8
Summary Conclusions and Recommendations

SUMMARY CONCLUSIONS

GEIS in Concept

The development of the Global Emerging Infections Surveillance and Response System (GEIS) is, conceptually, an appropriate U.S. Department of Defense (DoD) response to Presidential Decision Directive NSTC-7 (NSTC, 1996) and to the concerns and recommendations expressed in the 1992 Institute of Medicine (IOM) report Emerging Infections: Microbial Threats to Health in the United States.

GEIS goals, as outlined in the GEIS strategic plan, address the areas of mission expansion that NSTC-7 mandates. GEIS provides a means of coordinating DoD efforts to address “global surveillance, training, research, and response to emerging infectious disease threats” (NSTC, 1996, p. 4), as directed. GEIS also possesses the components necessary to be consistent with IOM guidance regarding the essential elements of an effective global surveillance network, including the following (IOM, 1992, p. 6):

  1. a mechanism for detecting (using clinical presentation as the criterion) clusters of new or unusual diseases or syndromes;

  2. laboratories capable of identifying and characterizing infectious agents;

  3. an information system to analyze reportable occurrences and disseminate summary data; and



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 8 Summary Conclusions and Recommendations SUMMARY CONCLUSIONS GEIS in Concept The development of the Global Emerging Infections Surveillance and Response System (GEIS) is, conceptually, an appropriate U.S. Department of Defense (DoD) response to Presidential Decision Directive NSTC-7 (NSTC, 1996) and to the concerns and recommendations expressed in the 1992 Institute of Medicine (IOM) report Emerging Infections: Microbial Threats to Health in the United States. GEIS goals, as outlined in the GEIS strategic plan, address the areas of mission expansion that NSTC-7 mandates. GEIS provides a means of coordinating DoD efforts to address “global surveillance, training, research, and response to emerging infectious disease threats” (NSTC, 1996, p. 4), as directed. GEIS also possesses the components necessary to be consistent with IOM guidance regarding the essential elements of an effective global surveillance network, including the following (IOM, 1992, p. 6): a mechanism for detecting (using clinical presentation as the criterion) clusters of new or unusual diseases or syndromes; laboratories capable of identifying and characterizing infectious agents; an information system to analyze reportable occurrences and disseminate summary data; and

