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GEIS at Naval Medical Research Unit 2, Indonesia

Naval Medical Research Unit 2 (NAMRU-2) was established in Guam during World War II. In the years following the war, NAMRU-2 was relocated, first to Taiwan and then to the Philippines. In 1970, a NAMRU-2 detachment began operating in Jakarta, Indonesia (GEIS, 2000e). Negotiations between the U.S. Navy, the U.S. Department of State, and the government of Indonesia resulted in the transfer of the NAMRU-2 parent command from the Philippines to Jakarta in 1990 (GEIS, 2000e). The initial agreement with the Indonesian Ministry of Health (MoH) establishing NAMRU-2 command in Indonesia has recently expired, and negotiations are under way to establish a new agreement directly between the two governments. NAMRU-2 is facing some uncertainty because of political unrest in Indonesia as the country enters a period of transition from extensive autocratic rule to a democratic society.

NAMRU-2 is a subordinate command of the Naval Medical Research Center, Forest Glen, Maryland (GEIS, 2000e). NAMRU-2 is distinguished by its extremely close working relationships with Indonesian public health institutions. Projects are jointly developed and implemented with Indonesian public health officials.

Historically, NAMRU-2 has focused on applied research in support of its medical mission. Its past research focus provides a strong framework for the new focus of the U.S. Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS) on surveillance and response capacity. NAMRU-2 projects receive funding from numerous sources including the Military Infectious Disease Research Program (MIDRP), GEIS, Pacific Command (PACOM), and the Navy Bureau



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 3 GEIS at Naval Medical Research Unit 2, Indonesia Naval Medical Research Unit 2 (NAMRU-2) was established in Guam during World War II. In the years following the war, NAMRU-2 was relocated, first to Taiwan and then to the Philippines. In 1970, a NAMRU-2 detachment began operating in Jakarta, Indonesia (GEIS, 2000e). Negotiations between the U.S. Navy, the U.S. Department of State, and the government of Indonesia resulted in the transfer of the NAMRU-2 parent command from the Philippines to Jakarta in 1990 (GEIS, 2000e). The initial agreement with the Indonesian Ministry of Health (MoH) establishing NAMRU-2 command in Indonesia has recently expired, and negotiations are under way to establish a new agreement directly between the two governments. NAMRU-2 is facing some uncertainty because of political unrest in Indonesia as the country enters a period of transition from extensive autocratic rule to a democratic society. NAMRU-2 is a subordinate command of the Naval Medical Research Center, Forest Glen, Maryland (GEIS, 2000e). NAMRU-2 is distinguished by its extremely close working relationships with Indonesian public health institutions. Projects are jointly developed and implemented with Indonesian public health officials. Historically, NAMRU-2 has focused on applied research in support of its medical mission. Its past research focus provides a strong framework for the new focus of the U.S. Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS) on surveillance and response capacity. NAMRU-2 projects receive funding from numerous sources including the Military Infectious Disease Research Program (MIDRP), GEIS, Pacific Command (PACOM), and the Navy Bureau

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review of Medicine for administrative support, including housing and force protection. In addition, NAMRU-2 receives funding from companies like Abbott Laboratories and SmithKline for support of collaborative projects. Fiscal year 2001 GEIS funding is expected to total $1,075,000 (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 NAMRU-2 from October 2 to 5, 2000. The subcommittee also visited a newly developed extension facility in Phnom Penh, Cambodia, that NAMRU-2 operates jointly with the Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand, on October 6 and 7, 2000. The IOM subcommittee consisted of committee members Ruth Berkelman and Ronald St. John. A list of the people met and interviewed and the itinerary followed can be found at the end of this chapter. LABORATORY NAMRU-2 houses an extensive laboratory facility within a 62,000square-foot laboratory, office, and storage space in Jakarta, Indonesia (GEIS, 2000e). The NAMRU-2 facility is collocated with the Directorate General of Communicable Disease Control and Environmental Health (a part of the MoH, hereafter referred to as “Indonesian CDC”) and the Litbangkes (Indonesian National Institute of Health Research and Development, part of the Indonesian Ministry of Health). Litbangkes allocates free space on the entire third floor of its building for NAMRU-2 laboratories. NAMRU-2 also occupies a large warehouse nearby that houses additional laboratories, materials and supplies, and administrative offices. The Association for the Assessment and Accreditation of Laboratory Animal Care-International accredits NAMRU-2 laboratory animal facilities (GEIS, 2000e). NAMRU-2’s Jakarta 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. Within this facility, a conventional scientific organizational structure consisting of bacteriology, virology, parasitology, and entomology departments is maintained along with a recently added emerging infectious disease component. The NAMRU-2 laboratory facility in Jakarta possesses a biosafety level 2 (BSL-2) capacity and a nearly complete BSL-3 capacity. Specimens from fatal cases and pathogens with rapid incubation periods are sent to collaborators and supporting facilities that possess BSL-4 capabilities for analysis. NAMRU-2 is establishing a subsidiary laboratory in Phnom Penh, Cambodia, to provide an operational base site to support disease surveillance and epidemiological activities. The Cambodian National Institute of

