Medical Branch
Douglas M. Watts, Department of Pathology, Center for Biodefense and Emerging Infectious Diseases, University of Texas Medical Branch
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Dr. David R. Challoner, Vice President for Health Affairs, Emeritus, University of Florida, and Charles C.J. Carpenter, the Miriam Hospital and Brown University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Preface
Influenza in humans is an acute respiratory disease caused by RNA viruses that continually undergo genetic change, allowing seasonal epidemics as the viruses evolve in subtle ways that permit them to evade preexisting immunity in portions of the human population. During seasonal epidemics, the very young and the elderly bear the brunt of mortality from influenza. However, every few decades a fundamental antigenic shift occurs in the virus, resulting in the emergence of a strikingly new influenza viral strain to which most of the human population is susceptible. If the new virus is particularly virulent, as well as antigenically distinct and readily transmissible between humans, a pandemic can ensue that represents a public health emergency with likely severe human and economic repercussions. The two most recent pandemics (1957 and 1968) are known to have resulted from a human influenza virus acquiring genes from an avian virus, resulting in a “reassorted” virus.
Three pandemics caused by influenza A viruses occurred in the 20th century, including 1918-1919 (H1N1 virus), 1957 (H2N2 virus), and 1968 (H3N2 virus). Among these, the 1918-1919 pandemic stands out because of the particularly severe clinical disease observed and the unusual epidemiologic behavior that ensued in which healthy young adults, in addition to the very young and elderly, suffered high mortality. During the 1918-1919 pandemic, U.S. armed services personnel on military installations in the United States experienced unprecedented fatality rates.
Fundamental strategies to minimize the impact of the next pandemic include the maintenance of a global surveillance system to detect emerging
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shifted influenza viruses, the rapid development of vaccines based on the newly emerged “shifted” strains, and use of stockpiled antiviral drugs. As both the 1957 and 1968 pandemic viruses apparently originated in East Asia, a critical component of current global influenza surveillance is based on the early detection of influenza-like disease and collection of influenza viruses from Asia.
In 1997 an outbreak of influenza in chickens in Hong Kong due to a highly lethal H5N1 avian influenza A virus also caused 18 human cases, of which six were fatal. Since 2004, other avian H5N1 viruses have wreaked havoc among domestic poultry in East and Southeast Asia and have also caused more than 300 human cases (among close human contacts of poultry), of which 60 percent were fatal. Thus far H5N1 viruses have not attained the capacity to transmit readily from human to human but the United States must be vigilant.
In 1996, the Executive Office of the President of the United States issued a Presidential Decision Directive declaring that national and international capabilities for infectious disease surveillance, prevention, and response were insufficient to protect the health of U.S. citizens from emerging infectious diseases and called on U.S. federal agencies to remedy the situation. The Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS), established in 1997, represents the DoD’s response to that Presidential Decision Directive. GEIS’s focus is primarily on sentinel surveillance of indigenous and expatriate populations for certain infectious disease targets, including influenza. For many decades the DoD has maintained a series of overseas medical research facilities in Asia, Africa, and Latin America that have been well poised to participate in the detection of emerging infectious disease threats. Collectively, these DoD facilities constitute an extraordinary array of surveillance assets.
In 2006, through the National Defense Authorization Act, Congress provided a $39 million supplement to GEIS, specifically to expand surveillance and response capabilities with respect to the threat of pandemic influenza of avian virus origin. An IOM Committee was assembled at the request of the DoD to evaluate how the GEIS pandemic influenza surveillance and response program utilized the supplemental funds, strengthened influenza surveillance efforts domestically and internationally, integrated DoD efforts with those of other Federal agencies, coordinated activities with host countries (and neighboring countries in regional efforts), and collaborated with the World Health Organization and other international agencies engaged in influenza pandemic preparedness. Toward this end, a Committee was assembled with expertise in influenza, epidemiology, public health laboratory management, virology, veterinary and human medicine, global health and military preventive medicine. The Committee made site visits to the DoD overseas medical research units where GEIS-supported
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projects are under way, as well as to key military medical laboratories within the United States involved in influenza surveillance. The findings of the Committee are summarized in this report, along with a series of recommendations.
The Committee found that the DoD’s overseas medical research units constitute an impressive network that has laudably utilized the supplemental funding to strengthen influenza surveillance, in addition to continuing their historically primary research activities. Perhaps the Committee’s most overarching recommendation is that DoD-GEIS headquarters should be formally charged with providing overall managerial and technical oversight (quality assurance, safety, etc.) and interagency communication for the multi-service influenza and respiratory disease surveillance program and the revised coordination structure. Part of this should be a codified chain of accountability to include timely reporting of findings. If the full set of recommendations are acted upon, the Committee is confident that the DoD-GEIS’s key role in global surveillance will be further strengthened and its effectiveness enhanced.
