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
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
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.
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 |
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 |
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
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-
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. |
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. |
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,
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-
cused within the NHRC in San Diego California, and the Air Force Institute for Environmental Safety and Occupational Health Risk Analysis (AFIERA), centered at Brooks Air Force Base in San Antonio, Texas. NHRC and AFIERA are the Navy and Air Force “hubs” (coordinating units) for GEIS within the MHS, respectively. GEIS, in seeking to build upon and coordinate existing DoD laboratory expertise, has identified facilities that possess particularly robust capabilities in a specified area. GEIS has identified the NHRC as a center of expertise and excellence in the area of respiratory viruses and bacteria and surveillance for acute respiratory diseases in military training centers. AFIERA has been designated a center of expertise and excellence in the areas of influenza and tuberculosis (Gaydos, 1999). In addition to providing funds to support projects, GEIS resources also support laboratory capacity building within these hubs.
NHRC The NHRC laboratory is a biosafety level 2 facility that possesses virology-, bacteriology-, and molecular biology-based study components. The NHRC conducts for DoD national surveillance for adenovirus, influenza viruses A and B, Streptococcus pyogenes, and invasive Streptococcus pneumoniae at U.S. Army, Navy, Marine Corps, Air Force, and Coast Guard sites identified as “high risk.” The laboratory’s work involves 17 collaborating military commands. Laboratory staff conduct surveillance for the emergence of new pathogenic strains and the development of antibiotic resistance. The laboratory team also follows large cohorts of military personnel in prospective epidemiological studies of respiratory disease and conducts large clinical trials of interventions for the prevention or treatment of respiratory diseases (NHRC, 2001b).
In fiscal year 2000, GEIS funds supported numerous NHRC project activities involving surveillance, evaluation of new diagnostic tools, identification of risk factors for respiratory diseases, and epidemic investigations (GEIS, 2000b). GEIS also provides capacity that the NHRC has been able to leverage to conduct research activities such as clinical trials. Ongoing and recently completed NHRC epidemiological studies of emerging illness among U.S. military personnel (supported to various degrees by GEIS) include the following (GEIS, 2000b; NHRC, 2001a,c; Ryan et al., 2000):
-
triservice surveillance for S. pyogenes infections among U.S. military personnel;
-
triservice surveillance for antibiotic resistance among S. pneumoniae isolates infecting U.S. military health care beneficiaries;
-
triservice population-based surveillance for viral respiratory pathogens among high-risk military personnel;
-
epidemiological study of respiratory diseases among midshipmen at the U.S. Naval Academy;
-
double-blind, placebo-controlled clinical trial of azithromycin as prophylaxis against bacterial agents causing acute respiratory disease among military trainees;
-
clinical evaluation of a rapid diagnostic test for adenovirus;
-
clinical evaluation of two rapid diagnostic tests for influenza virus;
-
double-blind, placebo-controlled clinical efficacy trial of pneumococcal vaccine or benzathine penicillin G as prophylaxis against bacterial agents causing febrile acute respiratory disease among ranger trainees;
-
double-blind, placebo-controlled trial of the 23-valent pneumococcal vaccine among military trainees at high risk of respiratory disease;
-
surveillance for Bordetella pertussis among military trainees with respiratory disease;
-
an evaluation of screening results for tuberculosis among young adults enlisting in the U.S. Navy;
-
evaluation of military recruit populations for respiratory syncytial virus infection;
-
clinical evaluation of Zstatflu and Directigen, two rapid diagnostic tests for influenza virus; and
-
development and support of unique virology and bacteriology capabilities and studies.
The NHRC has also participated in collaborative epidemic response efforts outside of the military population, upon request (e.g., identification of respiratory disease in Tijuana, Mexico, in collaboration with Mexican and Californian public health authorities) (NHRC, 2000a,c). The NHRC maintains a website that provides detailed information about ongoing and recently completed projects. This site is linked to the GEIS website (GEISWeb). The NHRC also produces a periodic GEIS Respiratory Disease Surveillance Newsletter that provides project information and updates and is publicly accessible on the Internet.
AFIERA Within the Air Force hub, AFIERA, GEIS support is focused particularly on influenza (Neville and Canas, 2001). The Air Force is the executive agent for DoD surveillance for influenza (Bailey, 1999) and the Air Force influenza surveillance program has existed for more than 20 years. Presidential Decision Directive NSTC-7 (NSTC, 1996), coupled with GEIS funding, fueled program expansion in 1998. The Air Forces’s etiology-based surveillance program, formerly called Project Gargle, is now the Department of Defense Laboratory-Based Influenza Surveillance Program, in which 19 global sentinel sites, 49 nonsentinel sites, and 3 DoD overseas medical research laboratories participate (GEIS, 2000b, 2001e).
