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GEIS at the Armed Forces Research Institute of Medical Sciences, Thailand

The Armed Forces Research Institute of Medical Sciences (AFRIMS) in Bangkok, Thailand, originated in 1959 through an agreement between the governments of the United States and Thailand. The original laboratory was created as the Southeast Asia Treaty Organization’s (SEATO’s) Cholera Research Laboratory. The laboratory was expanded in 1961 to include research on other tropical diseases and was renamed the SEATO Medical Research Laboratory. SEATO was dissolved in 1977, and the U.S. component of AFRIMS was reorganized as a joint Royal Thai Army-U.S. Army medical research laboratory under the overall command of a Royal Thai Army Officer of flag rank. The U.S. component functions as a special foreign activity of the Walter Reed Army Institute of Research (WRAIR) (GEIS, 2000d). Historically, AFRIMS has been closely linked to and collocated with a Royal Thai Army laboratory. It is physically separated from but collaborates with various other national institutions, including the Thai Ministry of Health (Department of Medical Sciences, National Institute of Health, Department of Communicable Disease Control, and the Office of the Permanent Secretary and its Field Epidemiology Training Program) and the Ministry of Agriculture (Department of Livestock Development).

AFRIMS is probably the most sophisticated diagnostic and research laboratory in all of Southeast Asia. For many years, AFRIMS was devoted exclusively to applied research in support of its medical mission. Research programs with a special emphasis on the development of diagnostic tests and therapeutic products for malaria and other tropical febrile illnesses have been successfully developed. AFRIMS research programs



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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review 4 GEIS at the Armed Forces Research Institute of Medical Sciences, Thailand The Armed Forces Research Institute of Medical Sciences (AFRIMS) in Bangkok, Thailand, originated in 1959 through an agreement between the governments of the United States and Thailand. The original laboratory was created as the Southeast Asia Treaty Organization’s (SEATO’s) Cholera Research Laboratory. The laboratory was expanded in 1961 to include research on other tropical diseases and was renamed the SEATO Medical Research Laboratory. SEATO was dissolved in 1977, and the U.S. component of AFRIMS was reorganized as a joint Royal Thai Army-U.S. Army medical research laboratory under the overall command of a Royal Thai Army Officer of flag rank. The U.S. component functions as a special foreign activity of the Walter Reed Army Institute of Research (WRAIR) (GEIS, 2000d). Historically, AFRIMS has been closely linked to and collocated with a Royal Thai Army laboratory. It is physically separated from but collaborates with various other national institutions, including the Thai Ministry of Health (Department of Medical Sciences, National Institute of Health, Department of Communicable Disease Control, and the Office of the Permanent Secretary and its Field Epidemiology Training Program) and the Ministry of Agriculture (Department of Livestock Development). AFRIMS is probably the most sophisticated diagnostic and research laboratory in all of Southeast Asia. For many years, AFRIMS was devoted exclusively to applied research in support of its medical mission. Research programs with a special emphasis on the development of diagnostic tests and therapeutic products for malaria and other tropical febrile illnesses have been successfully developed. AFRIMS research programs

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review in infectious diseases, including diarrheal disease, malaria vaccine and drug research, viral diseases (specifically, dengue fever and hepatitis), entomology and disease vector research, and retrovirology (including human immunodeficiency virus [HIV] infection/AIDS), existed long before the introduction of the Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS). In some ways GEIS represents a new departure for AFRIMS, although in other ways GEIS is a natural extension of the field research that has been AFRIMS’s mainstay. For example, the GEIS malaria pillar complements ongoing surveillance for antimalarial drug resistance, whereas surveillance for acute febrile illness is a somewhat new area of involvement. AFRIMS’s overall strategy integrates GEIS activities into traditional research streams to leverage AFRIMS resources and expertise already in place, to reduce program overhead costs, and to complement the activities of the Thai government. This integration results in more than 80 percent of GEIS funds being allocated to program implementation rather than overhead costs. In addition, this integration complements and reflects the activities of the Thai government. AFRIMS’s annual budget ranges from $5 million to $7 million and is derived from multiple sources, including the Military Infectious Disease Research Program (MIDRP), HIV prevention and vaccine development programs, the U.S. National Institutes of Health (NIH), various biotechnology and pharmaceutical companies, and the World Health Organization (WHO). GEIS funding for fiscal year 2001, approximately $1,075,000 (GEIS, 2000c), complements these multiple sources of funding. GEIS funding was delayed in the first year of the program, and at the time of the subcommittee’s visit, GEIS was in its first full year of funding and many projects were just getting under way. A subcommittee of the Institute of Medicine (IOM) Committee to Review the Department of Defense (DoD) Global Emerging Infections Surveillance and Response System visited AFRIMS from October 9 to 13, 2000. The IOM subcommittee consisted of committee members Ruth Berkelman, Donald Burke, 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 AFRIMS has an extensive laboratory facility housed within a 191,000square-foot laboratory building and animal research unit (GEIS, 2000d). AFRIMS is jointly housed with and shares laboratory space with Royal Thai Army facilities. AFRIMS also occupies a large, modern, extremely well equipped veterinary medicine and animal facility that operates primarily at biosafety level 2. In addition, AFRIMS is linked to approxi-

