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GEIS at Naval Medical Research Center Detachment, Peru

The Naval Medical Research Center Detachment, Peru (NMRCD; formerly the Naval Medical Research Institute Detachment [NAMRID]), facility in Lima was established in 1983 through an agreement between the surgeons general of the Peruvian and U.S. Navies, with the concurrence of the U.S. Department of State and the Peruvian Ministry of Foreign Affairs. The agreement established a cooperative medical research program to study infectious diseases of interest to both parties. NMRCD is a field detachment of its parent command, the Naval Medical Research Center, Forest Glen, Maryland (GEIS, 2000g; NMRCD, 2000d).

Historically, NMRCD has focused on applied research in support of its medical mission. Its past research focus provides a strong framework for the U.S. Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS) focus on surveillance and response capacity. NMRCD projects receive funding from numerous sources, including the Military Infectious Disease Research Program, the Southern Command (SOUTHCOM), and GEIS. GEIS funding for NMRCD activities totaled $950,000 in fiscal year 2000 (GEIS, 2000b) and is expected to total $1,075,000 in 2001 (GEIS, 2000c).

A subcommittee of the Institute of Medicine (IOM) Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System visited NMRCD from June 19 to 23, 2000. The subcommittee consisted of committee members Kathleen Gensheimer and Ronald St. John, accompanied by Institute of Medicine staff member Heather O’Maonaigh. A list of the people met and interviewed and the itinerary followed can be found at the end of this chapter.



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 2 GEIS at Naval Medical Research Center Detachment, Peru The Naval Medical Research Center Detachment, Peru (NMRCD; formerly the Naval Medical Research Institute Detachment [NAMRID]), facility in Lima was established in 1983 through an agreement between the surgeons general of the Peruvian and U.S. Navies, with the concurrence of the U.S. Department of State and the Peruvian Ministry of Foreign Affairs. The agreement established a cooperative medical research program to study infectious diseases of interest to both parties. NMRCD is a field detachment of its parent command, the Naval Medical Research Center, Forest Glen, Maryland (GEIS, 2000g; NMRCD, 2000d). Historically, NMRCD has focused on applied research in support of its medical mission. Its past research focus provides a strong framework for the U.S. Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS) focus on surveillance and response capacity. NMRCD projects receive funding from numerous sources, including the Military Infectious Disease Research Program, the Southern Command (SOUTHCOM), and GEIS. GEIS funding for NMRCD activities totaled $950,000 in fiscal year 2000 (GEIS, 2000b) and is expected to total $1,075,000 in 2001 (GEIS, 2000c). A subcommittee of the Institute of Medicine (IOM) Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System visited NMRCD from June 19 to 23, 2000. The subcommittee consisted of committee members Kathleen Gensheimer and Ronald St. John, accompanied by Institute of Medicine staff member Heather O’Maonaigh. A list of the people met and interviewed and the itinerary followed can be found at the end of this chapter.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review LABORATORY NMRCD’s primary laboratory facility is housed within a 33,000square-foot laboratory and animal research unit in Lima, Peru. Within this facility is maintained a traditional scientific organizational structure consisting of bacteriology, virology, parasitology, and entomology departments. NMRCD’s Lima laboratory is equipped to support medical research- and disease surveillance-related activities, activities that use approaches ranging from classical microbiology to modern molecular biology-based approaches. The laboratory animal facility is accredited by the Association for Assessment and Accreditation of Laboratory Animal Care-International. A field laboratory in Iquitos, Peru, provides an operational base site for ecological and epidemiological studies, including disease surveillance, in the Amazon basin (GEIS, 2000b; NMRCD, 2000c; Watts, 1996). The Iquitos laboratory facility is equipped primarily for specimen collection and processing. The NMRCD laboratory facility in Lima possesses biosafety level 2 (BSL-2) and incomplete BSL-3 capacities. Specimens from fatal cases and pathogens with rapid incubation periods are sent to collaborators and supporting facilities that possess BSL-4 capabilities for analysis. Strong linkages with the Centers for Disease Control and Prevention (CDC) and the University of Texas Medical Branch, Galveston, as well as the U.S. Army Medical Research Institute for Infectious Disease, enhance NMRCD’s ability to identify new or novel pathogens. The Peruvian health authorities have accepted a paradigm shift from surveillance of laboratory-confirmed diagnoses to syndromic surveillance, which blends epidemiology with clinical findings and laboratory diagnosis, as required. Expanding laboratory diagnostic capacity is, however, a Peruvian public health priority. The Instituto Nacional de Salud (INS; Peruvian National Institutes of Health) serves as the