AFIERA is an active collaborator in the WHO influenza surveillance
laboratory at the CDC and provides input to the U.S. Food and Drug Administration regarding annual influenza vaccine components (Canas et al., 2000). In 1999, AFIERA was able to isolate and subtype a strain of the influenza A virus (H3N2), which was subsequently forwarded to the CDC and became the seed virus for the 2000–2001 and 2001–2002 vaccine component (Gaydos, 2001d). Also of note, AFIERA’s work with the Naval Medical Research Center Detachment, Peru, identified the presence of an influenza virus strain (H1N1) in the Americas, and led to its inclusion in the influenza vaccines for both the Northern and Southern Hemispheres during both the 2000–2001 and 2001–2002 flu seasons. AFIERA surveillance also covers people living in proximity to overseas DoD research facilities, as well as military personnel. AFIERA is also working to conduct studies to evaluate the clinical effectiveness of influenza vaccine in military personnel (GEIS, 2000b).
To more effectively disseminate surveillance findings, AFIERA produces influenza activity reports for sentinel and nonsentinel sites, updated biweekly, and has made them available on its website (monthly summary information is available to nongovernment users), which is linked to GEISWeb. GEIS-supported, AFIERA-managed activities also include additional surveillance work (e.g., trainee health surveillance and West Nile virus surveillance), provision of support for epidemic investigations (e.g., acute febrile illness among trainees at Lackland Air Force Base, Texas), support and enhancement of existing programs (e.g., AFRESS and molecular biology capabilities), and special studies (e.g., case-control study of influenza vaccine and chlamydia prevalence study) (GEIS, 2000b; Neville and Canas, 2001).
AFIERA GEIS program accomplishments in fiscal year 2000 include the following (GEIS, 2000b, p. 79):
-
implementation of a record validation program for communicable disease reports to ensure records meet the criteria specified for DMSS;
-
design of layout for World Wide Web-based interactive reports on reportable events;
-
conversion of AFRESS influenza reporting from routine to urgent;
-
implementation of weekly influenza activity reports for each sentinel site as well as for nonsentinel sites;
-
design of layout for World Wide Web-based interactive reports for influenza surveillance;
-
establishment of protocols and data collection mechanisms for influenza vaccine effectiveness study;
-
molecular biology-based protocols for extraction of RNA;
-
expanded surveillance efforts to include genetic characterization of neuraminidase;
-
retrieval of command support for chlamydia prevelance study; and
-
evaluation of adenovirus outbreak at Lackland Air Force Base.
Mortality Surveillance
In 1997, recognizing the lack of a comprehensive DoD system for mortality surveillance, the Armed Forces Epidemiology Board formally recommended the institution of mortality surveillance within the DoD. In response, the Uniformed Services University of the Health Sciences (USUHS) and the AFIP, funded by GEIS, developed a registry that will permit more timely capture of data in integrated databases, allowing long-term analysis (through the triservice database, DMSS). The registry as presently constructed, however, does not include an emerging infectious disease alert component, a feature that is important to GEIS. GEIS is working with AFIP to add an emerging infectious disease alert component to the DoD Epidemiology and Mortality Surveillance System and associated Mortality Registry (Gardner et al., 2000).
The alert component will serve to rapidly identify deaths possibly attributable to emerging infectious disease agents, based on uniform criteria for the identification of suspicious cases of illness. The identification of a death suspected of being caused by an emerging infectious disease will trigger a rapid investigation, beginning with telephone contact with the attending physician to determine whether a specific investigation of the diagnosis is required and to identify specimens that might need to be forwarded for sophisticated laboratory examination at both DoD and non-DoD laboratories. The Armed Forces Medical Examiner is to be charged with responding to “red flags” raised by this system (Gaydos, 2001c). Although GEIS is providing funding and guidance for the development of the emerging infectious disease alert component, ultimately the registry will be maintained by the AFIP and CHPPM.