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review mately 38 field sites in Thailand, Nepal, Vietnam, and Cambodia. AFRIMS supports projects at a Naval Medical Research Unit 2 (NAMRU-2)-maintained subsidiary laboratory in Phnom Penh, Cambodia. This facility provides AFRIMS with an operational base site for additional laboratory and epidemiological studies, including disease surveillance activities. At AFRIMS, a traditional scientific organizational structure consisting of emerging infectious disease, bacteriology, virology, parasitology, and entomology departments is maintained with extensive capacities in immunology, pharmacology, molecular biology, arthropod culture, and tissue and cell culture. AFRIMS’s Bangkok 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 Association for the Assessment and Accreditation of Laboratory Animal Care-International accredits the laboratory animal facility (GEIS, 2000d). AFRIMS possesses an extensive collection of frozen specimens that are archived in a large number of freezers located throughout the hallways of the laboratory. The specimens are not cataloged centrally through electronic means. Each individual AFRIMS laboratory is responsible for maintaining its own collection. AFRIMS currently uses its laboratory capacity to support Thailand’s infectious disease diagnostic efforts by providing reference testing services, diagnostic support, and support for special epidemic investigations when requested. Thai public health priority areas, along with AFRIMS’s training activities, are incorporated into GEIS project areas. Conclusions The laboratory capacity at AFRIMS is sufficient to support current GEIS program activities in Thailand. Nevertheless, AFRIMS laboratories are severely constrained by a lack of adequate laboratory space. All laboratories are severely cramped. Hallways are crowded with freezers housing the extensive collections of specimens maintained by departmental laboratories. There has been little expansion of space over the years, despite the addition of new equipment (e.g., flow cytometers, systems for polymerase chain reaction capacities, etc.) and staff. Technical resources for the laboratory appear adequate, but laboratory space is insufficient. STAFFING At the time of the IOM subcommittee’s visit, AFRIMS staff included a total of 306 professional and support personnel (22 U.S. Army staff, 122 foreign service national staff, and 162 contracted personnel). Royal Thai Army staff are not included in this total. In the field, AFRIMS supports 16

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review nonmilitary staff in Nepal with funding from MIDRP and the NIH. There is no written agreement between the government of Nepal or its national institutions and AFRIMS or the U.S. government acknowledging or providing support for this field station. FSN staff include senior researchers, laboratory technicians, and contract support personnel, including veterinary and animal care technicians and individuals with expertise in the areas of management and administration. GEIS is not a department at AFRIMS. Although the GEIS coordinator works within a specific department, GEIS operates as part of the mission of all departments. All department heads have significant involvement in programs other than GEIS, including MIDRP projects. In addition, AFRIMS staff are actively engaged in a multitude of training activities, both formal and informal, for a variety of personnel (laboratory technicians; field survey personnel; and students from the United States and Southeast Asian national and regional institutions, including master’s and doctoral candidates, physicians and medical students, and others). Training activities are undertaken without dedicated funding to support the organization and implementation of training activities.1 Conclusions At AFRIMS, GEIS benefits from a dedicated, skilled scientific team, but there is little expertise in epidemiology and public health. The GEIS coordinator needs to possess experience and extensive applied epidemiology and public health expertise for GEIS to reach its objectives. Regional expansion of AFRIMS’s activities in Thailand, as well as in other countries in Southeast Asia, will generate additional responsibilities for the GEIS coordinator. Training needs at the national and regional levels are likely to continue in the future. The subcommittee was impressed with staff members’ (DoD, FSN, and contract personnel) commitment to and enthusiasm for GEIS projects. Staff relationships appeared to be supportive and mutually reinforcing. The committee notes that retention of personnel contributes to the formation and enhancement of working relationships and is of particular importance given the emphasis of GEIS on collaborative activities. 1   Training for national, international, and U.S. personnel is compatible with the Presidential Directive, that is, “Expand formal training and outreach to health care providers” (NSTC, Executive Office of the President, 1996).