national reference laboratory for Peru. It is currently supporting the decentralization of laboratory capacity to 14 of Peru’s 34 health regions. In addition, the INS is constructing a BSL-2 laboratory in Iquitos and a BSL-2 and BSL-3 facility in Lima. Currently, the largest-capacity laboratory maintained by the INS operates at BSL-2 and is located in Lima. NMRCD uses its laboratory capacity to support Peruvian infectious disease surveillance efforts by augmenting regional laboratory supplies and providing specimen-processing assistance when requested. The INS has identified as priority areas regional laboratory capacity in diarrheal disease diagnosis, serological testing, and quality assurance of antibiotic resistance testing. These priority areas are largely compatible with GEIS project areas, and the INS welcomes GEIS-supported surveillance projects.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Conclusions Laboratory capacity at current BSL levels, augmented by collaborating laboratory networks, is sufficient to support GEIS. The NMRCD laboratory facility in Lima provides a good example of close collaboration between U.S. and national laboratories. Support for such a collaboration is one of the objectives of GEIS (GEIS, 1998). STAFFING At the time of the IOM subcommittee’s visit, NMRCD staff included six professional, uniformed services personnel1: the officer in charge (a Navy commander, physician-epidemiologist); the head of the Bacteriology Department, who also serves as the manager of GEIS (a Navy captain, microbiologist); a scientist assigned from the CDC (a Public Health Service captain, physician-epidemiologist); the head of the Virology Department (a Navy lieutenant commander, epidemiologist-physician); the head of the Entomology Department; and a scientific director, based in Washington, D.C. An Army physician-investigator was added to the NMRCD staff shortly after the subcommittee’s visit. Three more professional personnel are to be added to the NMRCD staff in the coming year, as are an administrative officer, a biomedical repair technician, and a veterinary technician. In addition, NMRCD employs a staff of foreign service nationals (FSNs), including 22 administrative support and 19 research personnel. FSN staff include laboratory technicians, a veterinarian, and contract personnel with expertise in the areas of departmental focus. Dedicated, contracted field personnel manage NMRCD field operations on a full-time basis. No full-time employee works exclusively on GEIS projects. All department heads have significant involvement in programs other than GEIS. Conclusions The NMRCD hosts a dedicated, skilled scientific team that attempts to fulfill GEIS objectives. At present, the program is efficiently run under the direction of its program manager, but because his responsibilities also 1   The subcommittee’s visit took place at a time of transition in NMRCD personnel. Both a new officer in charge and a new Entomology Department head were installed at NMRCD as of June 2000. Also, as of August 1, 2000, an Army physician-investigator was assigned to NMRCD.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review include directing the Bacteriology Department, continued coordination of GEIS may be difficult. The project is given strong support from the NMRCD officer in charge (transitioning out at the time of the subcommittee visit), who has worked diligently to lay a strong foundation to secure the success of the GEIS mission. Currently, the CDC epidemiologist who is assigned to NMRCD and who heads GEIS’s antimalarial drug resistance projects offers some needed support in public health and applied epidemiology. However, the CDC epidemiologist is clearly occupied with directing the various components of the malaria studies and is not available to provide the overall epidemiological support that GEIS requires. The subcommittee was impressed with the high level of staff (DoD and contract personnel) commitment to and enthusiasm for GEIS projects. Staff relationships appeared to be supportive and mutually reinforcing. However, duty assignments to NMRCD frequently last only one rotation (generally 2 to 4 years), and the costs of employee turnover are high. Longer terms of service (more than one rotation) contribute to the formation and enhancement of working relationships and are of particular importance given the emphasis of GEIS on collaborative activities. NMRCD connections with agencies and organizations central to Peru’s political and public health infrastructures are jeopardized when staff changes occur, potentially affecting GEIS activities. Increased hiring and assignment of U.S. civilian and FSN scientists can help to ameliorate this issue. TECHNOLOGY AND INFORMATION MANAGEMENT Within NMRCD’s Lima laboratory, communications systems provide e-mail, Internet, fax, and telephone access. An on-site data center supplies computer systems support, as well as data entry and analysis services and surveillance data reporting, as needed. At the Iquitos field site, access to e-mail, fax, telephone, and photocopying capabilities are available. Within the NMRCD laboratory, frozen specimen archives are maintained, but they are not cataloged electronically. A version of the Laboratory Information Tracking System Plus software, developed by the CDC, is to be modified and used to catalog this information once a useable version of this application is available. Conclusions A tour of the NMRCD facility and its field site in Iquitos impressed the subcommittee members with the sophistication of the technology available. Computer and communications technologies (access to the World Wide Web, e-mail, library facilities, and an office computer network) appeared to be sufficient to support GEIS. The planned addition of

