Executive Summary

In the years following World War II, the successful development and use of vaccines and antibiotics led to speculation that infectious diseases were vanquished foes. Defying these predictions, infectious diseases continue to be a leading cause of morbidity and mortality globally. In the 1980s, recognition of the devastating global epidemic of human immunodeficiency virus infection/AIDS focused the attention of the public and the public health community on the issue of emerging infectious diseases. Between 1987 and 1992, the Institute of Medicine (IOM) released three reports collectively urging improvements in the public health infrastructure in place nationally and internationally to address infectious diseases. The 1992 report, Emerging Infections: Microbial Threats to Health in the United States (IOM, 1992), was particularly instrumental in focusing attention on the threat of infectious disease emergence.

These concerns spurred a number of national and international initiatives, including the development of a Centers for Disease Control and Prevention (CDC) strategic plan for addressing emerging infectious diseases, a World Health Organization (WHO) resolution calling for strengthened infectious disease surveillance and response capabilities, and a formative National Science and Technology Council (NSTC) report. In 1996, the Executive Office of the President issued Presidential Decision Directive NSTC-7 (NSTC, 1996), which declared that national and international capabilities for infectious disease surveillance, prevention, and response were inadequate to protect the health of U.S. citizens from emerging infectious diseases and which called for a more robust national policy to improve these capabilities. NSTC-7 directed many U.S. federal agencies



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Executive Summary In the years following World War II, the successful development and use of vaccines and antibiotics led to speculation that infectious diseases were vanquished foes. Defying these predictions, infectious diseases continue to be a leading cause of morbidity and mortality globally. In the 1980s, recognition of the devastating global epidemic of human immunodeficiency virus infection/AIDS focused the attention of the public and the public health community on the issue of emerging infectious diseases. Between 1987 and 1992, the Institute of Medicine (IOM) released three reports collectively urging improvements in the public health infrastructure in place nationally and internationally to address infectious diseases. The 1992 report, Emerging Infections: Microbial Threats to Health in the United States (IOM, 1992), was particularly instrumental in focusing attention on the threat of infectious disease emergence. These concerns spurred a number of national and international initiatives, including the development of a Centers for Disease Control and Prevention (CDC) strategic plan for addressing emerging infectious diseases, a World Health Organization (WHO) resolution calling for strengthened infectious disease surveillance and response capabilities, and a formative National Science and Technology Council (NSTC) report. In 1996, the Executive Office of the President issued Presidential Decision Directive NSTC-7 (NSTC, 1996), which declared that national and international capabilities for infectious disease surveillance, prevention, and response were inadequate to protect the health of U.S. citizens from emerging infectious diseases and which called for a more robust national policy to improve these capabilities. NSTC-7 directed many U.S. federal agencies

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review to take action and provided the following direction to the U.S. Department of Defense (DoD) (NSTC, 1996, pp. 4–5): The mission of the DoD will be expanded to include support of global surveillance, training, research, and response to emerging infectious disease threats. DoD will strengthen its global disease reduction efforts through: centralized coordination, improved preventive health programs and epidemiologic capabilities; and enhanced involvement with military treatment facilities and overseas laboratories. DoD will ensure the availability of diagnostic capabilities at its three domestic and six1 overseas laboratories, using existing DoD resources. DoD will make available its overseas laboratory facilities, as appropriate, to serve as focal points for the training of foreign technicians and epidemiologists. If necessary, DoD will seek Chief of Mission concurrence to raise personnel ceilings at overseas laboratories, in accordance with NSDD [National Security Decision Directive]-38 procedures. Since NSTC-7 was issued, U.S. agencies and international partners have taken many steps to achieve the goals of the directive and, more generally, to address global emerging infectious disease priorities. The DoD Global Emerging Infections Surveillance and Response System (GEIS) embodies the DoD’s response to Presidential Decision Directive NSTC-7. GEIS was established in 1997 by the assistant secretary of defense for health affairs, in response to NSTC-7, to serve as the focal point for DoD efforts to address emerging infectious diseases. In fiscal year 2001, funding for GEIS is expected to total approximately $8 million.2 GEIS’s annual budget is projected to increase over the next several years—to $9 million in fiscal year 2002, $10 million in 2004, and $11 million in 2005 (Kelley, 2000a). GEIS is a triservice program, and its activities are implemented within all three branches (Army, Navy,3 and Air Force) of the armed forces, although GEIS has no direct command authority over the facilities that implement its activities. GEIS operates predominantly within the five currently operating Army and Navy overseas medical research laboratories and the infrastructure of the military health system (MHS). GEIS is managed by a Central Hub office located at the Walter Reed Army Institute of Research. The MHS4 network of clinical and laboratory resources 1   At the time that NSTC-7 was issued, the DoD operated six medical research laboratories overseas. In 1999, one laboratory (in Brazil) closed. At the time of this review, five DoD medical research laboratories are operating overseas. 