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review TECHNOLOGY AND INFORMATION MANAGEMENT A tour of the AFRIMS facility in Bangkok, including the renovated veterinary medicine and animal facility, revealed considerable technical capacity. 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. Conclusions In Bangkok, AFRIMS’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 adequate to support GEIS. In Phnom Penh, plans for equipping the laboratory appear to be sufficient. The introduction of computer-based uniform cataloging software would improve AFRIMS’s ability to store and retrieve the data and specimens contained in its extensive collection. SURVEILLANCE At AFRIMS GEIS includes four standard pillars defined by the GEIS Central Hub (AFRIMS, 2000). These pillars are drug-resistant malaria surveillance, surveillance for enteric pathogens and antibiotic resistance, acute febrile illness surveillance, and influenza surveillance. AFRIMS has developed several specific projects within each pillar. In addition, AFRIMS has developed veterinary medicine projects (zoonotic disease surveillance) with GEIS funding. In the conduct of these studies (e.g., studies of leptospirosis), GEIS-supported staff work closely with the Thai Ministry of Agriculture. AFRIMS has also developed extensive expertise for the study of scrub typhus, a commonly encountered cause of febrile illness in Thailand. AFRIMS has under way studies of both the vector and the rickettsial agent of scrub typhus. Thailand’s network of regional and local hospitals provides an extensive infrastructure for infectious disease reporting. AFRIMS does not play a major role in the Thai national surveillance system and thus is not involved in the day-to-day management of infectious disease programs including epidemic investigations. Through joint collaborations, common research studies, and a long history of mutual assistance, Thai public health authorities have come to value AFRIMS’s expertise and unique

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review capabilities in specific infectious diseases, especially malaria. AFRIMS’s contributions are uniquely suited to meet the specific needs of individual countries in the Southeast Asian region. AFRIMS has made a conscious decision to concentrate GEIS field activities in border areas (especially in the west, along the Thai-Myanmar [Burma] border) because the Thai Ministry of Public Health has extensive surveillance coverage and health care service delivery capacities in the more central geographical areas of the country and because large numbers of displaced individuals, including refugees, are located in these areas. AFRIMS’s infectious disease surveillance activities are generated by specific study protocols and are generally limited to patients seeking care at public and nongovernmental (missionary) health care facilities. The subcommittee did not ascertain the proportion of the Thai population that is estimated to seek care in publicly funded or missionary hospitals. Presumably, this segment of the population represents the more disadvantaged segment that is most likely to suffer a severe burden of infectious disease. GEIS projects sample only a portion of the Thai population in distinct ecological zones. All current GEIS surveillance activities depend on sentinel surveillance rather than population-based methods. Sentinel surveillance is, however, a reasonable approach for a supplemental surveillance activity such as GEIS. Drug-Resistant Malaria Surveillance AFRIMS’s malaria research program is long-standing and internationally recognized. Funds from multiple sources support a variety of projects. The largest funding source is MIDRP. AFRIMS’s malaria research program is well situated in Thailand, where all four vectors and malaria species are present and significant drug resistance occurs. AFRIMS carries out extensive surveillance and testing for drug-resistant strains. As a result, AFRIMS has traditionally participated in the development and field testing of new therapeutic agents (e.g., tafenoquine) and combination therapies (e.g., mefloquine-artesunate). In addition, basic research on malaria vaccine candidates as an alternative to therapeutic and prophylactic drugs continues. Malaria research at AFRIMS is backed up with an extensive insectary and entomological expertise. Studies are conducted in multiple field sites along the northwest border with Myanmar and the eastern border with Cambodia, as well as in the Hospital for Tropical Diseases at Mahidol University in Bangkok. In addition, field sites exist in Vietnam, Nepal, and Bangladesh. The malaria surveillance and research effort is a single integrated program, and GEIS funding is used to support its ongoing surveillance for resistant strains. In addition, GEIS efforts in acute febrile illness surveillance are piggybacked on the infrastructure created at malaria field