Surveillance for and Response to STDs and Antibiotic Resistance
GIS Development and STD Surveillance On the basis of the success at Ft. Bragg, North Carolina, in which geographic information systems (GISs) were used to track sexually transmitted diseases (STDs) and gastrointestinal illnesses, GEIS is providing funding for implementation of a similar effort at Ft. Lewis, Washington (GEIS, 2000b; Gunzenhauser, 2000). Although STDs are the diseases of focus, the larger purposes of this work are (1) to develop a GIS-based surveillance system that can be used as an epidemic investigation tool (GEIS, 2000b) and (2) to assess the validity of immediately reported outpatient data (like the data used in the Electronic Surveillance System for the Early Notification of Community-Based Epidemics [ESSENCE], a project for syndromic surveillance for emerging infectious diseases and bioterrorism events in the National Capital Area)
by comparing it with CHCS laboratory data (Gunzenhauser, 2000). Evaluating the feasibility and value of sharing data with local civilian health officials is also a planned part of this pilot project. The project is being coordinated with the GEIS ESSENCE project (Gunzenhauser, 2000).
GISP GEIS is working with the CDC to add additional sites to the CDC Gonococcal Isolate Surveillance Project (GISP), a CDC-sponsored active surveillance program designed to track changes and reveal trends in antibiotic resistance in Neisseria gonorrhoeae. Within the MHS, surveillance will focus on the DoD beneficiary population at both domestic and non-U.S. locations. The overseas medical laboratory component of this work calls for collaboration with the WHO and other countries for surveillance in foreign national populations (GEIS, 2000b). The first DoD site chosen for addition to the network was Tripler Army Medical Center in Hawaii due to a recent increase in the incidence of drug-resistant gonococcal organisms in Hawaii.
Antibiotic Resistance Surveillance To advance antibiotic resistance surveillance activities within the DoD, GEIS has also established a cooperative research and development agreement with MRL, Inc., to test automated approaches for standardized, real-time antibiotic resistance surveillance at several DoD health care facilities (GEIS, 2000b). Participating DoD facilities enroll as sentinel sites with MRL. Resistance data are then submitted to MRL and subjected to an “extensive quality assessment process.” Participating sites can query the MRL database, The Surveillance Network Database (GEIS, 2001g), via a secure connection to the World Wide Web for information pertinent to their site and to compare statistics for the site with regional and national data. Data can be shared between sites and with the Central Hub. One DoD site (Wilford Hall Air Force Medical Center) has already begun participating in this arrangement. Two other sites (Tripler Army Medical Center and Keesler Air Force Medical Center) are in the process of developing agreements (GEIS, 2000b).
Health Indicator Surveillance
ESSENCE The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) has been a focus of GEIS health indicator surveillance funding. ESSENCE was developed by the GEIS Central Hub in collaboration with CHPPM and numerous other agencies and academic institutions. This program is intended to detect emerging infectious disease epidemics, including bioterrorist events, for the purposes of instigating a timely response, promoting rapid epidemiology-based targeting of limited response assets (e.g., personnel and drugs), and equipping leaders in civil government to communicate risk
on the basis of estimates of levels of exposure to reduce the spread of panic and unrest (GEIS, 2001d; Pavlin, 2000, 2001a).
To date, efforts have focused largely on the National Capital Area, which has more than 100 DoD primary health care clinics. As part of the project, ESSENCE receives ambulatory care data on a daily basis from the Ambulatory Data System currently in place at all continental U.S. military treatment facilities (data are collected by the Tricare Management Agency). Data are aggregated into syndrome groups on the basis of the codes in the International Classification of Diseases, 9th edition. These syndromic clusters are monitored for changes in incidence or clustering of cases of illness that could signal an emerging infectious disease event. A geographic information component of the system developed by CHPPM is used to plot cases for graphic assessment. Collaborative input has been sought from the Washington Metropolitan Council of Government’s Subcommitee on Public Health and local universities (GEIS, 2000b). ESSENCE is still in development. To date, data feeds from reporting locations have been established, basic trend analyses with historical data have been produced, the basic GIS mapping component has been developed, and partnerships for the sharing of data have been cultivated (Pavlin, 2001a). GEIS’s work on the development of this and other surveillance systems spawned the Conference and Workshop on Syndromic and Other Surveillance Methods for Emerging Infections held in May 2001 (GEIS, 2000b).