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review an electronic specimen-cataloging system is an important effort that coincides with GEIS’s goals (GEIS, 1998). SURVEILLANCE2 The GEIS focus on surveillance and response capacity was added in fiscal year 1997 to the existing NMRCD operating structure, which was historically dedicated to laboratory-based medical research. At NMRCD GEIS is conceptually organized around five pillars, four of which were defined by the GEIS Central Hub and one of which (entomological surveillance) was added by NMRCD. These pillars are (NMRCD, 2000a,c) drug-resistant malaria surveillance, influenza surveillance, surveillance for drug-resistant enteric pathogens, acute febrile illness (AFI) surveillance, and entomological surveillance (specifically, insect vectors of the malaria parasite and arboviruses). GEIS-related pillars are integrated across all four NMRCD departments, with department heads using existing personnel to support the work of GEIS. Within each pillar, NMRCD has developed several specific projects. In fiscal year 1999, NMRCD GEIS-funded projects involved sentinel surveillance for influenza, antibiotic-resistant enteric infections, and antimalarial drug resistance (GEIS, 1999a). NMRCD is essentially rebuilding programs that faltered during the 1990–1995 period of terrorism in Peru. Most GEIS projects are in their infancies; others are still waiting to begin. Initially, a great deal of effort was spent to prepare for GEIS implementation and integration with national and other partners. Most GEIS projects are in their first year of full funding. Projects funded in fiscal years 2000 to 2004 include continued studies of drug-resistant malaria, surveillance for influenza and drug-resistant enteric bacteria, as well as projects addressing acute febrile illness and entomological surveillance activities. Drug-Resistant Malaria Surveillance Antimalarial drug resistance monitoring is to be conducted during fiscal year 2000–2001 at sites in Peru, Surinam, Bolivia, and Ecuador. 2   The summaries in this section reflect project planning at the time of the subcommittee site visit in June 2000. At that time, many projects were in their planning stage or had recently begun.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Project collaborators include the Walter Reed Army Institute of Research, the Naval Medical Research Center, the CDC, and the University of Toronto, as well as the Pan American Health Organization, the INS, the Peruvian Navy, and ministries of health. Clinical and parasitological failures of antimalarial drug therapy will be studied in patients with Plasmodium falciparum or Plasmodium vivax infections. In vivo testing of approximately 50 specimens per surveillance site will be conducted each year, with in vitro testing conducted where logistically possible. Training of Ministry of Health personnel will be undertaken as part of this work. The long-term goal of this project is the transfer of a sustainable antimalarial drug resistance program to host country public health authorities (NMRCD, 2000a,b). Influenza Surveillance Specimens containing influenza virus are to be collected at U.S. embassy health units, as well as surveillance sites, and forwarded to the DoD Laboratory-Based Influenza Surveillance Program at Brooks Air Force Base in San Antonio, Texas, for virus isolation and characterization. Basic demographic information will be collected at the time of specimen collection. Approximately 40 samples are to be collected per site per year. Influenza surveillance sites have already been established in Argentina, Ecuador, and Peru. Additional sites are planned in Chile, Bolivia, and Ecuador. Secondary goals of this project include the training of locals and capacity building (NMRCD, 2000a,b). Surveillance for Enteric Pathogens NMRCD has sporadically collected enteric bacterial isolates for several years, but now, under the auspices of GEIS, plans for a more systematic surveillance effort are in place. Surveillance sites have been established in Bolivia, and there are plans to include sites in Peru and Ecuador as well. No plan to collect specimens from the U.S. embassy population was noted. The number of antibiotics used in resistance screening will be increased from 7 to 13. Samples (25 from each site) will be collected from surveillance sites during four peak periods of diarrheal occurrence each year (NMRCD, 2000a,b). Acute Febrile Illness Surveillance Specimens from patients presenting with undifferentiated fevers will be collected from sites in Peru and a site in Bolivia, with plans to add a surveillance site in Ecuador at a later date. Samples are to be collected from 250 individuals from each site during the first year of the study