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review sites. This integration was clearly demonstrated for the subcommittee during the field visit to the Sangkhlaburi study site in rural Thailand, along the Myanmar border. Surveillance for Enteric Pathogens and Antibiotic Resistance AFRIMS has sporadically collected enteric isolates for several years, but now, under the auspices of GEIS, more systematic surveillance efforts are being developed by a recently appointed director for this activity. Enhancement of surveillance activities for enteric pathogens, improvement of the local laboratory infrastructure, and tracking of antibiotic resistance patterns are all program goals. Laboratory capacity includes molecular genetics capabilities. Case-control studies in Thailand (at three sites, including locations involved in the military exercise Operation Cobra Gold), Vietnam, and Nepal have identified Salmonella, Shigella enterotoxigenic Escherichia coli, and Campylobacter as common pathogens. Isolate characterization and antibiotic resistance testing are performed by the AFRIMS facility. Specimens from cholera epidemics have also been collected. Additional sentinel surveillance sites in Thailand, Nepal, and Vietnam are planned. The criteria used to select these sentinel sites include access to travelers, ease of implementation, and use of existing field sites. Of six proposed enteric pathogen surveillance projects, three are currently funded. Acute Febrile Illness Surveillance Surveillance for acute febrile illness is based in sentinel surveillance sites that were established previously for other projects, such as long-standing antimalarial drug resistance surveillance sites. New sites (e.g., Chiang Rai Hospital) are being developed with GEIS funding. GEIS-coordinated acute febrile illness surveillance recently began at the Kamphaeng Phet Provincial Hospital, which has been a virology-dengue sentinel site since the 1980s. The records of hospitalized patients are reviewed daily for dengue-like illness, encephalitis, hemorrhagic fever or sepsis, febrile respiratory infection, hepatitis or jaundice, malaria, and unexplained sudden death. Nevertheless, surveillance is passive, with no proactive component for a quick response to trends in specific syndromes. Reports of syndromes appear to be analyzed months after they are reported, thus limiting the opportunity for timely epidemiological investigation and providing little opportunity for specimen collection and accurate diagnosis. The subcommittee visited the malaria-acute febrile illness sentinel surveillance site in Sangkhlaburi, a small town in the tropical rain forest very close to the Myanmar border in western Thailand. The site is located

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review in an established missionary hospital serving a predominantly rural and displaced population living along the border. Surveillance is set up to evaluate the incidence of emerging diseases in febrile patients in both the inpatient and outpatient settings. This sentinel site has documented a significant incidence of leptospirosis among febrile patients. These patients had previously been misdiagnosed with malaria. Malaria, leptospirosis,2 and undifferentiated pneumonia are common diagnoses confirmed by the AFRIMS laboratory on site. A significant proportion of all fever cases are undiagnosed, on the basis of AFRIMS and missionary hospital data. Virology and Influenza Surveillance The virology laboratory capacity at AFRIMS is extensive for specific viral entities, including flavivirus (the agent of dengue) and hepatitis viruses. AFRIMS’s virological capacity and interests go well beyond the goals of GEIS. A mixture of MIDRP and GEIS funding supports the virology laboratory infrastructure. Influenza surveillance is conducted as part of the DoD Laboratory-Based Influenza Surveillance Program, Brooks Air Force Base, San Antonio, Texas. GEIS-supported sentinel sites for specimen collection exist in Nepal and Thailand. Emphasis is on the collection of specimens from travelers and trekkers who acquire influenza viruses through their travels. Specimens are sent to Brooks Air Force Base for processing. Only 39 specimens from Thailand and Nepal had been collected at the time of the subcommittee’s visit. A Thai influenza laboratory, linked to the WHO Influenza Collaborating Reference Laboratory in Australia, conducts separate influenza surveillance activities. The Thai laboratory has collected more than 100 specimens for processing through the WHO system. Conclusions There is considerable concordance between Thai national and GEIS objectives, with some notable exceptions. Thai public health authorities often mentioned tuberculosis (TB) and multi-drug-resistant TB (MDR-TB) as serious national concerns. Although MDR-TB does not pose an acute threat to deployed military forces, it certainly poses 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 MDR Mycobacterium 2   According to AFRIMS, 27 percent of the patients with fever and rash were diagnosed with leptospirosis.