NEHC The Navy Environmental Health Center (NEHC) receives funding from GEIS to improve syndromic and other surveillance capabilities for its shipboard deployed forces and special forces personnel. U.S. Navy and U.S. Marine Corps forces are continuously deployed to remote regions throughout the world and thus are at increased risk of encountering emerging infectious diseases. In particular, the focus of GEIS at NEHC has been on the merging of two existing surveillance systems, the Naval Disease Reporting System and the Shipboard Non-Tactical ADP Automated Medical System. Integration of the two systems is to result in one system that is administered by the Space and Information Warfare Center but through which data are channeled to NEHC epidemiologists for analysis and response. Systems integration is intended to provide direct and smooth acquisition of shipboard surveillance data (a function that is available to other medical settings within the Navy and the Marine Corps) and to make data more useful for syndromic surveillance purposes. An effort has also been directed to the development of sentinel (nonshipboard) surveillance sites in areas where personnel are deployed (e.g., a training site in Ecuador), and data sharing and epidemiological support relationships with the host country and Naval Medical Research Center Detachment, Peru (NMRCD) are being cultivated (Morrow, 2000;
Murphy, 2001). Ultimately, plans are to deploy the combined Naval Disease Reporting System/Shipboard Non-Tactical ADP Automated Medical System at sentinel sites as well.
GEIS also sponsors a separate surveillance activity, conducted by Navy Environmental and Preventive Medicine Units 2 (NEPMU-2) and 5 (NEPMU-5) (subordinate commands of NEHC) in collaboration with Naval Medical Research Unit 2 (NAMRU-2), for viral gastroenteritis surveillance aboard deployed Navy vessels. This work focuses on the detection and identification of shipboard epidemics and the development of methods, tools, and protocols for case identification and response (Thornton, 2001), predominantly for the Norwalk and Norwalk-like viral agents. NEPMU-5 is also seeking to become a DoD reference laboratory for enteric pathogens. NEPMU-5 has also indicated an interest in operating as the DoD laboratory hub or center of excellence for enteric pathogens (Thornton, 2000).
Malaria and Other Public Health Threats in Republic of Korea
GEIS has provided partial support for 18th Medical Command (MEDCOM) projects in the Republic of Korea. GEIS funding has been used to improve field, nonhuman surveillance capabilities in the 18th MEDCOM. The recent reemergence of vivax malaria in South Korea and ongoing morbidity in both South Korean and U.S. troops provides particular motivation for this support. Adult and larval mosquitoes are trapped, processed, and analyzed (by enzyme-linked immunosorbent assay) with some support from the Armed Forces Research Institute of Medical Sciences (AFRIMS), to identify areas of transmission and relative risks. Surveillance of mosquitoes for Japanese encephalitis virus and surveillance of rodents for rodent-borne diseases (diseases caused by Hantaan and Seoul viruses, scrub typhus, murine typhus, and leptospirosis) are also conducted in collaboration with USAMRIID and Korea University. Work is also under way to identify high-risk breeding sites for mosquitoes, to assess the knowledge of soldiers serving in the area regarding personal protective measures, and to explore the relationship between compliance with prophylaxis and occurrence of possible drug resistance (Klein and Lee, 2001). Health data supplied by CHPPM, the Korean National Institutes of Health, and the Republic of Korea Military are also being used to identify trends in the prevalence of vivax malaria in U.S. forces, Republic of Korea forces, and civilians in surrounding communities (Klein and Lee, 2001).
Potential tick-borne diseases are also being investigated in U.S. military personnel. Additional tick surveillance will provide an analysis of potential human pathogens associated with sites where U.S. forces train
in Korea. This work is conducted in collaboration with the Korean National Institutes of Health and Chanbuk University, Korea.
Other Central Hub-Managed Projects
Remote Sensing (Collaborations with NASA) GEIS collaborates with the National Aeronautics and Space Administration (NASA) on the use of satellite-based remote sensing to predict epidemic infectious diseases. Although the field is still in its infancy, results to date have been quite encouraging. Most of the collaboration is with the Goddard Space Flight Center, but GEIS also collaborates with several other agencies. The objectives of the program are to identify links between the environment and emerging diseases, develop methods to detect linked environmental events by remote sensing, conduct surveillance, predict emerging infectious diseases by use of remote sensing, and publish maps of areas of risk on the World Wide Web for use by the WHO and other agencies. Remote sensing is particularly suited to this type of problem because it may be the only technology capable of realistically conducting surveillance continually over time and over large geographical areas. The technique has been used to identify close coupling between ecology (remotely sensed vegetation index), interannual climate variability such as that brought about by the El Niño-Southern Oscillation, and epidemics of Rift Valley fever in East Africa. The mechanism is thought to be due to an effect of rainfall on flooding and the hatching and emergence of the mosquito vectors of Rift Valley fever. The remote-sensing profiles used to draw these associations have been used to create and publish, on a monthly basis, maps of areas in continental Africa, Madagascar, and the Arabian Peninsula at risk for Rift Valley fever. A similar method is being developed to conduct surveillance for conditions favorable to the occurrence of epidemics, including epidemics of Ebola and Marburg viruses, in Africa. Preliminary data suggest that a similar approach may be used to develop maps of areas in Southeast Asia at risk for dengue hemorrhagic fever (Linthicum, 2001).