2   Excludes salaries for uniformed services personnel. 3   Medical support for and public health surveillance of Marine Corps personnel are provided by the Navy. 4   For the sake of brevity, the committee uses the term “military health system,” as does GEIS, to describe the clinical, nonclinical/research based (excluding the overseas laborato-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review provides infrastructure important for GEIS. Within the MHS, the emphasis of GEIS is on the strengthening of laboratory-based surveillance, particularly for influenza and other respiratory illnesses, for reportable illnesses, for changes in antibiotic resistance patterns, and for other evidence of emerging infections. DoD overseas laboratories provide forward sites for GEIS activities. At overseas laboratories, GEIS’s focus is primarily on sentinel surveillance of indigenous and expatriate populations for specific infectious disease target areas, or “pillars,” specifically: influenza, drug-resistant enteric organisms, drug-resistant malaria, and febrile illnesses, including dengue. THE STUDY The committee that prepared this report, the Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System, was convened at the request of GEIS management to evaluate the progress of the nascent GEIS. This committee’s task was defined as follows: The committee will assess the extent to which the strategic plans of the five Department of Defense Global Emerging Infections System laboratories appropriately address the surveillance needs for the identification and tracking of emerging infectious disease in their respective locations. Specific questions to be addressed by the committee are: How well does each plan meet the minimal infectious disease surveillance requirements as prescribed in Presidential Decision Directive NSTC-7 and the DoD Strategic Plan? How well do the laboratory programs agree with the approach to emerging infection surveillance espoused in the IOM report on emerging infections and the Centers for Disease Control and Prevention (CDC) national strategic plan? How well do the laboratories meet the World Health Organization and/or CDC standards for evaluating surveillance systems making reasonable allowances for 1) the need to balance the interests of the host country against those of DoD and the U.S., and 2) the varying governmental infrastructures in the different countries?     ries), and field/deployable laboratories, as well as the military treatment facilities, which are a part of the military health system and within which GEIS is implemented. The com-mittee recognizes that this distinction is somewhat simplistic, but considers it is a necessary distinction to make in discussing spheres of GEIS operation.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review How well does each strategic plan respond to the particular infectious disease surveillance challenges and the cultural dictates extant in the region in which it is to be implemented? How well are the laboratories working on the other goals of GEIS (response, training and capacity building, and research) in support of their surveillance activities? The committee will also assess: How well are GEIS program goals, objectives, and activities being carried out domestically; namely, within the military health system (MHS) and the GEIS Central Hub? The committee’s charge left room for interpretation regarding a number of its tasks. In particular, the committee interpreted its charge as intending review of all information available, including, but not limited to, overseas laboratory strategic planning documents. Also, the committee focused its review on the development of conclusions and recommendations with long-term, program-level relevance rather than on evaluating specific GEIS projects. The committee used WHO and CDC guidelines as reference tools in conducting this review. Discussion of the committee’s approach to addressing its charge and additional background information regarding GEIS are presented in detail in Chapter 1, this report’s introduction. As part of this review, members of the committee visited Naval Medical Research Center Detachment, Peru; Naval Medical Research Unit 2, Indonesia; the Armed Forces Research Institute of Medical Sciences, Thailand; Naval Medical Research Unit 3, Egypt; the U.S. Army Medical Research Unit, Kenya; the Naval Health Research Center,5 San Diego, California; and the U.S. Army Medical Research Institute of Infectious Diseases, Washington, D.C. It was not practical to visit all MHS sites that host GEIS-funded projects. Instead, the committee relied heavily on written documents and on summary presentations from and discussions with DoD personnel and collaborators to gain an understanding of GEIS efforts within the MHS and the Central Hub. Chapters 2 through 7 of this report present the committee’s assessments of GEIS implementation at overseas laboratories, at sites within the infrastructure of the MHS, and through the GEIS Central Hub. Each chapter contains distinct conclusions and recommendations. Chapter 8 of this 5   During this trip, the committee also visited Navy Environmental and Preventive Medicine Unit 5 and the U.S. Naval Hospital, San Diego.