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Public Health donated space for this laboratory and secured access to hospital sentinel facilities. The laboratory facility is undergoing construction and modification. This laboratory possesses a serology capacity only, but in the near future it will operate at a BSL-2 level for bacteriology. No BSL-3 level is planned. The laboratory is directed by a U.S. Centers for Disease Control and Prevention (U.S. CDC) staff person supported by NAMRU-2 through an interagency personnel agreement. NAMRU-2 has numerous other collaborating surveillance sites throughout Indonesia and Indochina. NAMRU-2 collaborates with the National Center of Laboratory and Epidemiology and the Pasteur Institute in Vientiane, Laos, and Ho Chi Minh City, Vietnam, respectively. These associations are with host-national partners generally charged with research and surveillance activities for their respective countries. NAMRU-2 has established relationships with hospitals in Vietnam through the Pasteur Institute and via key government and public health officials who serve as collaborators and liaisons. Satellite laboratories in Lumprapang and Champassak in Laos are located in hospital compounds. In Indonesia, a NAMRU-2 satellite laboratory facility in Jayapura (Man Jaya) is adjacent to a hospital complex but occupies a distinct compound. NAMRU-2 personnel staff this laboratory. Additional laboratories in Medan, Bali, Jakarta, Batam, and Padang are located in network hospitals. In Pontianak and Makassar, NAMRU-2 has a presence at the provincial laboratories. Collaborative relationships have been established with numerous hospitals to collect laboratory data on diarrheal diseases (those caused by Shigella, Campylobacter, enterotoxigenic Escherichia coli, etc.). NAMRU-2 provides training and limited equipment and supplies to these laboratories, as well as a quality control program, and in return, it is provided with data. The Indonesian national strategy for building a network of public health laboratories recognizes the need for a central public health reference laboratory. Laboratory services at the provincial and district levels— where capacities are variable and often rudimentary—and hospital-based laboratories fall under separate directorates in the MoH. Expansion of the laboratory diagnostic capacity in local areas is a public health priority in Indonesia. A new policy of expansion and decentralization will affect the national laboratory capacity. A planned central public health laboratory within the Indonesian CDC would serve to establish national norms, guidelines, and standards and would provide basic skills training for workers in the decentralized laboratory network. During an interview with the subcommittee team, Dr. Umar F.Achmadi, director general of the Indonesian CDC, reported that NAMRU-2 is expected to contribute to the development of this central laboratory—by assisting with standards development and staff training, for instance. NAMRU-2 uses its laboratory capacity to support Indonesian infectious disease diagnostic efforts