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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. If it is not brought under control, MDR-TB will continue to pose a threat to U.S. citizens. The current GEIS does not contain a tuberculosis pillar, and GEIS may wish to address this important global public health issue. GEIS efforts to examine drug-resistant malaria and drug-resistant enteric disease pathogens are of undeniable importance and are well matched with Thai health objectives. The combination of MIDRP, GEIS, NIH, WHO, and pharmaceutical company funding for malaria surveillance and research supports projects that will contribute to national health policy formulation, as well as to the global WHO Roll Back Malaria Program, and military health objectives. Surveillance of antimicrobial resistance in enteric pathogens is just beginning, and linkages to the Ministry of Health to share the resulting data are needed. Timely sharing of surveillance results is important for the development of informed national policies for human, animal, and agricultural antibiotic use. AFRIMS staff, supported by GEIS, provide considerable training in the course of establishing enteric pathogen sentinel sites in the Southeast Asian region. Improvements in hospital laboratory capacity also result from the establishment of enteric pathogen surveillance sites and contribute to the building of local public health capacity. Syndromic surveillance is a valuable tool for rapid decision making; however, it requires timely investigation and laboratory diagnosis to confirm the etiologies of the syndromes. Epidemiological investigation of unusual trends in acute febrile syndromes, along with active feedback of surveillance results to the reporting institutions, is necessary to establish a robust system for detection of unusual events. Timely analysis of trends in syndromic surveillance, coupled with laboratory diagnosis and strong interactions with the reporting institutions, may create an environment in which rapid notification of an unusual event by an astute clinician will occur. The initial work at Sangkhlaburi on acute febrile illness with AFRIMS laboratory support is exemplary. Data from GEIS acute febrile illness surveillance efforts have resulted in epidemiological and laboratory investigations into new areas (e.g., leptospirosis and scrub typhus in both Thailand and Cambodia). The results of this program can aid in development and treatment efforts in Thailand and the region. However, acute febrile illness surveillance efforts would benefit from a reevaluation of project goals. If the purpose is to find a previously unknown pathogen, protocols to study specific syndromes need to be developed. For example, at the Sangkhlaburi and Kamphaeng Phet Hospitals, a significant proportion of the patients present with a pulmonary infection syndrome, but no specific protocol has been developed to pursue a laboratory diagnosis in this subgroup. Similarly, other acute febrile

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review syndromes could be explored one by one. On the other hand, if the overall purpose of the surveillance is to evaluate rapid methods for the detection of multiple disease agents (e.g., Dip-S-Ticks, currently in use) or to identify persons infected or colonized with known pathogens for further study of risk factors associated with their illness, then other types of studies are required. Influenza surveillance as currently structured in Bangkok may be redundant in the presence of a WHO collaborating laboratory in Thailand. Focusing specimen collection efforts on other populations not sampled by the WHO collaborating laboratory, for example populations of travelers, trekkers in Nepal, and U.S. Embassy personnel, may more effectively supplement the surveillance conducted by the national center. 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 AFRIMS participation in response efforts in Thailand is usually requested only when AFRIMS specialized expertise or capabilities are needed. AFRIMS GEIS response to epidemics in Thailand is usually carried out in collaboration with the Thai Department of Communicable Disease Control (Thai CDC) and the Thai Field Epidemiology Training Program (FETP). National authorities in other countries have also requested AFRIMS collaboration in investigations of epidemics. AFRIMS has collaborated in identifying the causative pathogens in several epidemics of acute febrile illness. As GEIS project data accumulate, ongoing epidemiological analyses of these data may be used to identify unusual events and possible epidemics. Conclusions At AFRIMS GEIS possesses unique 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 Thailand and in the region. COLLABORATIONS To understand AFRIMS’s role in infectious disease surveillance in Thailand, it is important to consider the existing programs and plans of