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review report presents summary conclusions and recommendations regarding GEIS as a whole. These summary recommendations are excerpted and presented here, in the Executive Summary, as well. The boxes at the end of this chapter provide, in brief, recommendations regarding the implementation of GEIS at the overseas laboratories, within the infrastructure of the MHS, and through the Central Hub. The recommendations that are presented in boxes in this chapter are discussed in greater detail elsewhere in this report (Chapters 2 through 7). Recommendations by their very nature focus on areas of program implementation where there exists room for improvement. For a more complete picture of GEIS and its component DoD partners—members of the “GEIS consortium”—readers are encouraged to refer to Chapters 1 through 8 of this report. SUMMARY CONCLUSION6 GEIS is an appropriate DoD response to Presidential Decision Directive NSTC-7 and to the threat posed to national security by emerging infectious diseases. The goals of GEIS are in U.S. military, U.S. civilian, and global health interests. GEIS, still in the early stages of development, has made substantial progress toward achieving its goals. With increased support, and some refinements, the program has the potential to meet and exceed the expectations of Presidential Decision Directive NSTC-7. SUMMARY RECOMMENDATIONS7 • GEIS is a critical and unique resource for the United States in the context of global affairs. It is the only U.S. entity that is devoted to infectious diseases globally and that has broad-based laboratory capacities in overseas settings. GEIS goals, as outlined in its strategic plan, Addressing Emerging Infectious Disease Threats: A Strategic Plan for the Department of Defense (GEIS, 1998), address the areas of mission expansion that NSTC-7 mandates (NSTC, 1996). GEIS has the potential to meet and even exceed the expectations of Presidential Decision Directive NSTC-7 in its implementation. To date, significant progress has been made toward meeting the goals of the program. The committee notes that investment in GEIS is small compared to the challenge of emerging infectious diseases. Consideration should be given to increasing DoD investment in GEIS to a level at which GEIS can have a more substantial impact internationally. The GEIS budget is quite small compared to the budgets of those agencies and programs with which GEIS seeks to partner. 6   Summary conclusions are presented in greater detail in Chapter 8. 7   Summary recommendations in this section are explained in greater detail in Chapter 8.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review It is important, however, to keep in mind that GEIS was created by appending programmatic requirements onto existing DoD bases of operation. The continued success of GEIS is predicated on the availability of resources, through GEIS and others, sufficient to support the facilities that host GEIS and on the ability of those facilities to balance the demands of multiple stakeholders. Research and public health surveillance missions are of critical importance to the DoD and are essential to national security. Emerging infectious disease surveillance is an important part of DoD capacity to assess potential threats to the health of U.S. forces. Research and public health surveillance missions can be balanced so that they are mutually beneficial. GEIS would also benefit from the expansion of the DoD facilities available to support it. Increased capacity within existing facilities and creation of additional laboratories in areas of high biodiversity and in other regions of the world where there is strong potential for infectious diseases to emerge would benefit GEIS surveillance efforts. The committee recognizes that to respond to the recommendations in this report and to fulfill the mission of the GEIS program, a considerable increase in funding and personnel resources will be required. Recommendation: Support for GEIS and the facilities that sustain it should be increased to allow GEIS to completely fulfill its potential. • If GEIS is to be of optimal benefit, its mission will need to be fully understood, accepted, and balanced against the needs and resources of other DoD laboratory stakeholders. To work in tandem with others, GEIS must function smoothly as a program. If GEIS is to work as a cohesive program, it is important that its activities be well coordinated within each laboratory, between laboratories, and with the Central Hub. At some facilities that are part of GEIS, a dedicated program manager has been designated to coordinate projects. This is a valuable approach and one that needs to be duplicated at all facilities to the extent possible. GEIS program managers need to possess expertise and experience in applied epidemiology and public health practice. Recommendation: The implementation of GEIS at all five overseas research laboratories and within the MHS service hubs should be coordinated by dedicated, on-site GEIS program managers who possess expertise and experience in applied epidemiology and the practice of public health. • Many of the facilities that are implementing GEIS projects lack an adequate number of staff possessing sufficient epidemiological expertise. As a result, some activities observed by the committee reflected incomplete incorporation of public health surveillance concepts. Infusion of