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review a response mechanism to provide feedback to reporting agencies and individuals and, if necessary, to mobilize investigative and control efforts of local and international agencies. Overseas laboratories, the military health system (MHS) infrastructure, and the GEIS Central Hub provide the basic framework necessary for GEIS to conform to this ideal type. Because GEIS supports activities at DoD overseas laboratories, it is also, in a sense, responsive to IOM recommendations calling for sustained support of these resources (IOM, 1992). GEIS in Context Within the DoD GEIS is a new mission that has been added to operations carried out at existing DoD facilities within the United States and abroad. GEIS does not and cannot sustain these facilities alone. The success of GEIS is predicated on the availability of resources at overseas research laboratories and supporting MHS capabilities sufficient to maintain an appropriate base for GEIS operations. DoD laboratory resources, particularly overseas medical research laboratories, have been and continue to be imperiled. In 1992, the IOM noted that (IOM, 1992, p. 149): The [Committee on Emerging Microbial Threats to Health] is concerned that some of these [DoD overseas medical research] laboratories have been closed in the past, for reasons related both to insufficient funding and changes in mission priorities, and that further closings could jeopardize the United States’ ability to detect and respond to emerging infectious disease threats. A new DoD research facility, the ninth largest biomedical research facility in the country, was recently completed in Maryland (Walter Reed Army Institute of Research, 1998). The facility houses Army and Navy medical research and development command headquarters, as well as the GEIS Central Hub. This facility is an outstanding resource domestically. It reflects an important investment in DoD laboratory infrastructure. Other DoD laboratories are also in need of revitalization. GEIS would benefit from increased capacity within existing laboratories and the introduction of additional DoD laboratories overseas, particularly in areas of high biodiversity and other locations where the potential for the emergence of infectious diseases is high. At a minimum, it is important to GEIS that existing laboratory facilities be maintained. At the time of preparation of the 1992 IOM report, seven overseas laboratories were in existence (IOM, 1992). By the time that Presidential Decision Directive NSTC-7 was released in 1996, there were six laborato-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review ries. At the time of this review, five overseas laboratories remain. Domestic capabilities have also been curtailed through the closure of the Letterman Army Institute of Research (GEIS, 1998). This is a discouraging trend that does not favor the success of GEIS. Loss of laboratory infrastructure, particularly overseas, limits the DoD’s global emerging infectious disease surveillance and response capacity and, accordingly, GEIS prospects. At some DoD laboratories, in the United States and overseas, the committee noted a lack of full integration between DoD research and infectious disease surveillance priorities. Establishing GEIS within the existing framework of the DoD laboratories can benefit the research and infectious disease surveillance missions of the DoD, respectively. GEIS can benefit from the scientific and technical facilities, staff expertise, established research efforts, and working relationships already in existence. In return, GEIS can strengthen and build partnerships and can provide surveillance information useful in guiding the development of future research projects, maximizing benefits to the U.S. military. Finding a balance between these missions is important to the success of both. Each mission is critically important and is essential to national security. The observed discontinuity benefits neither and harms both. 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. GEIS is not optimally positioned to receive or provide direction, which weakens its effectiveness overall. Clear and consistent channels for reporting GEIS information to higher command authorities are also not sufficiently defined. It is important that GEIS management authority is commensurate with GEIS management responsibility if the information that GEIS generates is to result in timely action. National Partners The DoD is one of several U.S. government agencies that have a significant interest in, and responsibility for, addressing emerging infectious diseases. Each agency brings to the table important resources and certain limitations, and each fills a particular niche. The DoD, for its part, possesses unique laboratory capabilities, many situated in diverse forward locations, and has a vested interest in addressing emerging infectious diseases as a matter of national security (NIC, 2000). The relationship between the Centers for Disease Control and Prevention (CDC) and the DoD is an important one and warrants particular attention. The DoD and the CDC have, in the past, provided each other with backup support and entered into collaborative relationships on an as-needed basis. Recent changes in the missions of both the CDC and the DoD are bringing their respective program interests and spheres of operation into increasingly close contact. Through GEIS, the DoD has ex-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review panded its role overseas to include emerging infectious disease surveillance, response, and training and capacity building (GEIS, 1998). Conversely, the CDC has recently developed a global infectious disease strategy that formalizes CDC interests and operations in emerging infectious diseases internationally and increases its research presence (Dowell, 2001). The committee is aware that the CDC plans to locate its first international surveillance program in Thailand and is considering the development of a site in Kenya as well. GEIS is active in both Thailand and Kenya. The CDC’s new global strategy for addressing emerging infectious diseases identifies six priority areas: international outbreak assistance, support of a global approach to disease surveillance, applied research on diseases of global importance, application of proven public health tools, and public health training and capacity building (Dowell, 2001). CDC and DoD GEIS strategies for addressing emerging infectious diseases reflect very similar goals, related infectious disease target areas, and overlapping arenas of operation. As these activites evolve, collaboration between the CDC and the DoD—at the management level, as well as in the field—will be of utmost importance if both are to make efficient and effective use of limited resources. International Partnerships Addressing emerging infectious diseases is an issue of global importance and shared responsibility. The GEIS strategic plan (GEIS, 1998) calls for collaboration with other international partners, such as the World Health Organization (WHO), and governmental agencies in foreign countries, such as ministries of health. The WHO, in particular, is the focal point for communicable disease control efforts worldwide, and it recognizes the need for “collaboration between WHO and all potential technical partners in the area of epidemic alert and response, including relevant public sectors, intergovernmental organizations, nongovernmental organizations, and the private sector” (WHO, 2001a, p. 1). The DoD, specifically GEIS, is considered to be such a partner (WHO, 1998). Many, but not all, members of the GEIS consortium—DoD partners in GEIS—are or are seeking to become WHO collaborating centers. WHO collaborating centers are an important part of the WHO “network of networks,” through which technical backup, research, training, and transfer of technology are directed to support disease surveillance and control efforts (WHO, 1996). It has been noted that incorporation of DoD laboratories into this network would be of benefit to global infectious disease surveillance efforts (D’Amelio and Heymann, 1998). The committee agrees that WHO Collaborating Center for Emerging Infectious Diseases and other WHO collaborating center status is in keeping with the intent of NSTC-7 (NSTC, 1996), GEIS goals (GEIS, 1998), and U.S. and international interests.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review GEIS in Practice Having reviewed the implementation of GEIS at the overseas laboratories, within the infrastructure of the MHS, and within the GEIS Central Hub, the committee concludes the following regarding GEIS as a whole: Surveillance The committee concludes that the GEIS pillars are reasonable targets for emerging infectious disease surveillance, given available resources and the partners and stakeholders to whom GEIS is responsible. Current GEIS pillar areas are generally being well addressed by GEIS, primarily through activities at the overseas laboratories, but also through activities within the infrastructure of the MHS and through the Central Hub. The committee is concerned, however, that the existing pillar structure is incompletely defined and understood. GEIS pillars are interpreted somewhat differently and acted upon somewhat differently at each of the overseas laboratories (see Chapters 2 to 7). Presentation of the pillar concept within the GEIS strategic plan (GEIS, 1998) is vague. Rigid adherence to a pillar construct can impinge upon the responsiveness of GEIS to regionally relevant emerging infectious disease threats. The committee notes, for instance, that disease areas of global importance, such as tuberculosis, are absent from the current GEIS pillar structure and are underaddressed within GEIS, even though host countries identify them as priorities. On the other hand, lack of structure can result in fragmented, inefficient activities that render GEIS ineffective as a program. It is important to the success of GEIS that the parameters and the intent of the pillar concept be clear to consortium members and partners alike. Systems Research, Development, and Integration [GEIS will] develop the information management tools for clinicians, laboratorians, pathologists, epidemiologists, and preventive medicine/ public health practitioners to address the unique aspects and concepts of emerging infectious disease detection and prevention (GEIS, 1998, p. 28). GEIS is actively involved in the development and implementation of new surveillance-related systems and in devising new components and uses for existing systems. Many of these developments show great promise (e.g., the DoD Directory of Public Health Laboratory Services, Early Warning Outbreak Response System, Electronic Surveillance System for the Early Notification of Community-Based Epidemics, and numerous others). It is important, however, that the needs and specifications for innovative systems be clearly defined before they are undertaken and