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review (calendar year 2000). Viral isolations will be performed with acute-phase serum specimens. Serologies will be performed with convalescent-phase serum specimens. Patients will be characterized as presenting with undifferentiated febrile syndrome, undifferentiated febrile syndrome with rash, hemorrhagic fever syndrome, febrile icteric syndrome, and acute respiratory syndrome. This study will be linked with other GEIS efforts, such as entomological, influenza, and antimalarial drug resistance surveillance activities. Improvements in regional laboratory capacity and the training of locals are additional benefits of this work. Local collaborators will be encouraged to make project data available to in-country surveillance networks, but NMRCD will not report the data directly (NMRCD, 2000a,b). Entomological Surveillance Activities Arthropod vector surveillance is to be conducted at Puerto Almendras, a site near Iquitos, in the Amazon, and at a site near Tarapoto, in the foothills of the Andes. Mosquitoes will be collected by a variety of methods. Surveillance events being monitored are the introduction of new mosquito species, changes in the distribution of previously known species, the identification of previously unrecognized vectors, characterization of the behaviors of important vectors, and the identification of arboviruses. Surveillance will be carried out at health clinics proximate to the mosquito surveillance sites to determine if viruses detected in the mosquito populations are appearing in humans (NMRCD, 2000a,b). Considerations NMRCD GEIS projects are designed to investigate the descriptive epidemiology of selected diseases in sentinel sites. AFI, enteric pathogens, and influenza projects use sentinel sites to access populations that are strategically located in all three of Peru’s ecological zones, namely, the coastal desert area, the lower highlands and northern coast, and the tropical eastern area. Sentinel sites have also been developed in neighboring Bolivia and Ecuador. Surveillance is limited to patients seeking care from public health care facilities. Thus, the projects sample only a portion of the Peruvian population in distinct ecological zones. For example, the National Social Security System, which provides clinical care for 25 percent of the Peruvian population, remains outside the scope of GEIS surveillance activities. Sampling from sentinel sites has some inherent limitations, including potential biases associated with site selection, health care-seeking behavior, clinical decisions to obtain laboratory samples, and the effects of previous self-medication. Data obtained from sentinel surveillance systems may not be generalizable to the entire population of inter-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review est. Sentinel surveillance is, however, a reasonable approach for a supplemental surveillance activity such as GEIS. To understand NMRCD’s role in infectious disease surveillance in Peru, it is important to consider the existing surveillance systems in the host country with which GEIS should interact. The Peruvian Ministry of Health, in collaboration with the U.S. Agency for International Development (USAID), has dedicated many resources to strengthening Peru’s national computerized surveillance system. In response to national priorities, USAID developed the Addressing Threats of Emerging and Re-Emerging Infectious Diseases (VIGIA) project in late 1997. This project is funded at $24 million ($18 million from USAID funds and $6 million from the Peruvian government) over a period of approximately 6 years (through September 30, 2004) (USAID and U.S. Embassy, Lima, Peru, 2000). The system is designed to build local capacity for data collection, data analysis, and response, including reporting and local investigation of epidemics. It is based on electronic linking of approximately 6,000 local health districts to the central Oficina General de Epidemiologia (OGE; Office of Epidemiology, Peruvian Ministry of Health) through the 34 health regions in Peru. Each district reports cases of notifiable infectious diseases to a health region on a weekly basis. Each region has a health situation room where weekly data are tabulated in graphic format and displayed on the walls. The rate of compliance with weekly reporting was stated to be approximately 90 percent. Each health region is linked to OGE by Internet television for visual conferences and rapid reporting and discussion of unusual situations. In many respects, the communications technology possessed by OGE is superior to the communications technology available at NMRCD. Since 1998, to staff this electronic system, Peru has provided basic training in epidemiology for approximately 900 people for district-level work. Three hundred people received more advanced training in epidemiology for region-level work, whereas 90 people received even more advanced training for work at the national level. In addition, 30 people received full training in epidemiology at the master’s level. This training program is operated under the aegis of the Peruvian Field Epidemiology Training Program, but it lacks a field training component and is considered to be weak. The current surveillance system generates local epidemiological bulletins and early warnings and alerts. Although the USAID investment is creating an impressive surveillance infrastructure for the rapid reporting of the incidence and prevalence of 14 legally notifiable infectious diseases, several observers noted that there is still room for greater analysis of the available data and for the subsequent use of the resulting information to formulate national health policy and to generate public health action. It