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review epidemiological input can help ensure that GEIS concepts are clearly understood and that surveillance objectives are fully realized. The presence of a dedicated, on-site GEIS program manager who is well versed in public health and applied epidemiology is important, as mentioned above. Additional epidemiological input, on site and through the Central Hub, is also desirable. Recommendation: GEIS should take steps to increase the number of personnel possessing applied epidemiological expertise available on site at laboratory facilities and within the Central Hub. • Current GEIS infectious disease-related training efforts (e.g., the Overseas Medical Research Laboratory Orientation Training Program) are laudable, but they are modest relative to the needs of the DoD and its public health partners and to the potential contributions of GEIS. Training professionals (including foreign national public health workers and DoD personnel) to understand, monitor, control, and prevent emerging infections is an important goal of GEIS. Providing training opportunities for U.S. civilian scientists may also prove to be a valuable use of GEIS resources. Additional investments could be made to bolster existing GEIS training activities and to develop additional, structured training programs. Training needs to be coordinated among GEIS consortium members and needs to be conducted in collaboration with public health partners (e.g., other DoD entities, the CDC, governments that host overseas laboratories, international organizations [such as the WHO], academic institutions, the Training in Epidemiology and Public Health Intervention Network [TEPHINET], and others). Recommendation: GEIS’s level of involvement in the training of DoD personnel, foreign national public health workers, and others should be increased. • Training is an extremely important but time-consuming GEIS goal. Current laboratory training activities appear to be largely project specific and do not appear to be closely coordinated within or between laboratories. Additional staffing is needed to effectively coordinate the training needs of DoD personnel, foreign national public health workers, and others. Recommendation: Facilities that support GEIS and that implement training programs should be staffed to accommodate their training needs. • Collaboration is necessary to ensure that GEIS activities succeed, and complement and support other efforts. GEIS is actively fostering collaboration and coordination with international partners and governmental agencies in partner countries. GEIS is also taking important steps to

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review strengthen collaborations with U.S. partner agencies, but more needs to be done to formalize these partnerships. New partnerships and means of expanding and strengthening existing partnerships can be pursued even more actively. In particular, relationships with other U.S. agencies, such as the U.S. Agency for International Development (USAID) and the CDC, need to be expanded and more closely coordinated to encourage joint planning and shared project implementation with these agencies. GEIS needs to have an identity within the global public health community such that when new initiatives related to global infectious disease surveillance and response activities are being considered by governmental and nongovernmental agencies, the potential usefulness of GEIS is considered by outside partners. The committee notes that hiring foreign nationals to fill senior positions at overseas laboratories can benefit GEIS integration with host-country and international partners. The committee encourages the hiring of additional foreign service national personnel into senior-level positions where possible. Similarly, personnel assigned to the DoD from U.S. partner agencies, such as the CDC, the National Institutes of Health, universities, and state public health agencies, can help meet staffing needs while increasing DoD ties with those agencies. The committee endorses such arrangements and encourages GEIS to actively pursue them as a means of meeting DoD staffing needs. Recommendation: Pursuit of collaborative, well-coordinated relationships with international organizations, U.S. government agencies (including other DoD entities), and relevant agencies of foreign governments should be continued and expanded to the extent possible. As part of these collaborations, GEIS should encourage arrangements for the sharing of staff between U.S. and international partner agencies and DoD laboratory facilities. • It is important that mechanisms for rapidly communicating data and other information to public health partners positioned to take action in response to an infectious disease threat be clearly identified and used. Some DoD laboratories have evolved successful communications strategies, but these mechanisms do not appear to have developed as part of a cohesive GEIS plan. Recommendation: In consultation with the GEIS Central Hub and collaborators, GEIS sites should prepare and act on information dissemination plans that provide for the translation of information into timely public health action. • Centralized data collection and analysis (as appropriate) and routine reporting of GEIS data and other information are also needed. Current methods of disseminating GEIS information are important but are

