10
Overarching Conclusions and Recommendations

In the preceding chapters the committee has provided site-specific conclusions and recommendations for improving the avian influenza/pandemic influenza (AI/PI) activities of the Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS) at DoD-GEIS headquarters and at each of the DoD-GEIS-supported laboratories. This chapter outlines the committee’s overarching recommendations for the DoD-GEIS influenza program and describes the steps the committee feels that the program should take in order to achieve and strengthen a sustained DoD-GEIS influenza surveillance and response effort.

These recommendations are based on the following evaluation criteria identified by DoD-GEIS: (1) consistency with DoD and national plans; (2) the utility of each funded project’s contribution to a comprehensive AI/PI surveillance program; (3) adequacy of the program in view of the evolving epidemiologic factors; and (4) coordination of efforts with the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and local governments. In addition, these recommendations seek to address the DoD-GEIS response to the congressional mandate of Sec. 748, H.R.1815, Pandemic Avian Flu Preparedness. Points 7 through 9 from this mandate relate specifically to DoD-GEIS:

  1. Surveillance efforts domestically and internationally, including those using the Global Emerging Infections Systems (GEIS), and how such efforts are integrated with other ongoing surveillance systems.

  2. The integration of pandemic and response planning in the Depart-



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10 Overarching Conclusions and Recommendations I n the preceding chapters the committee has provided site-specific conclu- sions and recommendations for improving the avian influenza/pandemic influenza (AI/PI) activities of the Department of Defense Global Emerg- ing Infections Surveillance and Response System (DoD-GEIS) at DoD-GEIS headquarters and at each of the DoD-GEIS-supported laboratories. This chapter outlines the committee’s overarching recommendations for the DoD-GEIS influenza program and describes the steps the committee feels that the program should take in order to achieve and strengthen a sustained DoD-GEIS influenza surveillance and response effort. These recommendations are based on the following evaluation criteria identified by DoD-GEIS: (1) consistency with DoD and national plans; (2) the utility of each funded project’s contribution to a comprehensive AI/PI surveillance program; (3) adequacy of the program in view of the evolving epidemiologic factors; and (4) coordination of efforts with the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and local governments. In addition, these recommendations seek to address the DoD-GEIS response to the congressional mandate of Sec. 748, H.R.1815, Pandemic Avian Flu Preparedness. Points 7 through 9 from this mandate relate specifically to DoD-GEIS: (7) Surveillance efforts domestically and internationally, including those using the Global Emerging Infections Systems (GEIS), and how such efforts are integrated with other ongoing surveillance systems. (8) The integration of pandemic and response planning in the Depart- 0

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0 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS ment of Defense with the planning of other Federal departments, including the Department of Health and Human Services, the Department of Home- land Security, the Department of Veterans Affairs, the Department of State, and USAID. (9) Collaboration (as appropriate) with international entities engaged in pandemic preparedness and response. CONSISTENCY WITH DEPARTMENT OF DEFENSE AND NATIONAL PLANS Department of Defense Plans Executive Agency Before 1997 the DoD influenza surveillance program consisted largely of the surveillance program of the U.S. Air Force. With the establishment of GEIS in the late 1990s and, more recently, with the $39 million fiscal year 2006 avian influenza supplement, the program has grown to include efforts far beyond those of the historic air force program (see Figure 10-1). These efforts include multimillion-dollar programs at the five DoD overseas labs and at the Naval Health Research Center in San Diego. Some of these new players have built enough independent laboratory capacity that they no longer are dependent on the laboratory services of the Air Force Institute for Operational Health (AFIOH). This has effectively moved AFIOH toward the margin. This independence from AFIOH and the difficulty that AFIOH experiences in directing and assembling timely data from a myriad of non-air force entities scattered around the world suggests that the overall DoD influenza effort should be administratively reorganized so as to effect better communications, direction, and data management. RECOMMENDATION 10-1. The executive agency functions of the DoD influenza and respiratory disease surveillance program should be reexamined in light of the evolution of the program in response to the potential of pandemic influenza. DoD-GEIS headquarters should be formally charged with providing managerial and technical oversight (quality assurance, safety, etc.) of the multi-service influenza and respi- ratory disease program and of the revised structure, including a codified chain of accountability. A key part of this recommendation would be to tie the funding source (GEIS headquarters) to the global oversight function by moving the execu- tive agency from AFIOH (see Box 9-1) to GEIS headquarters. This tran-