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review by providing reference testing services and supporting special epidemic investigations when requested. Strong linkages exist between NAMRU-2 and the Naval Medical Research Center, AFRIMS, the Walter Reed Army Institute of Research, and the U.S. Army Medical Research Institute for Infectious Disease. NAMRU-2 also collaborates with the U.S. CDC. Conclusions Laboratory capacity in Jakarta is sufficient to support current GEIS activities in Indonesia. Construction and modification of facilities will provide sufficient space for the expansion of GEIS activities in Cambodia. Joint collaboration between the AFRIMS and NAMRU-2 will enhance the laboratory capacities for GEIS in Cambodia. Indonesian expectations of NAMRU-2 support for development of a central laboratory, including standards development and staff training, will challenge NAMRU-2 staff and will represent an added operational burden. STAFFING At the time of the IOM subcommittee’s visit, NAMRU-2 staff included 23 U.S. military personnel, including 14 scientists. In addition, NAMRU-2 employs a staff of more than 100 foreign service nationals (FSNs). FSN staff include laboratory technicians and contract support personnel with expertise in the areas of management and administration. Dedicated, contracted field personnel manage NAMRU-2 field operations on a full-time basis. All department heads have significant involvement in programs other than GEIS, including MIDRP projects. Within NAMRU-2, a small, dedicated Emerging Disease Program collaborates extensively with other NAMRU-2 programs and is highly dependent on them. NAMRU-2 has recognized the advantage of having additional epidemiological expertise to support GEIS and has requested that additional U.S. CDC personnel be assigned to enhance NAMRU-2’s capacity in epidemiological science. Conclusions NAMRU-2 supports a dedicated, skilled scientific team that effectively fulfills the objectives of GEIS. At present, GEIS is efficiently run under the direction of the Emerging Disease Program director, but the expansion of NAMRU-2 activities in Indonesia, as well as in other countries, will generate additional responsibilities for the staff. The MoH’s new decentralization policy will create a demand for more training and support of national, provincial, and local public health initiatives in Indo-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review nesia. GEIS at NAMRU-2 would benefit from a full-time, on-site coordinator possessing, at a minimum, applied epidemiology and public health experience. The subcommittee was impressed with the high level of staff (DoD, FSN, and contract personnel) commitment to and enthusiasm for GEIS. Staff relationships appeared to be supportive and mutually reinforcing. The committee notes that personnel retention contributes to the formation and enhancement of working relationships and is of particular importance given the emphasis of GEIS on collaborative activities. NAMRU-2 has worked to promote an extensive collaborative and training role in the Indonesian medical community, and 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 addition, no staff are assigned responsibilities for communicating or disseminating surveillance information to other partners. TECHNOLOGY AND INFORMATION MANAGEMENT A tour of the NAMRU-2 facility in Jakarta (including the new BSL-3 space), the warehouse, and the repair shop revealed considerable technical capacity. At the Phnom Penh subsidiary laboratory (under construction), equipment is being procured and installed. A backup generator that will maintain electrical power for all laboratory equipment was in the process of being installed and calibrated. Given current construction and laboratory development efforts, the subcommittee could not assess the available technology in Phnom Penh. In Jakarta, 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. A separate, but currently overloaded server provides support for the Early Warning Outbreak Response System (EWORS); this server will be upgraded in the near future. In Phnom Penh, communications systems are still under development, although telephone linkages with EWORS sites have been established. Within the NAMRU-2 laboratory, frozen specimen archives (approximately 300,000 specimens) are maintained and cataloged electronically with an early DOS-based version of the Laboratory Information Tracking System (LITS) software. The U.S. CDC is committed to revising this software in a Windows environment. Although delays have been encountered in the revision, the new software will improve NAMRU-2’s ability to store and retrieve data contained in the LITS both in Indonesia and at other field sites.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Conclusions In Jakarta, NAMRU-2’s technology needs appear to be adequately met for current GEIS operations. Computer and communications technology (access to the World Wide Web, e-mail, library facilities, and an office computer network) appeared to be adequate to support GEIS. In Phnom Penh, plans for equipping the laboratory appear to be sufficient. SURVEILLANCE To understand NAMRU-2’s role in infectious disease surveillance in Indonesia, it is important to consider the existing programs and plans of the Ministry of Health and its directorates, which include the Indonesian CDC and Litbangkes. According to the senior adviser to the Minister on Environmental and Disease Control, Indonesian public health priority areas include the World Health Organization (WHO) Expanded Program on Immunization, tuberculosis control (considered to be a very serious problem in Indonesia), malaria, dengue and dengue hemorrhagic fever, human immunodeficiency virus (HIV) infection/AIDS, and pneumonia and diarrhea in children. The adviser also mentioned a current epidemic of human rabies that requires public health attention. Infectious disease surveillance in Indonesia is generally inadequate and is confined to passive reporting. All current NAMRU-2 GEIS surveillance activities depend on sentinel surveillance rather than population-based methods. The NAMRU-2 GEIS is conceptually organized around the four pillars defined by the GEIS Central Hub. These pillars are acute febrile illness surveillance, drug-resistant malaria surveillance, surveillance for enteric pathogens, and influenza surveillance. All NAMRU-2 GEIS activities are protocol driven, and protocols are defined before any funding is committed. A great deal of effort was spent to prepare for GEIS implementation and integration of GEIS 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, influenza surveillance, and drug-resistant enteric bacteria surveillance, as well as projects addressing acute febrile illness and entomological surveillance. Within each pillar, NAMRU-2 has developed several specific projects (NAMRU-2, 2000a).