Myron M. Levine, M.D., D.T.P.H.
Chair
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Contents
ABBREVIATIONS AND ACRONYMS
xix
SUMMARY
1
1
INTRODUCTION
21
Background,
21
Charge to the Committee,
28
The Study Process,
29
References,
30
2
DOD-GEIS HEADQUARTERS AI/PI MANAGEMENT AND SUPPORT ACTIVITIES
33
DoD-GEIS AI/PI Funding,
35
Headquarters Management of DoD-GEIS AI/PI Activities,
37
DoD-GEIS Headquarters and Other Military Health System Influenza Surveillance and Response Activities,
46
Conclusions,
50
References,
52
List of Contacts,
54
3
NAVAL MEDICAL RESEARCH UNIT 2 INDONESIA AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
55
Influenza in Indonesia,
56
Management and Planning,
57
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Surveillance,
59
Laboratory,
63
Response Capacity,
66
Capacity Building,
70
Collaboration and Coordination,
72
References,
75
List of Contacts,
77
Schedule of Events,
78
4
ARMED FORCES RESEARCH INSTITUTE OF MEDICAL SCIENCES THAILAND AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
81
Influenza in Thailand,
82
Management and Planning,
84
Surveillance,
84
Laboratory,
86
Response Capacity,
87
Capacity Building,
89
Collaboration and Coordination,
90
References,
92
List of Contacts,
93
Schedule of Events,
95
5
NAVAL MEDICAL RESEARCH UNIT 3 EGYPT AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
97
Influenza in Egypt,
99
Management and Planning,
99
Surveillance,
102
Laboratory,
105
Response Capacity,
107
Capacity Building,
111
Collaboration and Coordination,
115
References,
119
List of Contacts,
120
Schedule of Events,
121
6
U.S. ARMY MEDICAL RESEARCH UNIT KENYA AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
123
Influenza in Kenya,
125
Management and Planning,
125
Surveillance,
128
Laboratory,
132
Response Capacity,
134
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Capacity Building,
136
Collaboration and Coordination,
137
Uganda,
139
References,
142
List of Contacts,
144
Schedule of Events,
145
7
NAVAL MEDICAL RESEARCH CENTER DETACHMENT PERU AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
147
Management and Planning,
149
Surveillance,
151
Laboratory,
154
Response Capacity,
155
Capacity Building,
156
Collaboration and Coordination,
158
References,
161
List of Contacts,
163
Schedule of Events,
164
8
NAVAL HEALTH RESEARCH CENTER SAN DIEGO AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
167
Management and Planning,
168
Surveillance,
169
Laboratory,
174
Response Capacity,
175
Collaboration and Coordination,
178
References,
179
List of Contacts,
180
Schedule of Events,
180
9
AIR FORCE INSTITUTE FOR OPERATIONAL HEALTH SAN ANTONIO AVIAN AND PANDEMIC INFLUENZA ACTIVITIES
183
Management and Planning,
184
Surveillance,
188
Laboratory,
190
Response Capacity,
193
Collaboration and Coordination,
195
References,
197
List of Contacts,
199
Schedule of Events,
200
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10
OVERARCHING CONCLUSIONS AND RECOMMENDATIONS
203
Consistency with Department of Defense and National Plans,
204
The Utility of Each Funded Project’s Contribution to a Comprehensive AI/PI Surveillance Program,
207
Adequacy of the Program in View of Evolving Epidemiologic Factors,
209
Coordination of Efforts with the Centers for Disease Control and Prevention, the World Health Organization, and Local Governments,
216
Conclusion,
222
References,
222
APPENDIX
Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO, 11 July 2007
226
LIST OF FIGURES
1-1
Nations with confirmed cases H5N1 avian influenza,
24
2-1
DoD-GEIS funding from fiscal year 1997 to 2006,
38
2-2
DoD-GEIS organizational chart,
40
3-1
DoD’s regional presence in influenza surveillance (South East Asia), 2007,
56
4-1
DoD’s regional presence in influenza surveillance (South East Asia), 2007,
83
5-1
DoD’s regional presence in influenza surveillance (Africa), 2007,
98
5-2
NAMRU-3 avian influenza assessment missions and outbreak support,
103
6-1
DoD’s regional presence in influenza surveillance (Africa), 2007,
124