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0 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS FIGURE 10-1 Department of Defense influenza surveillance sites worldwide, 2007. SOURCE: DoD-GEIS, 2007b. Figure 10-1 sition would strengthen DoD-GEIS headquarters’ leadership role in the execution of DoD-GEIS influenza activities as well as improve the execution of the program. Relocating the top-level leadership, data synthesis, and coordination functions to GEIS headquarters makes sense for a number of reasons: GEIS headquarters has growing technical depth with respect to influenza; it is located near the Walter Reed Army Institute of Research and the Naval Medical Research Center headquarters for the DoD overseas labs (which between them are conducting most of the surveillance); it is located near the U.S Food and Drug Administration (FDA); and it is located near most of the key offices for DoD health leadership and influenza leadership at the Department of Health and Human Services (HHS). DoD Communication and Coordination The current level of collaboration among domestic and overseas labo- ratories and between the overseas laboratories and the DoD-GEIS head- quarters is commendable, but it could be improved. Despite efforts to foster interlaboratory dialogue and information sharing, certain laboratories ap- peared to be working in isolation and would benefit from additional infor- mation sharing and closer collaboration. Most laboratories are relatively new to the influenza field, and the learning curve over the past fiscal year has been steep.

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0 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS RECOMMENDATION 10-2. Structured communication mechanisms should be strengthened between DoD-GEIS headquarters and field sites (domestic and international) as well as among sites to create a func- tional network to enhance coordination of influenza and respiratory disease surveillance activities (epidemiologic, clinical, and laboratory) and to share best practices among all sites. Each laboratory has learned valuable lessons in using the first year of the supplemental AI/PI funds, and, if shared, these lessons would greatly improve the continued program development of AI/PI activities at all DoD- GEIS sites. Increased interlaboratory dialogue could decrease the likelihood of unintentional overlap of activities between different units and encourage more coordination of activities. Examples of possible mechanisms and tools used for coordination by DoD-GEIS would be monthly teleconferences, periodic website surveillance summaries (with host country concurrence), annual face-to-face meeting—for example, in conjunction with the annual American Society for Tropical Medicine and Hygiene meeting—and sharing of information technologies. RECOMMENDATION 10-3. In Asia, the Naval Medical Research Unit No. 2 (Indonesia) and the Armed Forces Research Institute of Medical Sciences (Thailand) should work together with DoD-GEIS headquarters to clarify the regional roles of each laboratory and to identify critical geographic areas requiring assistance to strengthen AI/PI surveillance programs in conjunction with World Health Orga- nization and member states regional plans. The laboratories should coordinate the assignment of additional activities as well as prepare contingency plans to cover for each other in the event of a crisis (politi- cal, geologic, etc). The same recommendation applies to Africa and the roles of the Naval Medical Research Unit No. 3 (Egypt) and the U.S. Army Medical Research Unit-Kenya. DoD-GEIS headquarters should also work with the Naval Medical Research Center Detachment (Peru) to optimize its regional role in conjunction with Pan American Health Organization and member states regional plans. National Plans DoD-GEIS, through its AI/PI activities at the overseas laboratories and headquarters, has contributed greatly to the development of laboratory and communications infrastructures within partner countries. Beneficial effects can be seen from current DoD-GEIS efforts in 56 countries to assist its public health partners in building capacity through training and support of laboratory and communications infrastructures. Within the DoD, GEIS is

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0 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS building capacity directly by supporting the development and maintenance of laboratory diagnostic capacity and indirectly through funding of projects that result in the development of laboratory infrastructure. However, sus- taining and expanding DoD laboratory diagnostic capacity is an important activity that could be better and more directly addressed. In their contin- ued implementation of AI/PI projects, GEIS headquarters and laboratories should consider the need to establish sustainable efforts to provide capac- ity to the host country even if funding is cut. As much as possible, in the selection of equipment and the support of influenza activities, specific items should be purchased that give host-country personnel the best chances of sustainability in meeting their needs within their local setting; when making these choices, the directive to coordinate plans and activities with the host country should be kept in mind. RECOMMENDATION 10-4. DoD-GEIS funding should be coordi- nated with funding from all sources to assure the likelihood that sur- veillance activities for influenza, other respiratory infections, and other emerging infections will be sustainable in overseas sites for the long term. THE UTILITY OF EACH FUNDED PROJECT’S CONTRIBUTION TO A COMPREHENSIVE AI/PI SURVEILLANCE PROGRAM While each individual project could not be evaluated in great detail given the available time and resources and the relative infancy of new initia- tives,1 the committee focused on assessing the utility of the DoD laborato- ries, given their extensive infrastructures and networks for the conduct of infectious studies in the field, to contribute to comprehensive AI/PI surveil- lance. The DoD units were established at various times between 1942 and 1983, each with a fundamental primary mission of carrying out research relevant to the health of military personnel (DoD-GEIS, 2007a). Over the years, the overseas laboratories have expanded their roles in host countries and in the surrounding geographic regions to include training activities, outbreak responses, and collaborative studies of pathogens of importance to the host nation; but taking on an extensive surveillance role, such as the AI/PI surveillance program, has been a significant departure from their portfolio as it existed prior to the establishment of DoD-GEIS. The laboratory budgets reflect the current balance of these activities (see Table 10-1). While the fiscal year 2006 AI/PI supplemental funds represent a significant increase in the DoD-GEIS funding going to these laboratories, 1 Related site-specific committee conclusions and recommendations are included in the ap- propriate chapters.