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Acute Febrile Illness Surveillance The EWORS project addresses the GEIS acute febrile illness surveillance pillar. EWORS was developed by NAMRU-2 and the Indonesian MoH, under the auspices of GEIS, with the objective of sharing surveillance information with the Indonesian government. EWORS is designed to collect standardized data to make area-specific and regional comparisons, to transfer information from network hospitals to a central hub, and to use a syndromic surveillance approach to arrive at a working hypothesis for the observed data (NAMRU-2, undated; NAMRU-2, 2000b). NAMRU-2 staff develop and maintain EWORS software and provide the equipment necessary to support the system. In Indonesia, the project makes use of eight strategically located sentinel reporting hospitals that provide timely data to identify epidemics. The identification of epidemics, in turn, leads to joint field investigations with the Indonesian CDC and Litbangkes. The eight hospital sites report syndromic data daily to the central EWORS servers, where analysis may identify greater than expected incidences of certain syndromes. In Cambodia, three sentinel sites have been enrolled in EWORS. EWORS surveillance in Indonesia is limited to patients seeking care from the eight sentinel public health care hospitals. The MoH reported to the subcommittee that previous surveys have indicated that approximately one-third of the Indonesian population seeks care in publicly funded hospitals and that this group probably represents the more disadvantaged segment of the population—the segment most likely to suffer a severe infectious disease burden. The project samples only a portion of the Indonesian population in distinct ecological zones. Data from EWORS have resulted in a small number of epidemiological and laboratory investigations (e.g., investigation of a dengue outbreak). NAMRU-2 has the flexibility to recognize unusual trends through EWORS and to respond to them. Because the MoH considers EWORS-based surveillance to be extremely important for timely reporting of outbreaks, EWORS computers are being installed directly in both Litbangkes and the Indonesian CDC with linkages to the EWORS server for direct national access to the raw data. Drug-Resistant Malaria Surveillance Overall, GEIS goals related to malaria include surveillance, drug resistance monitoring, technology transfer, training of local personnel, and in some instances, provision of supplies and materials to implement specific projects. Clinical and parasitological failures of antimalarial drug therapy will be studied in patients with Plasmodium falciparum or Plasmodium vivax infections. In an area where a dramatic resurgence of malaria

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review has recently been identified, efforts to train and supply MoH personnel to characterize the epidemics are under way. Included in this GEIS-supported project is a study of primaquine drug resistance. The long-term goal of this project is the transfer of a sustainable antimalarial drug resistance program to public health authorities in the host country. The combination of MIDRP and GEIS support, and U.S. National Institutes of Health grant funding for surveillance and research to study multiple aspects of malaria parasite microbiology and drug resistance will contribute to national policy formulation, since current standard therapy in Indonesia with chloroquine and pyrimethamine (Fansidar) is often ineffective. Surveillance for Enteric Pathogens NAMRU-2 has sporadically collected enteric isolates for several years, but now, under the auspices of GEIS, more systematic surveillance efforts are in place. Surveillance sites have been established in seven hospitals (some of which overlap with EWORS sites). These local laboratories isolate and identify a variety of enteric bacteria. Further characterization and antibiotic resistance testing are performed by the NAMRU-2 facility. A variety of enteric pathogens—for example, Vibrio cholerae, Shigella, Salmonella, Campylobacter, and Vibrio parahaemolyticus—are included in the surveillance activity. In addition, NAMRU-2 staff supported by GEIS provide ongoing training and support to personnel at these sites. In some hospitals, existing laboratories have been strengthened; in others, laboratories for surveillance of enteric pathogens have been established under GEIS. Virology and Influenza Surveillance The virology laboratory capacity at NAMRU-2 includes tissue culture capabilities along with serological and molecular biological testing technologies. A mix of MIDRP and GEIS funding supports the laboratory infrastructure. Specimens infected with influenza virus are sent to Australia for characterization, and efforts are not closely coordinated with the DoD Laboratory-Based Influenza Surveillance Program, at Brooks Air Force Base, San Antonio, Texas. Influenza surveillance is conducted under the auspices of GEIS through four sentinel specimen collection sites at two different hospitals and primary health care centers for virus isolation and characterization. Surveillance is complicated by the resistance of the Indonesian population to specimen collection that entails the use of nasopharyngeal swabs. In addition, influenza has not been identified as a national priority, although it is a United States and an international priority. Surveillance activities will be expanded to include a site in Bali, which