WRAIR WHO Center for Antimalarial Drug Surveillance For more than 30 years, Military Infectious Disease Research Program (MIDRP)-supported malaria research projects have been under way. These projects are based at WRAIR and capitalize on the opportunities afforded by the overseas research laboratories. These projects have emphasized and contributed greatly to antimalarial drug discovery and development. GEIS seeks to add to the existing capacity by enhancing mechanisms for the timely and systematic exchange of laboratory specimens between the overseas laboratories and public health partners (Milhous et al., 2000). To
accomplish this, GEIS is partnering with the Multilateral Initiative for Malaria (MIM).2
In 1999, after a WHO workshop, “Markers of Antimalarial Drug Resistance: Practical, Clinical, and Epidemiological Applications,” a National Institute of Allergy and Infectious Diseases grant was issued to sponsor, in support of MIM, the development of the Malaria Research and Reference Reagent Repository, a repository designed to improve access to reagents for the evaluation of parasites, vectors, and humans and to promote the standardization of assays with well-characterized and renewable reagents (Milhous et al., 2000; MIMCom, 2001). WRAIR’s Division of Experimental Therapeutics has been identified as the focal point for GEIS surveillance and detection of drug-resistant malaria (Milhous et al., 2000). As a partner in MIM, GEIS contributes funds in support of research projects at WRAIR and at the overseas laboratories (Milhous et al., 2000).
Surveillance for Viral Respiratory Pathogens and Causes of Severe Acute Febrile Illness in Uganda GEIS surveillance for viral respiratory pathogens and for severe acute febrile illnesses is planned in Uganda. As part of the viral respiratory pathogen surveillance study, individuals who present at the Rakai Project Clinic (Rakai District, Uganda) with fever will be sampled for influenza A and B viruses; parainfluenza virus types 1, 2, and 3; adenovirus; enterovirus; and herpes virus. Samples will be sent to Brooks Air Force Base for testing. This project is intended to improve influenza surveillance efforts in sub-Saharan Africa, an area largely undercovered in terms of international surveillance for influenza. Surveillance for severe acute febrile illnesses is to be conducted in Kalisizo Hospital (Rakai District, Uganda). Laboratory testing is to involve the efforts of an on-site project technician, U.S. Army Medical Research Unit, Kenya (USAMRU-K), and the WHO. Project reports are to be sent to the GEIS Central Hub and relevant collaborators. Though this work has been in development for some time, neither project has been implemented as both projects have yet to receive approval from appropriate governmental authorities (Pavlin, 2001b).
Miscellaneous Outbreaks and Projects The GEIS Central Hub maintains contingency funds to support emerging infectious disease response efforts, as needed, and to conduct surveillance projects that are time sensitive (i.e., that cannot wait for the next funding cycle).
For instance, in fiscal year 2000 one contingency activity included surveillance for West Nile virus. At the request of the CDC, the GEIS Central Hub coordinated the reporting of DoD human, bird, and mosquito surveillance data and represented the DoD in weekly conference calls with the CDC and state West Nile virus coordinators (GEIS, 2000b). As part of DoD activities for surveillance for West Nile virus, extensive mosquito surveillance was conducted by CHPPM along the East Coast, information on suspected human cases (none were confirmed) was supplied by Walter Reed Army Medical Center, the North Atlantic Veterinary Command coordinated the testing of birds (four birds were found to be positive for West Nile virus), and the Air Force reported extensive data obtained by the trapping of mosquitoes. Further DoD participation in the West Nile virus surveillance effort is contingent on national plans (GEIS, 2000b).
Also, through participation in military medical conferences, AFEB and IOM meetings, meetings of the Joint Preventive Medicine Policy Group and other staff meetings, and review of documents, GEIS attempts to identify emerging infectious disease problem areas, document these problems, develop an awareness regarding the problems, and develop and recommend solutions and foster the implementation and evaluation of interventions. Examples of this are the studies, publications, and presentations on acute respiratory diseases in the military that have been used to (1) inform the DoD, the military leadership, AFEB, and IOM; (2) to educate health care providers; and (3) to assist the U.S. Army Medical Research Acquisition Activity and the U.S. Army Medical Research and Materiel Command to develop requests for proposals for adenovirus vaccine development and means for evaluating the proposals (Gaydos, 2001e). Similarly, studies, publications, and presentations on STDs in the military have been used to inform the DoD, the military leadership, and AFEB and to educate health care providers (GEIS, 2000b; Gaydos, 2001e). GEIS has facilitated and fostered the development of an AFEB recommendation on screening for chlamydial infection, reports from the DoD STD Prevention Committee to the DoD medical and nonmedical leadership, the exchange of data and information on STDs among the services, and initiatives to improve STD programs for the Air Force and Coast Guard (Gaydos, 2001e).