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0 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS TABLE 10-1 Department of Defense Laboratories Funding for Fiscal Year 2006 Percent of Other Total Laboratory DoD-GEIS DoD-GEIS Laboratory Funding Organization AI/PI Funding Funding Funding Made up by Funded (Thousands) (Thousands) (Thousands) DoD-GEIS NAMRU-2 $2,665 $1,340 $11,040 36% AFRIMS $6,140 $1,340 $18,868 40% NAMRU-3 $3,988 $1,340 $14,000 38% USAMRU-K $2,634 $900 $15,000 24% NMRCD $1,741 $1,340 $9,400 33% NHRC $3,164 $954 $24,500 17% AFIOH $4,182 $713 $42,100 12% Total $24,514 $7,927 $134,908 24% SOURCE: DoD-GEIS and DoD laboratory budget data for fiscal year 2006. overall DoD-GEIS funds still represent, on average, only 24 percent of the total funding for projects at these DoD laboratories. The majority of the laboratories’ funds remain committed to research-oriented projects. It is the committee’s view, however, that the surveillance and research activities are complementary to one another. Research contributes to basic scientific knowledge and methods, while the public health surveillance identifies is- sues that need research and contributes to the overall health and security of host countries and the global community. The AI/PI surveillance program has built on established relationships and has expanded collaborative activities to include a broader public health agenda. For some overseas laboratories, the implementation of the AI/PI program has been a considerable challenge, with the introduction of a new disease area, new relationships with national and international agencies, and new collaborative opportunities in national and international surveil- lance activities. In general, though, the overseas laboratories have been successful in developing beneficial ties with appropriate host government components and universities in areas of mutual interest or expertise, with the more established laboratories being particularly successful. Strategic long-term planning for pandemic influenza-preparedness surveillance and response programs, supported by stable funding, would enable the DoD laboratories to determine the appropriate combination of research and public health surveillance needed to best meet the challenge of pandemic

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0 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS influenza as well as other possible emerging pathogens in their areas of responsibility. RECOMMENDATION 10-5. DoD should issue a directive reaffirm- ing that these traditionally research-oriented laboratories, particularly overseas, have a public health mission with respect to the host country and region; the directive should also provide strategic direction on the balance of military medicine-related research and public health activities. ADEQUACY OF THE PROGRAM IN VIEW OF EVOLVING EPIDEMIOLOGIC FACTORS Influenza Surveillance Using supplemental funding, DoD laboratories have established or improved influenza surveillance in all of their areas of responsibility. With continued funding, both the quality and the utility of surveillance infor- mation should improve. The following sections contain recommendations which the committee felt applied to multiple DoD-GEIS surveillance pro- grams. Specific recommendations for each laboratory’s activities are in the laboratory-specific chapters. Human Influenza Surveillance Institutionalizing influenza surveillance in host countries and within the populations of these host countries provides DoD-GEIS laboratories with opportunities to assist host governments in using the data to priori- tize future surveillance activities. Expanding the scope of data collection and analysis to look beyond H5N1 and developing surveillance activities that are amenable to other emerging diseases would greatly benefit overall public health capacity. Military-to-military partnerships, in which militaries with advanced public health capabilities commit to helping other militaries develop labora- tory and epidemiologic capacity, are another way of improving surveillance in developing country militaries (Chretien et al., 2007). Acute respiratory diseases, including viral pathogens such as influenza, have been of special interest to all militaries. The influenza pandemic of 1918 had a devastating impact upon military operations. There are also methodological advantages for using military popula- tions for influenza surveillance including regimentation of the population, known denominators, and quality of resources for care. An additional benefit of implementing a febrile respiratory infections surveillance and