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review insufficient. Tools such as the GEIS website (GEISWeb) and the DoD Directory of Public Health Laboratory Services can be very useful communication resources. Production of a periodic GEIS-wide publication that synthesizes GEIS information (e.g., surveillance data, progress reports, and updates on new capabilities and accomplishments) may also be appropriate. Recommendation: Communication of surveillance and other information within the GEIS consortium, within the DoD, to public health partners, and to the public should be improved. • Many of the innovative systems and techniques that GEIS is developing or encouraging, such as the DoD Directory of Public Health Laboratory Services, the Early Warning Outbreak Response System, the Electronic Surveillance System for the Early Notification of Community-Based Epidemics, and numerous others, show great promise. It is important, however, that the need for new systems and techniques be thoroughly evaluated and that plans for system development and use be clearly defined (including identification of product developers with extensive relevant expertise and experience) before projects are undertaken. Prototype systems and techniques should also be systematically evaluated before they are put to widespread use. These steps are needed to ensure that new systems and techniques contribute optimally to GEIS, to the DoD, and to global emerging infectious disease surveillance efforts. Recommendation: Novel surveillance systems and techniques, though potentially an important part of GEIS, should be thoroughly evaluated and plans for their development and use should be clearly defined before substantial GEIS investments in their implementation are made. • Periodic external review can help to determine whether the goals of GEIS are being addressed and whether those goals remain appropriate. Recommendation: GEIS as a whole should be subject to periodic external review (every few years) to ensure that it remains focused on its goals and that its goals remain appropriate. • Apart from this formal, periodic program review process, it is also essential that GEIS management (i.e., the Central Hub) has available to it clear, consistent means of routinely receiving authoritative and timely management guidance from appropriate DoD authorities as well as a means of providing feedback to appropriate DoD authorities. It is also important that there be in place within the DoD command structure clear, consistent channels through which GEIS information can be reported to achieve timely action.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Recommendation: Clear, consistent mechanisms for providing guidance to GEIS management and channels for the reporting of GEIS information within the DoD infrastructure should be in place. • 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. To ensure that project guidance is acted upon, GEIS management must be positioned so that it has the authority, as well as the responsibility, to affect GEIS project implementation. Recommendation: GEIS management authority should be commensurate with GEIS management responsibility if program objectives are to be effectively and efficiently met. • GEIS would benefit from a broader, more standardized project review process (to include use of structured proposal guidelines and timelines). Reviews need to incorporate input from various interested parties, such as partner agencies, overseas and MHS laboratory personnel, and other DoD representatives (e.g., Military Infectious Disease Research Program staff), as well as Central Hub staff. It may be useful to lengthen the project approval and funding cycle to allow projects to mature and to allow improved planning of new projects between reviews. Recommendation: Consideration should be given to revising the GEIS project review and approval process so that review and approval of GEIS projects is part of a more formally structured process—based on a set of guidelines and timelines that are clearly understood by GEIS consortium members—that includes input from individuals who represent various disciplines and interests. • Apart from the formal project review and approval process, Central Hub senior management staff need to make additional periodic visits to the respective laboratory facilities to provide project guidance and to assess needs for assistance and opportunities for collaboration. Increased guidance from the Central Hub may help to compensate for staffing deficiencies and can foster improved coordination of GEIS projects. Recommendation: Staffing levels permitting, overseas and MHS-based GEIS activities should receive additional periodic assessment and guidance from the GEIS Central Hub.