GEIS Training and Development Activities
Training and Capacity Building
Overseas Medical Research Laboratory Orientation Training Program The Overseas Medical Research Laboratory Orientation Training Program has as its objectives “to expand the cadre of DoD personnel with an interest in pursuing a career in tropical public health surveillance and research with a particular focus on emerging infections” (Writer, 2001b). Trainees are selected from among those who are already on active duty with the DoD, who are interested in international infectious disease work, and who are willing to consider assignment at one of the overseas research laboratories. Interested individuals are encouraged to identify the location where they would like to work, the subject of their project, and the potential time that they are available. Selected individuals work with laboratory staff on research or public health projects that are being conducted by the laboratory (GEIS, 2000b). The first team was selected in late 1999, and by the end of fiscal year 2000 a total of 16 students had been funded for an average length of rotation of 39 days. Continued training cycles are planned in 2001 (Writer, 2001b).
Peruvian Laboratory-Based Public Health Surveillance Project Using humanitarian assistance funds from the U.S. Southern Command (SOUTHCOM), the GEIS Central Hub has provided computers (5 in the year 2000 and 15 to date, with additional donations planned) and software to the Peruvian Instituto Nacional de Salud (INS; Peruvian National Institutes of Health) to facilitate transmission of data between local, regional, and national facilities. The Central Hub has also provided training to INS personnel in the use of CDC’s Public Health Laboratory Information System. The goals of this effort are to assist the Peruvian national health system in developing a laboratory-based surveillance system and, ultimately, a locally sustainable electronic disease and syndromic surveillance system in Peru. Humanitarian assistance funds for this project are being contributed by SOUTHCOM (GEIS, 2000b; Writer, 2001a).
Caribbean Laboratory-Based Public Health Surveillance Project and U.S. Army Health Facilities Planning Agency Support to the Caribbean Epidemiology Center In 1996, WRAIR staff, dispatched to the Caribbean region at the request of the Atlantic Command, determined that the existing public health surveillance capacity was insufficient (Writer, 2001b). After the introduction of GEIS, the Caribbean Laboratory-Based Public Health Surveillance Project was developed to assist the Caribbean Epidemiology Center (CAREC; a center of the Pan American Health Organization’s Division of Disease Prevention and Control) in assem-
bling a computerized network to support disease surveillance and communication among CAREC’s 21 member nations (GEIS, 2000b, 2001b). GEIS, with SOUTHCOM and Atlantic Command funding, has provided computers, software, and training in basic computer use and surveillance systems (the CDC’s Public Health Laboratory Information System) in support of this effort to assemble an Internet-based regional computerized surveillance network. GEIS Central Hub staff have made repeated trips to the region to provide equipment and training. To date, 145 computers have been donated. In addition, as many as 250 public health workers from CAREC member countries have received basic instruction in computer use and surveillance systems and about 200 workers have received more advanced training (GEIS, 2000b). Currently, 24 sites in 10 countries are participating in the network, and the network continues to grow as individuals trained as a part of this project are now able to train others with minimal input from CAREC staff.
Also, at the request of the U.S. ambassador in Trinidad and Tobago, SOUTHCOM, GEIS, WRAIR, the U.S. Army Health Facilities Planning Agency, and CAREC worked together to assess current CAREC laboratory and administrative space to document structural and safety planning needs and to begin the design of a new 64,000-square-foot facility. The initial survey product has led the government of Trinidad and Tobago to commit $400,000 (U.S.) to begin detailed design (GEIS, 2000b).
Systems Research, Development, and Integration
In its 1997 report the Committee on International Science, Engineering, and Technology (CISET) Emerging Infectious Diseases Working Group acknowledged the creation of a DoD Internet-based Central Communications Hub (a GEIS website) as one of the early accomplishments of GEIS. The working group expressed expectations that the site would grow in time to include a private intranet chat line to link the overseas laboratories and a public site that would allow searching of several DoD databases and that would provide the groundwork for the automatic reporting of bacterial resistance patterns and certain reportable diseases (CISET, 1997).