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0 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS response program through a DoD entity is the strong relationship with the host-country military that DoD-GEIS laboratories can build upon. DoD- GEIS has opportunities to partner with militaries from host countries to improve surveillance capabilities and public health infrastructure (Chretien et al., 2007). DoD-GEIS projects have already found ways to leverage military-to-military relationships to expand surveillance capabilities in both Thailand and Peru (AFRIMS, 2007, NMRCD, 2006). RECOMMENDATION 10-6. DoD-GEIS programs in the overseas laboratories should explore opportunities to develop or strengthen mili- tary influenza surveillance activities in collaboration with host-country military populations. Animal Influenza Surveillance Most of the DoD-GEIS laboratories that received AI/PI supplemental funds are implementing animal surveillance programs, a majority of which are in wild bird populations (Table 10-2). Historically there has been no country in which H5N1 highly patho- genic avian influenza (HPAI) was first detected in healthy wild birds. Prevalence of H5N1 highly pathogenic avian influenza in wild birds has historically been low; therefore sampling numbers need to be sufficiently large to detect the virus. In addition, wild bird surveillance must be appro- priately targeted to be of value. Capturing wild birds is difficult, especially migratory wild birds, and, depending on the species, requires expertise and a substantial amount of money. Surveillance should be cost-effective. In most cases, surveillance of mortality events is more fruitful. Despite the challenges, wild bird surveillance can, if done well, yield useful information on highly pathogenic influenza viruses. Understanding the influenza transmission cycles that involve humans is of value in the areas where labs are located. While the DoD-GEIS strategy of assessing relevant transmission cycles should focus on human testing, teasing out transmission cycles from wild birds to domestic animals to humans is a relevant part of DoD-GEIS influenza research and surveillance projects. The committee noted that DoD-GEIS could provide valuable expertise at the country level with the integration of animal and human surveillance activities. Better coordination is needed at all levels between human sur- veillance activities and surveillance for influenza viruses in domestic birds (which have more opportunities to transmit influenza viruses to humans than do free-flying birds) and in other animals. Inadequate coordination affects both the effectiveness of the DoD laboratories and the quality of integrated information regarding the presence of influenza viruses being re- ported from the host country. DoD-GEIS laboratory personnel could serve

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS TABLE 10-2 Animal Surveillance Activities at the DoD Overseas Laboratories DoD Overseas Laboratory Animal Surveillance Activities NAMRU-2 NAMRU-2 works with the Indonesian government to develop and conduct surveillance of avian influenza viruses in migratory and wild birds, to train Indonesian government scientists in field and laboratory techniques for collecting and testing for virus, and to use remote sensing to determine environmental correlates for transmission. AFRIMS AFRIMS provides laboratory support to the Thai government’s animal surveillance activities. NAMRU-3 NAMRU-3 supports avian influenza surveillance in migratory birds in Ukraine, Egypt, and Kenya with such partners as the Egyptian Ministry of the Environment. In addition, NAMRU- 3 acts as a reference laboratory in the EMRO region for other suspected H5N1 animal cases. USAMRU-K Working with NAMRU-3, USAMRU-K conducts surveillance to detect highly pathogenic H5 and H7 influenza viruses (or other highly pathogenic influenza viruses) in ducks and other waders as they migrate from Europe and Asia. NMRCD NMRCD participates in the Global Avian Influenza Network Surveillance, managed by the World Wildlife Conservation Society at the Bronx Zoo as well as provides veterinary diagnostic support for ongoing Peruvian government activities. SOURCE: DoD laboratories, DoD-GEIS annual report. as catalysts to enhance dialogue between national agencies responsible for each of these activities. RECOMMENDATION 10-7. DoD-GEIS headquarters should assess all of the current wild and domestic bird and animal surveillance activi- ties and firmly establish goals, specifically targeting species and situa- tions to fulfill these goals. DoD-GEIS headquarters and laboratories should seek collaborative opportunities to partner with organizations already studying influenza transmission in wild and domestic birds and animals in their areas. Laboratory The AI/PI supplemental funding has been allocated for expanding or enhancing physical structure and laboratory capacity in all of the DoD- GEIS-supported sites (Table 10-3).