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review BOX 1-A Recommendations That Are Repeated in Each Overseas Laboratory Evaluation DoD commitment to GEIS at overseas laboratories should be long term. Consideration should be given to refining the focus of GEIS at the overseas laboratories to better enable diseases outside of the pillar areas to be addressed. Consideration should be given to revising the current GEIS project application and review process. Senior staff at overseas laboratories actively involved in GEIS projects should be conversant in the dominant language of the host country or should pursue, with the support of GEIS, language training, and should seek to become conversant to the extent possible.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review BOX 1-B Chapter 2 Naval Medical Research Center Detachment, Peru (NMRCD) Full-time staff members should be assigned to NMRCD to meet staffing needs in the following areas: GEIS program management. The GEIS program manager should not have simultaneous responsibility for departmental management and administering overall NMRCD GEIS activities. The GEIS program manager should be full-time and on-site, and should possess, at a minimum, applied epidemiology and public health experience. Support for training activities. The coordination of training activities is an important but time-intensive GEIS task. This task should not be consigned to NMRCD department heads as a secondary responsibility. Epidemiology. Additional epidemiological support (including, but not necessarily limited to, a dedicated GEIS program manager) should be provided to help facilitate public health-oriented data analysis and study design and to provide a permanent link between NMRCD and the Oficina General de Epidemiologia (OGE) national surveillance system, as well as other public health partners. Administrative support. Extensive administrative requirements can impede the work of a scientific staff that is already stretched thin. Additional administrative (nonclerical) support should be provided so that NMRCD scientists can devote their talents to GEIS studies under way. DoD and Peruvian training needs should be assessed formally, and the development of a structured NMRCD-hosted training program should be considered. As GEIS project data are accumulated, they should be better used to supplement the OGE national surveillance system, provide early warnings of epidemics, and help guide public health responses. NMRCD should take continued steps to maintain and enhance the multiple national and international partnerships that are necessary to fulfill the GEIS mission and to build national capacity in Peru.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review BOX 1-C Chapter 3 Naval Medical Research Unit 2, Indonesia (NAMRU-2) The development of a structured NAMRU-2-hosted training program should be pursued. As GEIS project data are accumulated, they should continue to be used to supplement the national surveillance system and should be better used to help guide public health response through improved sharing of information with international partners, such as the WHO and USAID. NAMRU-2 should take continued steps to maintain and enhance the multiple national and international partnerships that are necessary to fulfill the GEIS mission and build national capacity in Indonesia. NAMRU-2 should continue to support the development of the field laboratory in Cambodia. The Early Warning Outbreak Response System should be evaluated for its capacity to serve as an early-warning system for the detection and investigation of epidemics and for the identification of new and novel pathogens before major investments in expanding the system are made. BOX 1-D Chapter 4 Armed Forces Research Institute of Medical Sciences, Thailand (AFRIMS) As GEIS project data are accumulated, they should be better used to supplement national and regional surveillance systems and to help guide public health responses through improved reporting to authorities in the host country. AFRIMS should continue to take steps to maintain and enhance the multiple national and international partnerships that are necessary to fulfill the GEIS mission. AFRIMS GEIS efforts should be coordinated with the efforts of other DoD facilities (i.e., laboratories, the GEIS Central Hub, and other GEIS partners) that host GEIS projects in the region. To fully realize GEIS objectives, AFRIMS should have a full-time, on-site GEIS program manager who possesses expertise in applied epidemiology and public health. Influenza surveillance efforts should be coordinated with the Thai WHO collaborating laboratory. The development of a structured AFRIMS-hosted training program should be considered.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review BOX 1-E Chapter 5 Naval Medical Research Unit 3, Egypt (NAMRU-3) Additional applied epidemiological input should be provided to guide the development and conduct of NAMRU-3 GEIS projects to fully realize program goals. Consideration should be given to obtaining a full-time, on-site manager possessing experience in applied epidemiology and public health for the GEIS program at NAMRU-3, or to providing more epidemiological and technical oversight responsibility to the manager of the Disease Surveillance Program, as the current NAMRU-3 organizational structure does not allow the Disease Surveillance Program to maximize collaboration and coordination of GEIS activities across the Research Sciences Department. NAMRU-3 should ensure the long-term presence of foreign service national personnel to maximize the continuity of individual GEIS projects and provide the institutional memory and cultural sensitivity necessary for success of GEIS. NAMRU-3, in coordination with the GEIS