GEIS views GEISWeb as part of its outreach program. It seeks to provide a “one-stop focal point” for the linking of information on infectious diseases from DoD and external parties, but it must do so within the constraints imposed by DoD security and privacy policies (Writer, 2001c). In particular, GEISWeb is designed to (Writer, 2001c):
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promote understanding of GEIS,
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generate an exchange of new ideas and best practices for countering emerging infections,
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provide resource information to health professionals,
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display information about emerging illnesses and broader programmatic issues,
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provide tools for outbreak investigations,
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provide information on training and conferences, and
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provide links to related sites.
The site was redesigned in fiscal year 2001 to improve its usability. GEIS is undertaking a market survey to better identify the needs of DoD and the public (GEIS, 2000b).
GEIS Program Management
In documents that set the stage for the development of GEIS, it was universally indicated that a central coordinating office for GEIS (a Central Hub) should be established at WRAIR (Bancroft and Schlagel, 1997; CISET, 1997; Zajtchuk, 1995). The Central Hub supports a staff of approximately 13 full- and part-time personnel, including a director and a deputy director and administrative, technical support, and scientific advisory personnel (GEIS, 2001c). The Central Hub is not, however, optimally staffed, according to planning documents (Bancroft and Schlagel, 1997; Cuddy, 1997; Martin, 1997a,b). GEIS has never received the full complement of staff that was intended.
The GEIS Central Hub has access to a flag-level3 advisory board (Lister, 1997). The GEIS Advisory Board is chaired by DoD (Health Affairs) with membership including the Army, Navy, and Air Force Deputy Surgeons General. Its purview is general oversight of GEIS to include adequacy of staffing, policy and program review, budgetary planning and decisions, and evaluation. Scientific advice is sought from the Armed Forces Epidemiology Board as the need arises. GEIS, through the Central Hub, reports to the Office of the Surgeon General of the U.S. Army (Martin, 1997c). GEIS has no direct command authority over members of its consortium. GEIS is in a period of transition in terms of its position within the organizational structure of the DoD. The IOM committee is aware of efforts to revise GEIS charter documents to improve its linkages within the DoD to position the program to better receive and provide scientific and management guidance (Kelley, 2001c).
The Central Hub’s primary role can generally be summarized as coordination and communication. The GEIS Central Hub has further specified description of its duties as follows (Kelley, 2001b):
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develop, coordinate, and monitor execution of strategic plan;
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review annual proposals for funding and prioritize support;
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coordinate distribution of funds;
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review and publish annual reports from GEIS-funded agencies;
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assist with obtaining supplementary resources;
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represent GEIS to higher headquarters and other federal, international, and local agencies;
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facilitate CINC-supported civic assistance projects;
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manage public and professional awareness initiatives; and
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foster solutions to emerging infections problems through sponsorship of professional forums.
The GEIS 5-year strategic plan, Addressing Emerging Infectious Disease Threats: A Strategic Plan for the Department of Defense, was published in 1998 (GEIS, 1998). The Central Hub also compiles, publishes, and distributes an annual report that documents program progress. Results of GEIS-supported studies are frequently published in the peer-reviewed literature, and select project updates, as well as information on the topic of emerging infections diseases, are posted on GEISWeb.
GEIS project review and the coordination of funding allocations are important tasks of the Central Hub. Such decisions are made by the GEIS director (who is a member of the U.S. Army) and staff (McCarthy, 1998, 1999a,b,c,d,e,f). Both MHS and overseas medical research laboratory activities are chosen for support and receive annual reviews based on the following criteria (GEIS, 2000b; Kelley, 2001b):
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potential to fill a critical gap in MHS public health programs,
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likelihood of triservice or service-wide benefits,
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facilitation of timely public health actions,
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responsiveness to critical operational theater needs,
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accessibility of the nonfiscal resources needed for execution,
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scientific quality,
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whether it is other than an existing core MHS public health program, and
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consistency with the GEIS 5-year strategic plan.