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review that caution be used when implementing unproven systems on a large-scale basis. Response A surveillance network must do more than detect cases of disease. It must also collect data on those cases, analyze them in some useful fashion, and disseminate the findings of the analyses to people who can use the information. Surveillance alone, however, is insufficient to address emerging infectious disease adequately. A response mechanism is necessary as well (IOM, 1992, p. 135). The missions, capabilities, roles, and priorities of all key organizations must be known and understood to accomplish effective, efficient communication and coordination. All key organizations must be in agreement to enable coordinated, timely, and appropriate responses to emerging infections (GEIS, 1998, p. 38). DoD overseas laboratories have historically been active in responding to emerging infectious disease epidemics, typically in response to the request of host-country governments or partner agencies. The mandate and the resources provided by GEIS benefit DoD epidemic response efforts. [GEIS will] improve rapid response capability and coordinated contingency plans for the emergence of new strains of known pathogens, particularly influenza, that threaten to cause pandemic disease (GEIS, 1998, p. 34). [GEIS will] develop and successfully staff a DoD assessment and response plan for military medical treatment facilities and DoD beneficiary populations (GEIS, 1998, p. 36). [GEIS will] develop and successfully staff a DoD assessment and response plan for a US military emerging infections response in a foreign country (GEIS, 1998, p. 36). GEIS has also contributed to the development of epidemic response capacity through the development of new systems, system components, and strategies (e.g., by fostering the Air Force Institute for Environmental Safety and Occupational Health Risk Analysis influenza alert component). GEIS does not, however, appear to have actively pursued the development of formal, laboratory-specific response plans to guide laboratories, particularly overseas laboratories, in managing requests for assistance. [GEIS will] enhance the prompt implementation of all prevention and control strategies for emerging infections to include improving communication about emerging agents (GEIS, 1998, p. 35). In addition to supporting responses to epidemics, as part of its efforts to respond to the threat of emerging infectious diseases, GEIS has con-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review ducted studies and prepared presentations and publications that document emerging infectious disease problems and that develop awareness of these problems. GEIS has also developed and recommended solutions and fostered the implementation and evaluation of interventions (e.g., for sexually transmitted diseases) aimed at preventing and controlling infectious diseases. The committee concludes that GEIS has generally contributed to national and international knowledge of emerging and reemerging infectious diseases as the result of these efforts. Training and Capacity Building The laboratories are…a vital source for recruiting and training laboratory personnel for the U.S. military (IOM, 1992, p. 149). DoD will make available its overseas laboratory facilities, as appropriate, to serve as focal points for training of foreign technicians and epidemiologists (NSTC, 1996, p. 5). [GEIS will] support programs and efforts, including residency training, to ensure the ready availability of the professional expertise and support personnel needed to better understand, monitor, control, and prevent emerging infections (GEIS, 1998, p. 37). GEIS supports training indirectly by supporting laboratories that in turn support their own distinct training activities. Through the Central Hub, GEIS has also implemented the Overseas Medical Research Laboratory Orientation Training Program, a resource for training DoD preventive medicine personnel, and is also providing training to foreign national public health professionals as part of its capacity-building efforts (e.g., it is providing training in laboratory information systems, computer use, and epidemiology). Additional opportunities exist to work more closely with GEIS consortium members, including the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), as well as with public health partners and academic institutions to further address DoD training needs. The committee concludes that current GEIS efforts to address training needs are laudable, but are modest relative to the needs of the DoD and its partners and to the potential contributions of GEIS. One of the biggest potential barriers to the implementation of a global surveillance network is the transfer of information from and to remote sites in many developing countries that have inadequate telecommunications capabilities (IOM, 1992, pp. 134–135). [GEIS will] conduct humanitarian assistance projects in conjunction with the CINC [commander in chief, unified combatant command] Overseas, Humanitarian, Disaster, and Civil AID Program (OHDACA) (GEIS, 1998, p. 38).