Central Hub, should expand partnerships with and continue to raise funds through (as applicable) sources such as USAID (country offices and its Global Bureau), the CDC (including FETP), the WHO, and other relevant agencies to the full extent possible to enhance in-country surveillance and response capacities. NAMRU-3 should continue to support the Egyptian Ministry of Health and Population (MOHP) in gradually strengthening the MOHP’s own capacity for surveillance across Egypt, with a particular focus on laboratory diagnostic capabilities. This support should also be extended to other countries of the region, resources permitting. A comprehensive NAMRU-3 information plan that outlines the needs and mechanisms for the reporting of information to partners in public health activities and to the GEIS Central Hub should be developed and acted upon. NAMRU-3 should actively pursue with its in-country partners resolution of issues regarding ownership of surveillance data and issues regarding the clearance of data for dissemination.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review BOX 1-F Chapter 6 U.S. Army Medical Research Unit, Kenya (USAMRU-K) Current GEIS surveillance projects and activities should be continued, as they represent activities in support of the GEIS mission. Expansion of the reach of GEIS activities should be considered. USAMRU-K and the GEIS Central Hub should facilitate the acquisition of reagents for the diagnosis of Ebola, Marburg, Crimean-Congo, and Lassa hemorrhagic fevers (and other infectious disease entities, as applicable) to the extent possible. Additional GEIS investment in improving USAMRU-K’s laboratory capacity is needed and should be pursued, within program limits. USAMRU-K should have a full-time GEIS program manager on site. The designated program manager should have training and expertise in applied epidemiology and public health. The assignment of a CDC epidemiologist to USAMRU-K, the assignment of a military public health physician with epidemiological experience, or the assignment of a civilian medical epidemiologist with public health experience should be pursued. To fully realize the GEIS surveillance mission, there should be strong epidemiological input in USAMRU-K GEIS development and management. USAMRU-K should explore the possibility of supplementing its military scientific staff with Kenyan nationals possessing comparable expertise to ensure continuity of projects, to expand expertise, and to foster collaborative relationships and project growth in important areas of public health surveillance. The availability of staff with virological expertise within USAMRU-K would assist in the achievement of GEIS’s goals and should be considered. Collaborative relationships should continue to be forged and fostered to ensure that USAMRU-K is involved as a full partner in infectious disease surveillance and response activities. DoD and Kenyan training needs should be assessed formally, and the development of a structured USAMRU-K-hosted training program should be considered. In consultation with the GEIS Central Hub and public health partners, USAMRU-K should develop and implement a system for the dissemination of public health data in a routine and timely manner to ensure public health action. Steps should be taken to link GEIS projects together as part of an integrated USAMRU-K GEIS effort. Expansion and refined application of communications technologies should be pursued by USAMRU-K with GEIS support. Effort should be directed to enhancement of the public health application of current geographic information system work (carried out in collaboration with the International Livestock Research Institute) so that such efforts can better result in information for action.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review BOX-2 Chapter 7 GEIS Central Hub and Military Health System Activities Staffing within the Central Hub should be increased so that its communication and coordination responsibilities can be optimally addressed. The Central Hub should have available to it improved means of obtaining more and more frequent management guidance. The Central Hub should be given more management authority so that it can successfully meet its objectives. 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. 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 development of new systems resources is an important goal of GEIS, but the needs and specifications for innovative surveillance systems and techniques should be clearly defined before they are undertaken, and caution should be used when implementing unproven systems and techniques on a large scale. Central Hub-managed international capacity-building projects should be better coordinated with DoD laboratory facilities overseas and within the MHS, as appropriate. Central Hub involvement in coordinating and supporting training activities relevant to emerging infectious disease surveillance and response should be increased.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 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. Given personnel and other resource shortages, Central Hub conduct of surveillance projects is undesirable and should be minimized and avoided to the extent possible. Improved means of centrally collecting, analyzing (as appropriate), and distributing surveillance data and other information in a timely manner need to be developed and implemented.

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