7-1
DoD’s regional presence in influenza surveillance (Latin America), 2007,
148
8-1
NHRC influenza surveillance sites and activities, 2006-2007,
170
9-1
AFIOH sentinel surveillance sites and activities, present and future, 2006-2007,
189
10-1
Department of Defense influenza surveillance sites worldwide, 2007,
205
10-2
DoD’s worldwide presence in influenza surveillance, 2007,
218
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LIST OF TABLES
1-1
Primary DoD Overseas and Domestic Laboratories Receiving DoD-GEIS AI/PI Funding,
25
2-1
DoD-GEIS Avian Influenza/Pandemic Influenza Supplemental Funding in Fiscal Year 2006,
38
3-1
Summary of Surge Capability at NAMRU-2,
68
4-1
Summary of Surge Capability at AFRIMS,
88
5-1
Summary of Surge Capability at NAMRU-3—Routine Operations,
109
5-2
Summary of Surge Capability at NAMRU-3—Altered Agorithm (Influenza A and H5 first),
109
5-3
Summary of Surge Capability at NAMRU-3—24-Hours-a-Day, Seven-Days-a-Week Operations and Altered Algorithm (Influenza A and H5 first),
110
5-4
Summary of Surge Capability at NAMRU-3—Outbreak Support,
111
6-1
Summary of Surge Capability at USAMRU-K,
135
8-1
Summary of Surge Capability at the NRDL, NHRC,
177
9-1
Summary AFIOH Surge Capacity,
194
10-1
Department of Defense Laboratories Funding for Fiscal Year 2006,
208
10-2
Animal Surveillance Activities at the DoD Overseas Laboratories,
211
10-3
Laboratory Capabilities at the DoD Domestic and Overseas Laboratories,
212
10-4
Estimated Laboratory Surge Capacity at DoD Domestic and Overseas Laboratories,
214
10-5
Information Sharing at DoD Domestic and Overseas Laboratories,
216
10-6
International Partners of DoD Overseas Laboratories,
218
10-7
DoD Laboratories Serving as WHO Collaborating Centers and Reference Laboratories,
219
10-8
U.S. Government Partners of DoD Domestic and Overseas Laboratories,
221
LIST OF BOXES
S-1
Chapter 2 Recommendations DoD-GEIS Headquarters
13
S-2
Chapter 3 Recommendations Naval Medical Research Unit No. 2 Indonesia,
13
S-3
Chapter 4 Recommendations Armed Forces Research Institute of Medical Sciences Thailand,
14
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S-4
Chapter 5 Recommendations Naval Medical Research Unit 3 Egypt,
15
S-5
Chapter 6 Recommendations U.S. Army Medical Research Unit Kenya,
16
S-6
Chapter 7 Recommendations Naval Medical Research Center Detachment Peru,
17
S-7
Chapter 8 Recommendations Naval Health Research Center San Diego,
17
S-8
Chapter 9 Recommendations Air Force Institute for Operational Health San Antonio,
18
2-1
DoD-GEIS Avian and Pandemic Influenza Emergency Preparedness Plan Program Staff’s Role and Responsibilities,
36
2-2
Early Warning Outbreak Recognition System (EWORS),
47
9-1
DoD Influenza Executive Agent Functions Identified by AFIOH,
196
10-1
National Strategy for Pandemic Influenza, Implementation Plan Roles and Responsibilities,
220
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Abbreviations and Acronyms
AAALAC American Association for the Accreditation of Laboratory Animal Care
AFCOM U.S. African Command
AFIOH Air Force Institute for Operational Health
AFIP Armed Forces Institute of Pathology
AFMIC Armed Forces Medical Intelligence Center
AFRIMS Armed Forces Research Institute of Medical Sciences, Thailand
AFRO WHO Regional Office for Africa
AI avian influenza
AI/PI avian influenza/pandemic influenza
AI/PI EPP Avian Influenza/Pandemic Influenza Emergency Preparedness Plan
AMSA U.S. Army’s medical surveillance activity
ARI acute respiratory infection
ASD-HA Assistant Secretary of Defense for Health Affairs
BSL-2 biosafety level 2
BSL-3 biosafety level 3
BSL-3E biosafety level 3 enhanced
BUMED Naval Bureau of Medicine and Surgery
CDC Centers for Disease Control and Prevention
CDHAM Center for Disaster and Humanitarian Assistance
CENTCOM U.S. Central Command
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CHPPM U.S. Army Center for Health Promotion and Preventive Medicine
COCOM Combatant Command
CONOPS concept of operations
CONUS continental U.S.