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review was noted, for example, that although the system generates a large amount of information of variable quality (not all data are coherent and internally consistent), the information generated is sufficient for a rough analysis of the local epidemiological profile and general infectious disease trends, but many of the data do not appear to be analyzed and converted into appropriate and timely public health action.3 The objective of OGE is to produce local data for local analysis and local decision making. During the visit to the regional health office in Iquitos, it was not apparent how well this process was working. There also appeared to be a lack of understanding regarding the goals of GEIS. When asked what GEIS could contribute at the regional level, the response from the OGE medical director was that GEIS could (1) conduct studies of hepatitis B and hepatitis delta viruses, (2) study the virology of diarrheal diseases, (3) provide more equipment for the regional laboratory, and (4) continue facilitating specimen transportation to Lima. These region-level wants do not seem to fall clearly within the mission of GEIS or the scope of its current project areas. At the OGE central level, the information and support contributed by GEIS were recognized and valued. Conclusions NMRCD’s laboratory capacity helps support the Peruvian national surveillance system by reinforcing INS laboratory capacity. Additionally, GEIS at NMRCD can serve a data quality assurance function by providing data from its studies to the INS and OGE. At present, the exchange of data and other information between NMRCD and its partners is project dependent and intermittent. NMRCD GEIS contributions to Peruvian surveillance efforts would be bolstered by the more systematic and timely exchange of information. GEIS also contributes to infectious disease surveillance in Peru through training and capacity building. It is primarily through laboratory capacity building and support and through other indirect means such as training that NMRCD GEIS is of benefit to Peru’s infectious disease surveillance system. With the exception of the influenza surveillance pillar, GEIS project areas and Peruvian national epidemiological priorities are compatible. Malaria parasite antimalarial drug resistance, enteric pathogen antimicrobial drug resistance, and undiagnosed fevers (especially those due to arboviruses, such as dengue virus) are all national health concerns. 3   The subcommittee did not have time to verify the validity of the large amount of data being generated or to explore how these data were being used to influence national health policies.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review GEIS efforts to examine drug-resistant malaria and drug-resistant enteric disease are of undeniable importance and are well matched with Peruvian health objectives; however, the subcommittee questions the public health value of the entomological surveillance studies. Much of this entomological surveillance work appears to be a virus hunt, about which the subcommittee has mixed feelings. Certainly, one cannot argue against the research-related importance of identifying new viruses; however, the public health relevance of the information that these studies will generate is questionable. When a new virus is identified in mosquito populations, such information may not be relevant for public health policy. This work would result in greater public health contributions if targeted to populated areas of high viral disease endemicity. The subcommittee recognizes the value of influenza surveillance in South America. Such information is useful to the World Health Organization’s (WHO’s) influenza surveillance system (FLUNET). At the Peruvian national level, where little influenza vaccine is used, the usefulness of such information is questionable. However, NMRCD GEIS influenza surveillance projects are low cost as a result of ties with the DoD Laboratory-Based Influenza Surveillance Program, and they are of use to the global community. For example, specimens sent by NMRCD to the DoD Laboratory-Based Influenza Surveillance Program in April 1999 identified the presence of the influenza strain A/New Caledonia/20/99 in the Americas and influenced the WHO recommendation to include this strain in the 2000 Southern Hemisphere and the 2000–2001 Northern Hemisphere vaccines (Gaydos, 2001d; GEIS, 2000b; Kelley, 2000b). The head of the Department of Virology, who is the director of the AFI studies, has developed a very comprehensive and reasonable network of sentinel study sites. He approximates that 20 percent of the febrile illnesses in Peru are attributable to the malaria parasites and that another 20 percent are attributable to arboviruses. An important question—one that GEIS AFI studies seek to address—is, What contributes to the remaining 60 percent of these syndromes? The study sites that have been established to address this question will be very helpful in addressing febrile illness-related morbidity in Peru. Despite the value of current GEIS project areas, many potentially important surveillance activities are left unaddressed. The subcommittee repeatedly heard concerns about respiratory disease syndromes and acute pneumonias; however, GEIS projects do not include these diseases. Multi-drug-resistant (MDR) tuberculosis (MDR-TB) is another disease entity that looms as a public health threat on a global basis. Although MDR-TB does not pose a direct threat to military security, it certainly poses a direct threat to the developing world, and if it is not brought under control, it will continue to pose a threat to U.S. citizens. To the extent that military personnel deployed overseas become infected with MDR Mycobacterium