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review the Ministry of Health and its relevant components, that is, the Department of Medical Sciences (DMS), which includes the National Institute of Health; the Thai CDC; and the Office of the Permanent Secretary, which houses the Field Epidemiology Training Program. In addition, the Ministry of Agriculture’s Department of Livestock Development is an important collaborating institution. Steps have been taken to integrate GEIS with current, ongoing activities within Thailand’s public health infrastructure. In-country relationships are person based as well as position based, and strong partnerships have resulted over the years. GEIS-funded AFRIMS activities serve the Thai Ministry of Health in important ways, including support of surveillance, assistance with epidemic response, provision of laboratory diagnosis and reference testing services, and training of personnel. AFRIMS has offered at-the-bench laboratory training for a variety of national and international personnel. Medical and public health students, residents, and visiting faculty—national and international—have benefited from time spent at AFRIMS in various training modes. AFRIMS collaborates closely with NAMRU-2, the U.S. Centers for Disease Control and Prevention (U.S. CDC), and other international and national institutions both in Thailand as well as in Nepal, Cambodia, and Vietnam. According to the director general of the DMS, Paijit Warachit, Thai Ministry of Health priority areas are, first and foremost, HIV infection, malaria, and tuberculosis. Other priority areas include dengue, encephalitis, leptospirosis, diarrheal diseases, and emerging infectious diseases, especially those that cross land borders. Thailand is completing the fifth year of its Eighth National Health Plan and will shortly begin a new 5-year plan (the ninth). The new plan contemplates the merging of the Thai CDC, the Office of Epidemiology (Office of Permanent Secretary), and the DMS into a single program area. AFRIMS is seen as a potential collaborator with the Thai Ministry of Health emerging infectious disease program in light of its expertise and its linkages with other international laboratory networks. Previous collaboration has been ad hoc and project oriented, although opportunities for more structured collaboration may arise. Laboratory support for surveillance (e.g., to help process specimens from the Mekong Malaria project), assistance with building a national laboratory capacity, information exchange, and facilitation of linkages to international laboratory expertise were areas identified for AFRIMS collaboration with the DMS and the Thai CDC. There appeared to be good relations with the U.S. CDC field station located near the Thai CDC; however, there was relatively little collaboration with AFRIMS, although the committee notes that the U.S. CDC is planning to expand its involvement in Thailand as part of a new U.S. CDC initiative (Dowell, 2001). Linkages between AFRIMS GEIS acute febrile illness surveillance activities and national epidemic investigation capacity were not clear. For

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review instance, the relationship between AFRIMS and the established Thai FETP and the Mekong Malaria project, involving epidemiological collaborations between among the six nations joined by the Mekong River, was unclear. In a conversation between one of the IOM subcommittee members (R.St. John) and Somsak Wattanasri, current director of the Ministry of Health’s International Health Office and former director of the Thai FETP in the Office of the Permanent Secretary, it was noted that ties with AFRIMS were much stronger in the past. Since FETP moved to the main Ministry of Health complex in Nonthaburi, some distance from the center of the city, the level of FETP-AFRIMS collaboration appears to have declined significantly. Strong traditional linkages exist with the research departments at WRAIR and various U.S. academic institutions. There are ongoing collaborations with multiple laboratories in both the academic and private sectors in such areas as antimalarial drug research. Ongoing relationships with academic institutions continue to provide AFRIMS with substantial expertise. AFRIMS has a long-standing collaboration with the Harvard School of Public Health for studies of Ehrlichia spp. Other institutions have collaborated in many research studies of dengue. Although AFRIMS has the flexibility required to recognize many but not all new pathogens identified through sentinel surveillance networks, with the broad variety of pathogenic agents encountered in Southeast Asia, the staff expressed an ongoing need to identify additional institutions with unique in-depth expertise in the detection of emerging pathogens. From time to time, AFRIMS may require in-depth expertise from outside sources. For example, the laboratory identification of strains of Leptospira (the agent of leptospirosis) is sometimes difficult, and additional expertise available in other U.S. institutions may be required. Additional linkages with other institutions for in-depth expert support would facilitate rapid collaboration for the identification of unusual pathogens. Conclusions AFRIMS staff currently involved with GEIS understand and accommodate the need to establish collaborative and collegial networks with the Thai, Nepalese, Vietnamese, and Cambodian scientific and public health communities, and their efforts to do so are producing many positive results. The collaborative relationships between and among organizations and agencies with public health interests in Thailand (including agencies of the Thai government, the U.S. government, and international organizations) are quite complex. Additional opportunities exist to share the fundamental scientific information generated by GEIS and other AFRIMS initiatives with institutions in the host country (e.g., in the area of enteric