CPE cytopathic effect
DCM Deputy Chief of Mission
DGE Directorate of General Epidemiology
DHP Defense Health Program
DHS U.S. Department of Homeland Security
DoD U.S. Department of Defense
DoS U.S. Department of State
DSO Defense Science Organization
EDCD Epidemiology and Disease Control Division
EID emerging infectious disease
EMRO Eastern Mediterranean Regional Office
EUCOM U.S. European Command
EWORS Early Warning Outbreak Recognition System
FAO Food and Agricultural Organization
FDA Food and Drug Administration
FISC Fleet and Industrial Supply Center
FRI febrile respiratory illness
FSN foreign service nationals
FTE full-time equivalent
GAINS Global Avian Influenza Network Surveillance
GEIS Global Emerging Infections and Surveillance Response System
GLP good laboratory practice
GOARN Global Outbreak Alert Response Network
GTZ German Agency for Technical Cooperation
HA hemagglutinin
HAI human avian influenza
HHS U.S. Department for Health and Human Services
HIV human immunodeficiency virus
HJF Henry M. Jackson Foundation
HPAI highly pathogenic avian influenza
ICEID International Conference on Emerging Infectious Diseases
IDSA Infectious Diseases Society of America
IEC information, education, and communication
IEIP International Emerging Infections Program
IF immunofluorescence
ILI influenza-like illness
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INS Instituto Nacional de Salud Peru
IOM Institute of Medicine
IRB institutional review board
ITI Idaho Technology Incorporated
JHU/APL Johns Hopkins University Applied Physics Laboratory
JISWG Joint Influenza Surveillance Working Group
KEMRI Kenya Medical Research Institute
LANL Los Alamos National Laboratory
LES locally employed staff
LRN Laboratory Response Network
MAAIF Ministry of Agriculture, Animal Industry, and Fisheries
MDCK Madin-Darby canine kidney
MHS military health system
MIDRP Military Infectious Diseases Research Program
MoA Ministry of Agriculture
MoE Ministry of Environment
MoH Ministry of Health
MoHP Ministry of Health and Population
MoPH Ministry of Public Health
MoU memorandum of understanding
MTF Medical Treatment Facilities
MUWRP Makerere University Walter Reed Project
NAMRID Naval Medical Research Institute Detachment
NAMRU-2 Naval Medical Research Unit No. 2, Indonesia
NAMRU-3 Naval Medical Research Unit No. 3, Egypt
NASA National Aeronautics and Space Administration
NBIC National Biosurveillance Integration Center
NCD Newcastle disease
NCLE National Center for Laboratory and Epidemiology
NEHC Navy Environmental Health Center
NGO nongovernmental organization
NHRC Naval Health Research Center, San Diego, CA
NIC National Influenza Center
NIH National Institutes of Health
NMRC Naval Medical Research Center
NMRCD Naval Medical Research Center Detachment, Peru
NORTHCOM U.S. Northern Command
NPHL National Public Health Laboratory
NRDL National Respiratory Disease Laboratory
NSTC-7 National Science and Technology Council, Executive Office of the President, Presidential Decision Directive
NTF National Task Force
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OASDHA Office of the Assistant Secretary of Defense for Health Affairs
OCONUS outside the continental United States
OIE World Organization for Animal Health
OTSG Office of the Army Surgeon General
PAHO Pan American Health Organization
PCR polymerase chain reaction
PI pandemic influenza
PIPM Pandemic Influenza Policy Model Extension
POM Program Objective Memorandum
PPE personal protective equipment
QA/QC quality assurance/quality control
RSD Research Sciences Department
RSV respiratory syncytial virus
RTA Royal Thai Army
RT-PCR reverse transcription polymerase chain reaction
RVF Rift Valley fever
SARS severe acute respiratory syndrome
SEATO Southeast Asia Treaty Organization
SME subject matter expertise
SOP standard operating procedure
SOUTHCOM U.S. Southern Command
TMA Tricare Management Activity
USACHPPM U.S. Army Center for Health Promotion and Preventive Medicine
USAID U.S. Agency for International Development
USAMC U.S. Army Materiel Command
USAMRIID United States Army Medical Research Institute for Infectious Diseases
USAMRMC U.S. Army Medical Research and Materiel Command
USAMRU-K U.S. Army Medical Research Unit, Kenya
USDA U.S. Department of Agriculture
USDAAPHIS U.S. Department of Agriculture’s Animal and Plant Health Inspection Service
USG United States government
USUHS Uniformed Services University of the Health Sciences
UVRI Uganda Virus Research Institute
VE vaccine effectiveness
VRBPAC Vaccines and Related Biological Products Advisory Committee
WARUN Walter Reed/AFRIMS Research Unit Nepal
WHO World Health Organization
WRAIR Walter Reed Army Institute of Research
WRP Walter Reed Project