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review tuberculosis, the risk to the U.S. civilian population is increased. The sub-committee questions how best to balance GEIS interests to evaluate not only those disease entities that may pose a direct threat to the U.S. military but also to integrate such surveillance and public health efforts with the needs of the host country, such as hepatitis B and hepatitis delta viruses.4 The subcommittee also questions whether the current annual review and funding process allows sufficient time for surveillance project maturation and planning between reviews. Annual review appears to rush the proposal preparation process and can culminate in the making of decisions about the merits of projects on the basis of incomplete information. RESPONSE CAPACITY NMRCD staff have participated in several investigations of epidemics. The processes leading to a response to an epidemic and the methods of epidemic response are described as varied. Response efforts are led by the Ministry of Health and, as needed, the involvement of NMRCD and other partners (e.g., the WHO and the CDC) is sought. As GEIS project data accumulate, ongoing epidemiological analyses of these data may be used to identify unusual events and possible epidemics for rapid reporting to OGE. Data linkages to OGE may facilitate ongoing monitoring of results from studies such as the AFI surveillance project. Conclusions At NMRCD, GEIS possesses resources (e.g., laboratory capacity, staff expertise, and collaborative relationships) that can be and that have been put to use in response to warnings of epidemics in Peru and the region. GEIS can foster NMRCD involvement in response efforts by supporting the prompt reporting of project data to OGE and by strengthening the ties between NMRCD and the Peruvian public health network. COLLABORATIONS Steps have been taken to integrate GEIS with current, ongoing activities at the INS, OGE, and the Universidad Peruana Cayetano de Heredia— 4   Also of potential public health interest: only 50 to 60 percent of the deaths in Peru are registered, potentially masking emerging infectious disease threats. Sentinel surveillance of deaths in the 15- to 49-year-old age group may uncover deaths due to unrecognized infectious causes (PAHO, 1998, pp. 415–421).

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review key components of Peru’s public health infrastructure. In-country relationships are largely person based rather than position based, and partnerships have benefited from staffing and programmatic changes at NMRCD and other agencies in recent years. GEIS staff seemed to be very well known and respected by the local and regional health officials. Collaborative relationships between organizations and agencies with public health interests in Peru (including agencies of the Peruvian government, the U.S. government, and international organizations) are quite complex. Of interest, the subcommittee heard various accounts of which disease entities posed public health challenges. Close collaborations are essential in making such determinations. The observed lack of concurrence suggests that the relationships observed could be more robust. Orientation slides provided to the subcommittee by OGE made no mention of GEIS or NMRCD, although other relationships were specified. VIGIA staff noted that NMRCD was helpful in maintaining relationships with U.S. laboratories; that NMRCD aided in the discovery of new viruses and bacteria; that NMRCD provided technical backup for the INS, especially in the area of quality assurance; that NMRCD assisted with technology transfer and laboratory training; and that NMRCD participated in and supported investigations of epidemics. VIGIA staff did not note a role for GEIS in the Peruvian surveillance system per se, despite similarities between the surveillance goals of VIGIA and GEIS. NMRCD also serves an important training role. NMRCD has offered at-the-bench laboratory training for a variety of national (Ryan, 2000) and international personnel. Medical students, residents, and visiting faculty, both national and international, have benefited from time spent at NMRCD in various training modes. Conclusions NMRCD staff currently involved with GEIS understand the need to establish collaborative and collegial networks with the Peruvian scientific and public health communities, and their efforts to do so are slowly producing positive results. In these regards, special credit needs to be given to the energy and vitality that FSN staff members bring to the program. Of note, the FSN contractor serving as the GEIS assistant manager understands the dynamics of the Peruvian scientific and governmental public health communities. She has worked to establish and maintain relationships that will be vital to the success and integration of the work of GEIS into the Peruvian public health infrastructure. In addition, the FSN manager of the Iquitos field site has an understanding of the NMRCD mission, as a result of her years of working in the Lima laboratory before transferring to Iquitos. Her interaction with the local population is critical to the success of the studies implemented in this Amazon field station. This staff