GEIS has also contributed to many professional symposia and professional forums, including the following (Kelley, 2001b):
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International Conference on Emerging Infectious Diseases (1998 and 2000)
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Military Public Health Laboratory Symposium and Workshop, September 21–23, 1999
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Conference and Workshop on Syndromic and Other Surveillance Methods for Emerging Infections, May 23–25, 2000
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Institute of Medicine Forum for Emerging Infectious Disease (ongoing)
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U.S. Medicine Institute-GEIS Forum on Vaccines (March 2001)
Through the Central Hub, GEIS is also represented on many committees, task forces, and related public health decision-making bodies. Among these are CISET, the Asia Pacific Economic Cooperation Office Industrial Science and Technology Working Group, the IOM Infectious Disease Forum, the CDC Overseas Infectious Disease Strategy Review Committee, International Conference on Emerging Infections Planning Committee, Federal Antibiotic Resistance Task Force, the Pan American Health Organization Emerging Infections Task Force, and the WHO Outbreak Response Network Committee (Kelley, 2001b). Additional ties are being pursued with many collaborative agencies. For instance, closer integration with the WHO is being sought through the assignment of a Navy preventive medicine physician to WHO headquarters in Geneva (Kelley, 2001b).
CONCLUSIONS
GEIS-supported activities within the MHS and the Central Hub constitute a collage of endeavors that, on balance, are consistent with GEIS goals.
Within the MHS and through the Central Hub, GEIS is supporting a number of infectious disease surveillance projects that have the potential to detect emerging infections. These projects encompass GEIS pillar targets, such as drug resistance (e.g., antimalarial drug resistance surveillance, antimicrobial resistance surveillance pilot project, GISP site development), acute febrile illnesses including malaria (e.g., febrile illness surveillance in the Republic of Korea and Uganda, and WRAIR and WHO antimalarial drug resistance surveillance), influenza and respiratory disease (e.g., NHRC triservice surveillance for viral respiratory pathogens, S. pyogenes, and antibiotic resistance among S. pneumoniae isolates, and the DoD Laboratory-Based Influenza Surveillance Program), and enteric pathogens.
In accordance with its capacity-building goals, GEIS supports the development and maintenance of laboratory capacity within the infrastructure of the MHS. Some of this support is direct (e.g., annual retainer paid directly to USAMRIID). Some capacity building occurs as a by-product of the conduct of GEIS projects. Supporting the development of DoD laboratory centers of excellence for target disease areas can help build capacity valuable to GEIS consortium members and the DoD more generally and
can help to encourage linkages within the GEIS consortium. AFIERA and the NHRC, designated centers for influenza and for respiratory disease excellence, respectively, possess laboratory capacity and expertise that have contributed notably to DoD (and U.S.) surveillance and response efforts. Development of additional DoD laboratory centers of excellence that address disease targets that are not well covered within the DoD, such as enteric pathogens, is also worthy of GEIS pursuit. Encouraging laboratories to obtain WHO collaborating center status can increase connections within the public health community by encouraging capacity building and recognition of that capacity.
GEIS has also done an astounding job of leveraging minimal resources to implement capacity-building projects in support of its public health partners overseas. Central Hub-managed efforts to provide training and communications and laboratory resources have been well received and are having tangible results (i.e., in the Caribbean and South America). The GEIS Central Hub has valuable expertise, resources, and linkages to bring to bear in these efforts. However, the committee notes that Central Hub and overseas laboratory capacity-building projects are often conducted separately, at times with little communication or coordination between them. For instance, at the time of subcommittee visits to overseas laboratories, Central Hub capacity-building efforts in Peru were not well coordinated with NMRCD, nor were Central Hub epidemiology training efforts in Kenya and infectious disease surveillance efforts in Uganda coordinated with USAMRU-K. Similarly, although GEIS-supported projects at the 18th MEDCOM in the Republic of Korea do receive some diagnostic support from AFRIMS, these projects are primarily coordinated with the Central Hub and not proximate overseas laboratories (AFRIMS and NAMRU-2). Lack of coordination risks duplication of efforts (e.g., the Central Hub and USAMRU-K have separate plans to implement epidemiology training programs for public health workers in Kenya) and detracts from the development of a cohesive, recognizable program whole.
GEIS, with its triservice focus and coordinating role, can contribute substantially to DoD training activities relevant to emerging infectious disease surveillance and response. The Central Hub-managed Overseas Medical Research Laboratory Orientation Training Program presents valuable opportunities for active-duty junior and midlevel physicians, USUHS students, and other such individuals to gain functional experience. Likewise, this program affords the DoD the opportunity to build an experienced staff base. This program is young, but already at least one individual has indicated that the opportunity to work briefly on a project overseas has solidified his interest in making a long-term commitment to working in an overseas laboratory (Writer, 2001b).
The Overseas Medical Research Laboratory Orientation Training Pro-
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-
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
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-
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
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
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 |
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 |
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
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
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