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review GEIS, through activities at the overseas laboratories and the Central Hub and with the support of the unified combatant commands, has done a noteworthy job of assisting with the development of laboratory and communications infrastructures within partner countries. Current GEIS efforts to build the capacity of its public health partners through the provision of training and support of laboratory and communications infrastructures are having beneficial effects. DoD will ensure the availability of diagnostic capacity at its [domestic and overseas laboratories] using existing DoD resources (NSTC, 1996, p. 5). GEIS is building capacity within the DoD by supporting the development and maintenance of laboratory diagnostic capacity directly (e.g., through funding of USAMRIID’s diagnostic capability) and indirectly (e.g., through funding of projects that result in the development of laboratory infrastructure). Sustaining and expanding DoD laboratory diagnostic capacity is an important activity that is in GEIS’s interests and that could be better and more directly addressed. Other Considerations The committee also identified a number of factors that are of crosscutting, paramount importance to GEIS and that are therefore discussed separately below. Staffing If necessary, DoD will seek Chief of Mission concurrence to raise personnel ceilings at overseas laboratories (NSTC, 1996, p. 5). DoD’s recent demand for epidemiologists…has resulted in a shortage recognized by the Army Personnel Command of roughly 50 preventive medicine physicians. In the overseas arena, although DoD labs have highly expert scientists and lab capabilities, their number is grossly insufficient to have a regional impact unless training of local scientists is implemented as a form of leveraging (GEIS, 1998, p. 37). The committee concludes that additional staffing is needed to support GEIS, particularly at the overseas laboratories, but within the Central Hub as well. Personnel at overseas laboratories have been added as the result of GEIS, but GEIS does not have the full complement of staff that was intended (Bancroft and Schlagel, 1997; Cuddy, 1997; Martin, 1997a,b). GEIS implementation has been adversely affected by this lack of staffing. In particular, insufficient numbers of personnel possessing applied epidemiological knowledge are available to guide surveillance activities.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Also, additional staffing is needed to effectively coordinate the training needs of DoD personnel, foreign national public health workers, and others. GEIS would also benefit from having additional project management staff available within the laboratories and the Central Hub. Presidential Decision Directive NSTC-7 explicitly recognizes that GEIS brings with it increased staffing needs. Personnel ceilings are, however, only one obstacle affecting GEIS staffing: there are simply not enough qualified DoD personnel available to fill vacancies. GEIS is pursuing training, the hiring of foreign service nationals, and the assignment of CDC staff to meet staffing needs. All of these approaches are appropriate and important and could be expanded and more actively pursued to meet staffing needs. Communication A surveillance network must do more than detect cases of disease. It must also collect data on those cases, analyze them in some useful fashion, and disseminate the findings of the analyses to people who can use the information (IOM, 1992, p. 135). [GEIS will] disseminate aggregate laboratory information about emerging infections and antimicrobial resistance obtained from DoD medical facilities worldwide to all DoD laboratories, hospitals, and practicing physicians (GEIS, 1998, p. 35). [GEIS will] use diverse communication methods for wider and more effective delivery of critical public health information, alert messages, and prevention and control recommendations (GEIS, 1998, p. 35). [GEIS will] establish mechanisms for timely and systematic exchanges of surveillance information and laboratory specimens among public health agencies of different countries, the CDC, WHO, and DoD (GEIS, 1998, p. 20). The CISET [Committee on International Science, Engineering, and Technology] subcommittee on quarantine and containment stated in its recommendations that surveillance data on military populations should be exchanged with relevant state health authorities to ensure that disease importations are properly managed not only within the DoD but also with respect to affected civilian populations (GEIS, 1998, p. 18). Current GEIS efforts to communicate surveillance and other information within the GEIS consortium, within the DoD, to public health partners, and to the public are noteworthy but insufficient. It is of particular importance that mechanisms exist for the rapid and effective communication of information to public health partners who are positioned to take response action, such as U.S. partner agencies, international organizations, and ministries of health. At present, strategies for sharing information with public health partners have not been formally developed, although in many cases good