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review support is instrumental in surmounting the many challenges posed by the complex organizational relationships that exist in Peru. To facilitate productive partnerships, it is useful for GEIS staff to have, at a minimum, a working conversational level of proficiency in Spanish. Attempts must be made to interact with Peruvian officials in their native language. That effort is not only appreciated but also works to assimilate staff into the local culture, an understanding of which promotes optimal working relationships. If GEIS is to be successful, NMRCD must continue to work through the complex set of relationships that exist within Peru and continue its work with other in-country organizations and agencies on a continual and productive basis. Closer collaboration, more coordination, and better communication are goals toward which all in-country parties need to strive. The subcommittee noted, for example, that there appears to be weak integration of GEIS and NMRCD capacity with the USAID-VIGIA project, despite NMRCD’s efforts to engage USAID as a partner. The subcommittee recognizes that, in many cases, improvements in relationships between organizations must follow improvements in coordination and communication within the organizations themselves. GEIS at NMRCD might, for example, benefit from clearer communication and closer coordination with the GEIS Central Hub. For example, INS staff noted that the recent introduction of Public Health Laboratory Information System (PHLIS) software into the INS could have been better coordinated between the GEIS Central Hub and NMRCD GEIS staff. Benefits may also be obtained by encouraging working relationships between the GEIS overseas laboratories. For instance, it may be useful to have the coordinators for all GEIS projects on AFI in all DoD laboratories develop criteria for definitions of cases for syndromic surveillance instead of having each site struggle with such criteria on its own. The review team heard several comments regarding the forms of support that NMRCD should be offering to in-country programs. Most of the comments concerned provision of more laboratory support (e.g., offering quality assurance programs for laboratories) and provision of laboratory equipment and reagents. The boundaries of GEIS are difficult to define, as GEIS responsibilities to the host country are not always clear. Clarification of this point would be useful to GEIS and to its in-country partners. NMRCD has worked to promote an extensive training role in the Peruvian medical community and also provides training for DoD personnel and other students. Such efforts can be expanded through GEIS. However, training is a time-consuming activity, especially in the absence of a planned, formal training program with a set of organized courses to meet needs for specific skill sets. The subcommittee noted the absence of a training officer to coordinate formal training programs in collaboration with Peruvian nationals.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review RECOMMENDATIONS • GEIS activities at NMRCD are critical to GEIS as a whole. The committee encourages the DoD to plan for GEIS activities at NMRCD on a long-term basis. NMRCD provides a unique resource for research and for public health missions. Demand for and support of these missions should be balanced so that neither is jeopardized. Recommendation: DoD commitment to GEIS at NMRCD should be long term. • It is important that unmet GEIS staffing needs be addressed. New positions should be created, as needed, to meet these needs. Recommendation: 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 of 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 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. • Partnerships benefit from knowledge of the native language by senior staff. Partnerships are of increased importance to NMRCD now that its research mission has been expanded to include GEIS activities, which necessitate more interaction with partner agencies. Staff familiarity and comfort with the local language can also improve personnel retention. Recommendation: NMRCD senior staff who are actively involved in GEIS projects should be conversant in the dominant language of