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review is a major international travel destination. Basic demographic information will be collected at the time of specimen collection. Conclusions The Indonesian government’s laboratory decentralization policy, along with attempts to build both surveillance and laboratory capacity, will bring challenges for NAMRU-2 and GEIS, which may be called upon to provide training for capacity building as well as continuing its current essential support of the MoH. Improved monitoring of infectious diseases with corresponding epidemic control is a national goal that coincides with the objectives of GEIS. The EWORS project is gathering momentum and is considered extremely important by host-country institutions such as the Indonesian CDC. Data on health care encounters for febrile syndromes is useful for MoH administrative purposes. Rarely is laboratory follow-up conducted to determine the etiologies of syndromes, however. With additional staffing supported by laboratory diagnostic capacity, the utility of EWORS for the monitoring of emerging infectious diseases would be enhanced. EWORS will likely not be the only source of information about epidemics. If a more traditional system of surveillance is established in Indonesia, the importance of EWORS may decline (although it is unclear at this time when the infrastructure needed to support such a system would be available). EWORS requires many resources and, as with all syndromic surveillance globally, still needs to be evaluated to better define its usefulness. Regardless, the establishment of a system for the reporting of syndromes and the provision of feedback to the reporting sites will encourage astute clinicians to report unusual events in a timely manner. EWORS is contributing to building the public health infrastructure in Indonesia through strong collaborative ties with key hospitals and the Indonesian CDC and Litbangkes. GEIS efforts to examine drug-resistant malaria and diseases caused by drug-resistant enteric pathogens are of undeniable importance and are well matched with Indonesian health objectives. NAMRU-2’s extensive mosquito insectary capacity is a major asset for the support of studies of malaria. Transfer of entomological expertise to host-country nationals will assist in reestablishing a lost technical capacity in Indonesia and elsewhere for both malaria and dengue. Improvements in hospital laboratory capacity and the training of locals result from the establishment of enteric pathogen surveillance sites and provide additional benefits for local capacity building. The periodic site visits together with expansion and support of the increased number of sites will result in a vigorous national sentinel surveillance system for diseases caused by enteric pathogens. Dissemination of data to the WHO

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review and other partners for both the prevention and the control of diarrheal diseases will benefit both the host country and the mission of GEIS. Influenza surveillance at the Indonesian sentinel sites is hampered by lack of acceptance of nasopharyngeal specimen collection techniques. Influenza surveillance may yield better results if it is focused on the U.S. and international communities. GEIS influenza surveillance activities at NAMRU-2 may also benefit from closer collaboration with the Department of Defense Laboratory-Based Influenza Surveillance Program. There is considerable concordance between national and GEIS objectives, with some notable exceptions. Despite the value of current GEIS surveillance projects, an important surveillance activity is left unaddressed. The subcommittee heard the MoH express concerns about tuberculosis (TB) and multi-drug-resistant TB (MDR-TB)—disease entities that are public health threats on a global basis. Although TB and MDR-TB do not pose an acute threat to deployed military forces, they certainly pose a long-term threat to the health of those forces and U.S. civilians. To the extent that military personnel deployed overseas become infected with Mycobacterium tuberculosis or MDR M. tuberculosis, the risk to the U.S. civilian population is increased. If it is not brought under control, MDR-TB will continue to pose a threat to U.S. citizens. The TB program in Indonesia is weak, and many cases of TB go undiagnosed and untreated throughout the country. Laboratories are ill equipped to diagnose and monitor drug resistance. In addition, biosafety concerns are frequently not addressed. The HIV epidemic is just beginning in Indonesia, and cases of TB may arise even more rapidly when the two epidemics intersect. GEIS does not contain a tuberculosis pillar, and GEIS may wish to consider addressing this important global public health issue. Surveillance data are distributed to national public health authorities and the GEIS Central Hub. Data are also included in the laboratory’s annual report and published in peer-reviewed scientific journals. Regular dissemination of NAMRU-2’s work to other partners in Indonesia, such as the WHO and the U.S. Agency for International Development (USAID), will enhance partnerships. The subcommittee 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 The response to epidemics in Indonesia through NAMRU-2 GEIS is carried out at the request of and in collaboration with the Indonesian