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review practices have evolved. The committee recognizes that the methods and needs for the sharing of data vary greatly within the GEIS consortium, but it concludes that it is important that these needs be assessed and that communication channels be identified and opened. It is also important for the GEIS Central Hub to collect surveillance data and other information from consortium members in a systematic, timely manner, analyze this information as appropriate, and report this information back to consortium members and other relevant DoD personnel, public health partners, and the public. Current GEIS information dissemination efforts include production of annual reports, publication of study results in the peer-reviewed literature, presentation of GEIS information at meetings and conferences, periodic publication of laboratory newsletters and updates, and posting of periodic updates on the GEIS website (GEISWeb). Current information dissemination efforts are diverse and important, but they do not constitute a cohesive, regular GEIS product. Coordination and Collaboration To be effective, any global infectious disease surveillance network must be interactive and reciprocal. It is especially important that U.S.-funded laboratories engaged in infectious disease surveillance in foreign countries operate in partnership with host-country facilities (IOM, 1992, p. 134). [GEIS will] ensure that DoD surveillance systems complement and support local, regional, national, and international surveillance efforts (GEIS, 1998, p. 17). [GEIS will] develop and maintain coordination and communications systems among clinicians, pathologists, laboratory personnel, preventive medicine personnel, researchers, DoD medical executives, and other DoD parties and external agencies to achieve an integrated GEIS (GEIS, 1998, p. 15). GEIS is actively fostering collaboration and coordination with international partners and governmental agencies in partner countries. This is important to ensure that GEIS projects complement and support other efforts. A DoD preventive medicine physician has been assigned through GEIS to work at WHO headquarters in Geneva, Switzerland. This sharing of staff benefits the DoD and GEIS by increasing awareness of GEIS within the public health community and by fostering the exchange of ideas. Additional steps, such as encouraging consortium members to seek WHO collaborating center status, can benefit the coordination and support of GEIS projects internationally. When engaging international partners, it is important that GEIS present a unified program front; that is to say, the Central Hub and