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review the host country or should pursue, with the support of GEIS, language training, and should seek to become conversant to the extent possible. • Training local personnel in laboratory technology and providing an opportunity for DoD personnel and students to receive research training are important ways in which GEIS is and can increasingly be of benefit to Peru and the DoD. Consolidating and coordinating NMRCD’s various training activities under the aegis of GEIS may make training activities more efficient, productive, and visible. Recommendation: DoD and Peruvian training needs should be assessed formally, and the development of a structured NMRCD-hosted training program should be considered. • The reporting of data to Peruvian authorities should be timely and systematic and needs to be targeted toward achieving public health action. Recommendation: 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 has established connections with the political and public health infrastructures in Peru and understands the subtleties of how to operate effectively in country. NMRCD should continue to strengthen and expand these connections. In particular, improved coordination between members of the U.S. team in country should be pursued. For example, NMRCD should continue to seek to be more involved in the ongoing planning and implementation of the USAID-VIGIA project. To these ends, assistance from the regional unified combatant command (SOUTHCOM) and the U.S. ambassador should be sought, as needed. Recommendation: NMRCD 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 Peru. • The subcommittee recognizes that the GEIS pillar disease areas are important ones and that defining these targets helps to provide some standardization of GEIS activities across sites, but the pillar structure should be flexible enough to permit, on a case-by-case basis, local infectious diseases that are of global concern (e.g., tuberculosis) to be addressed as high priorities through GEIS. This serves to take full advantage of the epidemiological setting of the facility, builds national health defenses in

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review the host country, and can be of long-term benefit to the health of many populations, including U.S. military personnel and civilians. Recommendation: Consideration should be given to refining the focus of GEIS at NMRCD to better enable diseases outside of the pillar areas to be addressed. • The current annual approval process does not allow optimal time for NMRCD project planning or maturation. Furthermore, it is important that the GEIS Central Hub review and approval process for GEIS projects provides NMRCD with follow-up guidance regarding project progress in a consistent and timely manner (see also Chapter 7). Recommendation: Consideration should be given to revising the current GEIS project application and review process. PEOPLE MET AND INTERVIEWED NMRCD Staff LCDR Kevin Russell, head, Department of Virology CAPT Trenton Ruebush, Public Health Service/CDC, Malaria Drug Resistance CAPT Stephen Walz, head, Department of Microbiology, and head, GEIS Program Dr. Monica Negrete, GEIS assistant manager Dr. Douglas Watts, scientific director CDR Trueman Sharp, officer in charge at the time of the subcommittee visit CDR (Select) James Burans, replacing CDR Sharp as officer in charge Carla Block, manager, Iquitos Field Site Jorge Cervantes, assistant, Iquitos Field Site NMRCD Associates Ambassador John Hamilton, United States COL Gilbert R.Perez, USA, Special Forces, Chief, MAAG-Peru Dr. O.Jaime Chang, coordinator, VIGIA project Dr. Eduardo Falconi Rosadio, Instituto Nacional de Salud Dr. Luis Seminario Carrasco, asesor en salud, Oficina De Salud, Nutricion y Poblacion, USAID Dr. Percy Minaya Leon, director, General Office of Epidemiology Dr. Marie Andree Diouf, representative in Peru, PAHO Dr. Ruben Figuero, epidemiologist, PAHO

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Dr. Carlos Calampa, director, Regional Health Department, Loreto Region Dr. Giro Maguina, director adjunto, Universidad Cayetano de Heredia ITINERARY Monday, June 19 0715 Depart hotel for U.S. Embassy 0800 Meeting with COL Gil Perez, chief of the Military Assistance and Advisory Group and SOUTHCOM representative in Peru 0830 Meeting with Ambassador John Hamilton 0915 Depart for NMRCD 1000 Welcome and overview of NMRCD (CDR Sharp) 1045 Tour of NMRCD 1115 Overview of NMRCD GEIS (CAPT Walz) 1200 Lunch 1330 Presentations and meetings with individual NMRCD GEIS staff 1700 Depart for hotel Tuesday, June 20 0730 Depart hotel 0815 Meeting with Dr. Falconi and other staff at Instituto Nacional de Salud (Peruvian National Institutes of Health) 1000 Meeting with staff of Oficina General de Epidemiologia (General Office of Epidemiology) 1130 Return to NMRCD and Lunch 1600 Flight to Iquitos 1700 Arrive Iquitos 1830 Visit NMRCD laboratory/house Wednesday, June 21 0730 Visit Laboratorio Referencial Loreto 0900 Appointment with Dr. Carlos Calampa, Director, Loreto Regional Health Department 1000 Hospital de Apoyo de Iquitos 1100 Centro de Salud San Juan 1200 Lunch 1530 Leave for airport 1700 Return flight to Lima

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Thursday, June 22 0800 Depart hotel 0830 Meeting with USAID VIGIA staff at USAID 1000 Meeting with Pan American Health Organization representative 1200 Return to NMRCD for lunch 1330 Follow-up discussions with NMRCD staff 1700 Return to hotel Friday, June 23 0815 Depart hotel 0900 Meet with staff, Universidad Peruana Cayetano de Heredia 1230 Return to hotel for discussion, drafting of preliminary assessment, and assignment of writing tasks