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review pathogens) and to strengthen relationships between AFRIMS and the Thai CDC and FETP. If GEIS is to be successful, AFRIMS must continue to work through the complex set of relationships that exist within Thailand and continue to work with other in-country international organizations and agencies on a continual and productive basis. Satellite laboratories and sentinel surveillance sites in Southeast Asia are most likely to operate efficiently and effectively if GEIS efforts are coordinated among GEIS consortium members in the region (including AFRIMS, NAMRU-2, and the 18th Medical Command in Korea). AFRIMS has worked to promote an extensive collaborative and training role in the Thai medical community, and such efforts can be expanded through GEIS. However, training for GEIS-related projects can be time-consuming, 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. RECOMMENDATIONS • GEIS activities at AFRIMS are of critical importance to GEIS as a whole. The committee encourages the DoD to plan for GEIS activities at AFRIMS on a long-term basis. AFRIMS 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 AFRIMS should be long term. • Data obtained from GEIS projects should be evaluated and, where useful, reported to Thai authorities and other relevant institutions working in Thailand and Southeast Asian countries, as well as regional WHO offices. Reporting should be timely and systematic and should be targeted toward achieving effective public health action. Recommendation: As GEIS project data are accumulated, they should be better used to supplement national and regional surveillance systems and to help guide public health responses through improved reporting to authorities in the host country. • AFRIMS has established connections with the political and public health infrastructures in Thailand and understands the subtleties of how to operate effectively in country. AFRIMS should continue to strengthen and expand these connections and take steps to overcome the geographical separation of GEIS from the Thai Ministry of Health. In particular, AFRIMS should consider reestablishing stronger ties with FETP, which

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review can serve as a link to multinational surveillance and epidemic investigation efforts, such as the Mekong Malaria project. Assistance from the regional unified combatant command and the U.S. ambassador should be sought, as needed. Recommendation: AFRIMS should continue to take steps to maintain and enhance the multiple national and international partnerships that are necessary to fulfill the GEIS mission. • 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 AFRIMS to better enable diseases outside of the pillar areas to be addressed. • To avoid duplication of efforts and to fully benefit from existing capabilities, all GEIS activities in Southeast Asia (e.g., those GEIS activities maintained by AFRIMS, NAMRU-2, and the 18th Medical Command) should be closely coordinated. Recommendation: AFRIMS GEIS efforts should be coordinated with the efforts of other DoD facilities (i.e., laboratories, the GEIS Central Hub, and other GEIS partners) that host GEIS projects in the region. Recommendation: To fully realize GEIS objectives, AFRIMS should have a full-time, on-site GEIS program manager who possesses expertise in applied epidemiology and public health. • Current approaches to influenza surveillance in Thailand may require revision to avoid duplication of effort with laboratories that currently participate in the WHO influenza surveillance network. Influenza surveillance would be more fruitful if it was coordinated with laboratories that currently participate in the WHO influenza surveillance system to avoid duplicate sampling of the same populations. AFRIMS surveillance could concentrate on different populations not sampled by the WHO site, such as travelers seeking care in U.S. Embassy facilities in Thailand, Nepal, and other countries.