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review CDC and Litbangkes. PACOM and GEIS resources are both important for supporting NAMRU-2 epidemic investigations. National authorities in other countries (e.g., Vietnam, following flooding) have also requested NAMRU-2 collaboration in epidemic investigations. Laboratory support has been provided for investigations of cholera, dengue, anthrax, pertussis, measles, and hepatitis E epidemics in Indonesia and by invitation in Laos and Vietnam. EWORS has also provided training in epidemic investigations for personnel in the host country. Conclusions At NAMRU-2 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 epidemics in Indonesia and in the region. External funding has also been required to support epidemic investigation capacity. COLLABORATIONS GEIS is integrated with current, ongoing activities within Indonesia’s public health infrastructure. In-country relationships are largely person based and proximity driven, and strong partnerships have resulted over the years. NAMRU-2 GEIS staff seemed very well known and respected by the national health authorities. The interaction between NAMRU-2 and Litbangkes staff is strong. The MoH, primarily Litbangkes, approves all projects funded by GEIS. GEIS activities are transparent to the Indonesian MoH, and most projects are jointly conducted. GEIS-funded NAMRU-2 activities serve the Indonesian MoH in important ways, including support of surveillance, assistance with epidemic response, provision of laboratory diagnosis and reference testing services, and training of personnel. NAMRU-2 has offered at-the-bench laboratory training for a variety of national and international personnel. Medical students, residents, and visiting faculty, both national and international, have benefited from time spent at NAMRU-2 in various training modes. NAMRU-2 collaborates closely with AFRIMS, the U.S. CDC, and other international and national institutions both in Indonesia and in Laos, Cambodia, and Vietnam. NAMRU-2 has been designated a WHO Collaborating Center for Emerging Diseases for Southeast Asia (GEIS, 2000e; NAMRU-2, undated). Collaborative relationships between organizations and agencies with public health interests in Indonesia (including agencies of the Indonesian government, the U.S. government, and international organizations) are quite complex. For example, the subcommittee was advised that the Field

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Epidemiology Training Program was located at a university and was not closely linked to the public health mainstream in Indonesia. Opportunities exist to better leverage the fundamental scientific information generated by GEIS and other NAMRU-2 initiatives with USAID and WHO programming for public health interventions. For example, GEIS has documented the resurgence of malaria in one particular geographical area with considerable ancillary data on drug resistance, parasite type, vectors, and other factors. With financing from USAID and the collaboration of WHO, these data could be used to design a pilot intervention project to control malaria in this region. Results could be scientifically evaluated and the definition of best practices for malaria control in the absence of the use of residual spraying with dichlorodiphenyltri-chloroethane (DDT) could make a major contribution to WHO’s Roll Back Malaria Program. Conclusions NAMRU-2 staff currently involved with GEIS understand and accommodate the need to establish collaborative and collegial networks within the Indonesian and Cambodian scientific and public health communities, and their efforts to do so are producing many positive results. Special credit needs to be given to the energy and vitality that NAMRU-2 FSN and military staff bring to the program. If GEIS is to be successful, it is important that NAMRU-2 continue its efforts to work through the complex set of relationships that exist within Indonesia to seek and foster productive relationships with other organizations and agencies operating in country. Decentralization will bring the need for closer collaboration with levels of government in Indonesia beyond those with which NAMRU-2 has traditionally shared ties. The subcommittee noted that there appears to be weak integration of GEIS and the NAMRU-2 capacity with USAID projects, despite NAMRU-2 efforts to engage USAID as a partner. Although USAID is giving high priority to HIV in Indonesia, its local programming could benefit from the public health data generated by GEIS at NAMRU-2. In addition, the WHO’s leadership of the multiagency Partners for Health project could also benefit from greater knowledge of GEIS-generated data. Although the WHO office in Jakarta is aware and appreciative of NAMRU-2’s contributions, linkages for the sharing of data between these institutions need to be forged and strengthened. RECOMMENDATIONS • GEIS activities at NAMRU-2 are of critical importance to the program as a whole. The committee encourages the DoD to plan for GEIS