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review overseas laboratory staff need to closely coordinate planning and implementation of all GEIS activities. GEIS is taking important steps to strengthen collaborations with U.S. partner agencies, but more needs to be done to formalize these partnerships. GEIS notes that the establishment of interagency agreements, for instance, with the CDC and the State Department, is a high priority (GEIS, 1998). Other potential partners, such as the U.S. Agency for International Development (USAID), have yet to fully realize the potential value that collaboration with GEIS can bring, and these partnerships are also worthy of vigorous pursuit. The committee agrees that formalizing and strengthening these relationships is important to the success of GEIS and, more generally, U.S. efforts to address emerging infectious diseases. GEIS has also done a noteworthy job of making use of existing DoD capabilities. Unified combatant command capabilities and resources have contributed greatly to GEIS. GEIS is also mindful of separate DoD public health surveillance activities (e.g., the Defense Medical Surveillance System, the Naval Disease Reporting System, the Shipboard Non-Tactical ADP [automated data processor] Automated Medical System, and the Air Force Reportable Events Surveillance System) in the conduct of its work. The current level of collaboration between overseas and MHS laboratories and between those members of GEIS and the GEIS Central Hub could be improved. To limit redundancy among GEIS projects, to leverage limited resources, and to ensure that the respective parts of GEIS function together as a whole, it is important that laboratory activities be well coordinated and that these activities be collaborative whenever possible. This not only includes collaboration among overseas laboratories with similar regional interests but also necessitates increased coordination among GEIS MHS-based activities and an increased focus of MHS activities and the MHS laboratory infrastructure in support of overseas laboratory surveillance efforts. It is important that the primary occupation of the Central Hub be the active coordination and guidance of projects carried out within MHS and overseas laboratories. Tools such as GEISWeb and the DoD Directory of Public Health Laboratory Services can improve means of interaction and can encourage collaboration. Also, at many facilities within the GEIS consortium, a dedicated program manager has been assigned to GEIS. This approach seems to benefit coordination of GEIS projects. Evaluation Regular, scientific- and management-related guidance and periodic program review are important at the GEIS management level. It is essential that GEIS management (i.e., the Central Hub) has available to it clear, appropriate means of routinely receiving authoritative, timely scientific and man-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review agement guidance. It is also important that GEIS be subject to periodic external review to determine whether the goals of GEIS are being addressed and whether those goals remain appropriate. On the basis of conversations with and documentation received from laboratory staff (Kelley, 2001c), it does not appear to the committee that the current mechanisms of providing direction to the GEIS Central Hub are sufficient. Routine, standardized review of GEIS projects is important. At present, GEIS projects are reviewed annually by a small number of Central Hub staff. GEIS may benefit from a broader, more standardized review process (including use of structured proposal guidelines and timelines) and expansion of the panel of reviewers to include non-Central Hub staff, such as representatives from partner agencies, overseas and MHS laboratory personnel, and other DoD representatives (e.g., Military Infectious Disease Research Program staff). It may also 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. [GEIS will] evaluate the effectiveness and economic benefit of existing and proposed strategies to detect and prevent emerging infections (GEIS, 1998, p. 29). It is important that the need for new systems and methodologies is assessed and the value of prototype systems is established before large GEIS investments are made in their development or use. GEIS is investing, according to its goals, in the development and introduction of a number of new surveillance-related systems and methodologies. It is important that GEIS thoroughly evaluate the need for new systems; thoroughly plan system development, including the identification of systems developers with extensive relevant expertise and experience; and evaluate prototype systems to ensure that they are structured to optimally contribute to GEIS. SUMMARY RECOMMENDATIONS • 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

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 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. 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 should be duplicated at all facilities to the extent possible. GEIS program managers should 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

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 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 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 on 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,

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 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 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 non-governmental 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 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.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review • 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 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

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 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. 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 should 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 should 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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