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Recommendation: Influenza surveillance efforts should be coordinated with the Thai WHO collaborating laboratory. • The coordination of training activities is an important but time-intensive task of GEIS. This task should be assigned to dedicated personnel whose full-time responsibility is the organizing, planning, and administration of training activities. Training of local personnel in laboratory technology is an important way in which GEIS can be of benefit in Thailand. Likewise, because AFRIMS capabilities are unique, training of U.S. civilian and military personnel in the AFRIMS environment may contribute to meeting GEIS’s future recruitment needs, as well as training needs within the DoD and public health community more generally. Recommendation: The development of a structured AFRIMS-hosted training program should be considered. • Partnerships benefit from knowledge of the local language by senior staff. Partnerships are of increased importance to AFRIMS 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 AFRIMS actively involved in GEIS projects should be conversant in the dominant language of the host country or should pursue, with the support of GEIS, language training, and should seek to become conversant to the extent possible. • The current annual approval process does not allow optimal time for AFRIMS project planning or maturation. Furthermore, it is important that the GEIS Central Hub review and approval process for GEIS projects provides AFRIMS 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 AFRIMS Staff COL G.Dennis Shanks MAJ Gaye Ruble LTC Art Brown MAJ (P) Russ Coleman

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review LTC Carl Mason LTC Timothy Endy LTC David Ruble MAJ R.Scott Miller Chansuda Wonsrichanalai MG Gobchoke (Royal Thai Army) AFRIMS Associates Ambassador Richard Hecklinger, United States Dr. Rapeegong Vongdee, director general, Ministry of Agriculture Dr. Paijit Warachit, deputy director general, Department of Medical Sciences, Ministry of Public Health Dr. Supamit, director, Division of General Communicable Disease Dr. Kamnuan, director, FETP Dr. Sonchai, dean, Faculty of Tropical Medicine, Mahidol University Dr. Pathom Sawanpanyalert, director, Department of Medical Sciences, National Institute of Health, Ministry of Public Health Dr. Sornchai Looareesuwan, dean, Faculty of Tropical Medicine, Mahidol University Dr. Punnee Pitisuttithum, Vaccine Trial Center, Faculty of Tropical Medicine, Mahidol University Dr. Srivicha Krudsood, Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University Dr. Somsak Wattansari, director, International Health Office, Ministry of Public Health ITINERARY Monday, October 9 0800 Depart hotel 0800 Meet with Dr. Rapeegong, Ministry of Agriculture 1030 Group meeting at the Ministry of Public Health Dr. Paijit, deputy director general, Department of Medical Sciences Dr. Supamit, Director, Division of General Communicable Disease Dr. Kamnuan, Director, FETP 1230 Lunch 1400 Meet with Dr. Sonchai, dean, Faculty of Tropical Medicine, Mahidol University 1630 Return to hotel

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review Tuesday, October 10 0800 Depart hotel 0830 Arrive at AFRIMS; meet with AFRIMS commander, MG Gobchoke, RTA 0900 IOM in brief 0915 USAMC-AFRIMS Commander, COL Dennis Shanks-overview of AFRIMS/mission 0945 AFRIMS-GEIS overview, MAJ Gaye Ruble 1015 Break 1030 Department briefs (30–45 minutes each) Retrovirology—LTC Art Brown Entomology—MAJ (P) Russ Coleman Enterics—LTC Carl Mason Virology—LTC Timothy Endy 1215 Lunch (at AFRIMS, room 302)—XO, officers, Thai scientists 1330 Depart for U.S. Embassy (IOM team, COL Shanks, MAJ Ruble) 1430 Meet with Ambassador Hecklinger 1515 Depart U.S. Embassy 1600 Return to hotel Wednesday, October 11 0800 Depart hotel 0830 Arrive AFRIMS Finish departmental briefs and tour facility Entomology Immunology Enterics Virology Retrovirology (time permitting) 1130 Lunch and depart for Sangkhlaburi (LTC Ruble, MAJ (P) Miller, MAJ Ruble, and IOM team) 1830 Arrive Sangkhlaburi Thursday, October 12 0800 Immunology brief, MAJ (P) Scott Miller Veterinary medicine brief, LTC David Ruble 0930 Tour hospital, villages Meet with local collaborators 1200 Lunch

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Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System: A Program Review   Depart Sangkhlaburi 1900 Arrive Bangkok Friday, October 13 0800 Depart hotel 0830 Arrive AFRIMS Final questions for AFRIMS staff 0900 Private IOM discussions; IOM out-brief, official good-byes