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review activities at NAMRU-2 on a long-term basis. NAMRU-2 has already had a substantial impact on Indonesia’s public health infrastructure and has contributed to knowledge of emerging infectious diseases. GEIS should be supported in the region even if political exigencies force the withdrawal of NAMRU-2 from Indonesia. NAMRU-2 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 NAMRU-2 should be long term. • The coordination of training activities is an important but time-intensive GEIS task. This task needs to be assigned to dedicated personnel responsible for organizing, planning, and administering training activities on a full-time basis. Training local personnel in laboratory technology and epidemic response is an important way in which GEIS can be of benefit in Indonesia. Likewise, training U.S. civilian and military personnel in the NAMRU-2 environment may contribute to meeting GEIS’s future recruitment needs as well as to the broader goal of improved global public health surveillance. Recommendation: The development of a structured NAMRU-2-hosted training program should be pursued. • The reporting of data to Indonesian authorities is being done well. In collaboration with the Indonesian MoH, GEIS should make a more concerted effort to share surveillance information with USAID, the WHO, and other relevant institutions working in Indonesia. Data sharing should be timely and systematic and should be targeted toward achieving effective public health action. Recommendation: As GEIS project data are accumulated, they should continue to be used to supplement the national surveillance system and should be better used to help guide public health response through improved sharing of information with international partners, such as the WHO and USAID. • NAMRU-2 has established connections with the political and public health infrastructures in Indonesia and understands the subtleties of how to operate effectively in country. NAMRU-2 should continue to strengthen and expand these connections. NAMRU-2 will need to monitor and to be sensitive to the decentralization policy of the MoH. NAMRU-2 may need to modify its GEIS approaches to enhance communication and cooperation at the provincial and district levels. Assistance from the U.S. ambassador should be sought, as needed, to forge alliances with public health partners.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Recommendation: NAMRU-2 should take continued steps to maintain and enhance the multiple national and international partnerships that are necessary to fulfill the GEIS mission and build national capacity in Indonesia. • GEIS development in Cambodia should continue to be supported through close collaboration between NAMRU-2 and AFRIMS. Recommendation: NAMRU-2 should continue to support the development of the field laboratory in Cambodia. • EWORS is a novel and innovative approach to sentinel surveillance and is one of several surveillance systems that may be useful in Indonesia under a policy of decentralization and reformulation of national surveillance. As a sentinel surveillance system, it needs to be evaluated before decisions are made to greatly expand its use. In addition, greater use of established laboratory capacity to verify the etiology of EWORS-defined syndromes should be initiated to enhance EWORS’s utility for the monitoring of emerging infectious diseases. Recommendation: EWORS should be evaluated for its capacity to serve as an early-warning system for the detection and investigation of epidemics and for the identification of new and novel pathogens before major investments in expanding the system are made. • The current annual approval process does not allow optimal time for project planning or maturation. Furthermore, it is important that the GEIS Central Hub review and approval process for projects provides NAMRU-2 with follow-up guidance regarding project progress in a consistent and timely manner. Recommendation: Consideration should be given to revising the current GEIS project application and review process. • 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 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 NAMRU-2 to better enable diseases outside of the pillar areas to be addressed.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review • Partnerships benefit from knowledge of the local language by senior staff. Partnerships are of increased importance to NAMRU-2 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 rates of retention of personnel. Recommendation: Senior staff at NAMRU-2 actively involved in GEIS projects should be conversant in the dominant language of the host country or should pursue language training, with the support of GEIS, and should seek to become conversant to the extent possible. PEOPLE MET AND INTERVIEWED NAMRU-2 Staff CAPT James R.Campbell, commanding officer, NAMRU-2 CDR William K.Alexander, executive officer, NAMRU-2 LT David G.Uwedjojevwe, administrative officer, NAMRU-2 HMC Jesse U.Ladrillono, administrative chief, NAMRU-2 CAPT(Sel) Andrew L.Corwin, director, Emerging Disease Program, NAMRU-2 LT Paul D.Mills, head, LITS, Emerging Disease Program, NAMRU-2 LT John W.Sisson, head, GEIS Emerging Disease Program, NAMRU-2 CDR Kevin R.Porter, director, Viral Disease Program LT James McArdle, Viral Disease Program HM2 Gregorio G.Flores, Viral Disease Program SSG Jonathan W.Sturgis, Viral Disease Program LCDR B.Anthony Oyofo, director, Bacterial Disease Program, and head, Microbiology Department & Ultrastructure Division CDR Michael Bangs, head, Entomology Department, Parasitic Disease Program LCDR Mark D.Lacy, head, Clinical Studies Department, Parasitic Disease Program HM1 Dennis J.Doolen, Clinical Studies Department, Parasitic Disease Program LCDR Robert A.Gramzinski, head, Immunology Department, Parasitic Disease Program LCDR Jason D.Maguire, head, Parasitology Department, Parasitic Disease Program LT Mazie J.Barcus, head, QA/GCP Department, Parasitic Disease Program

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review MAJ James W.Boles, head, Laboratory Animal Medicine Department LCDR Adorado B.Yabut, comptroller SKCS Aurelio C.Cruz, supply senior chief HM1 David J.Fontannaz, equipment engineer Dr. James Olson, assigned to NAMRU-2 from the U.S. Centers for Disease Control and Prevention, National Center for Infectious Diseases NAMRU-2 Associates Robert Gelbard, ambassador, United States Umar F.Achmadi, director general, Indonesian CDC Sumarjati Arjoso, senior adviser to the Minister on Environmental and Disease Control, Ministry of Health, Republic of Indonesia Sri Astuti S.Soeparmanto, director, Litbangkes, Department of Health, Ministry of Health, Republic of Indonesia Jonathan Ross, public health adviser, Office of Population, Health, and Nutrition, U.S. Agency for International Development Pamela Wolf, senior technical adviser, Office of Population, Health, and Nutrition, U.S. Agency for International Development Leslie Curtin, director, Office of Population, Health, and Nutrition, U.S. Agency for International Development Alene Gelbard, senior communications advisor, Office of Population, Health, and Nutrition, U.S. Agency for International Development Georg Peterson, representative, World Health Organization Dr. Mam Bunheng, secretary of state for health, Ministry of Health, Kingdom of Cambodia ITINERARY Monday, October 2 Overview presentations regarding GEIS at NAMRU-2. Tour of the NAMRU-2 facility. NAMRU-2 GEIS presentations, including presentations on EWORS, outbreak response activities, enteric surveillance, monitoring, malaria drug resistance, influenza surveillance, and regional surveillance of hemorrhagic diseases. Tuesday, October 3 Working visits to Litbangkes, Indonesian CDC, and Ministry of Health and other partners and collaborators (i.e., the Thai Field Epidemiology Training Program, USAID, WHO, agency of the host country re

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review sponsible for epidemiology, collaborating academic partners, etc.), and the U.S. ambassador. Wednesday, October 4 Continued visits to infectious disease surveillance partners and collaborators. Follow-up meeting(s) with NAMRU-2 staff involved with GEIS projects. Thursday, October 5 Conclude Jakarta visit. Depart for Bangkok. Friday, October 6 Travel from Bangkok to Phnom Penh. Meeting with MoH officials. Hospital site visit. Saturday, October 7 Depart hotel. Return to Bangkok for discussion, drafting of preliminary assessment, and assignment of writing tasks. NAMRU-2 site visit concluded.

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