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 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS TABLE 10-3 Laboratory Capabilities at the DoD Domestic and Overseas Laboratories Laboratory Capabilities Multiplex DoD Laboratory BSL-3 PCR System NAMRU-2 The construction of BSL-3 Yes Yes at Litbangkes is under way and expected to be completed in 2008. AFRIMS The design and Yes Yes construction of a BSL-3 lab is under way and expected to be completed by early 2008. NAMRU-3 Yes Yes No Noa USAMRU-K Yes No NMRCD Yes Yes No NHRC The design and Yes No construction of a BSL-3 lab is under way. AFIOH Yes Yes No aWhile they do not operate a BSL-3 facility themselves, USAMRU-K and the Kenyan NIC do have access to a BSL-3 laboratory on the grounds of KEMRI. SOURCE: DoD laboratories, DoD-GEIS annual report. All of the laboratories have added systems based on reverse transcrip- tion polymerase chain reaction (RT-PCR) to increase laboratory throughput and increase their diagnostic capacity. Many of the sites have also used the supplemental funds to increase the biosafety levels of their laboratory space in order to be able to manage highly pathogenic human and animal influenza A viruses. To appropriately staff the laboratories, new personnel with substantial expertise have been hired. All of the improvements to the laboratory facilities have great potential to increase capacity, improve data quality, and ensure rapid identification of the viruses detected. RECOMMENDATION 10-8. To achieve successful influenza virus surveillance, each of the DoD overseas labs should have the capacity to provide reliable, definitive influenza diagnostic results in a safe and timely way.

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS Additionally, the expansion of laboratory capacity in domestic and overseas DoD laboratories has the potential to expand each laboratory’s autonomy and self-sufficiency in terms of virus isolation and identification as well as in terms of decreasing the reliance on off-site and sometimes distant laboratory facilities. This in-house capacity will also increase the speed at which accurate results are available for decision makers. As the laboratory capacities expand, DoD facilities will need to implement proper procedures to ensure quality assurance. RECOMMENDATION 10-9. In keeping with the goal of detecting newly recognized drifted or shifted influenza virus (or other emerging pathogens), the DoD-GEIS AI/PI surveillance system should be de- signed to capture influenza illness that could potentially present with different or unusual symptoms (e.g. conjunctivitis and diarrhea), bring- ing in outside help and support in the case of novel findings. Response Capacity The period between the first convincing evidence of human-to-human transmission of a pandemic strain in one or more geographic areas and the subsequent widespread transmission of the disease worldwide could range from a few weeks to a few months. During that period laboratory testing can determine where the pandemic strain is and where it is not. Once the first clusters of human–to-human transmission have been unequivocally identified, any outbreak of respiratory illness anywhere in the world will likely create concern (and even panic) that the illness is caused by the emerging pandemic virus. Ruling out a pandemic strain as being respon- sible for influenza-like illness in a community could avoid or lessen panic and confusion among the general population. Rapid testing may help limit overreactions and reduce needless depletion of antivirals, vaccines, masks, and other protective stocks. Laboratories must be prepared for expanded laboratory-based surveil- lance activities during this critical period between the initial epidemiologic harbingers of an influenza pandemic and eventual global spread. Laborato- ries currently testing a few samples a day, a week, or a month will be called upon to test many more during this period. Without necessarily adding new instruments or expanding in space, these laboratories could gear up to work more shifts if they could deploy trained lab technicians from other parts of the lab and rely upon sufficient supplies of reagents to perform the tests. Taking the steps of redeploying technicians and working in shifts would be facilitated if a lab has already devised a surge capacity plan, trained the other lab staff, and secured a source of reagents and supplies. Developing a surge capacity plan prior to human-to-human transmission could mean

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 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS TABLE 10-4 Estimated Laboratory Surge Capacity at DoD Domestic and Overseas Laboratories Altered 24-Hours–a- Algorithm Day, Seven- Routine (Flu A & Target Days-a-Week Laboratory Operation H5 first) H5 Gene Only Operations NAMRU-2 360/week 4,900/week 11,000/week 19,200/week AFRIMS 400/week 600/week 2,000/week 5,000/week NAMRU-3 2,250/week 3,400/week *** 8,800/week USAMRU-K 200/week 2,000/week 2,000/week 4,000/week NMRCD 300/week *** *** 1,300/week NHRC 336/week 1,112/week 1,988/week 4,760/week AFIOH 1,300 /week *** 1,500/week 6,000/week SOURCE: DoD laboratories surge capacity estimates. adapting to the increase in the number of samples in a few hours instead of days or weeks. Each of the DoD domestic and overseas laboratories estimated its own surge capacity in the event of an influenza pandemic in its host country (Table 10-4). The committee found that surge planning within these labora- tories as well as the strategic planning at the DoD-GEIS headquarters level could be greatly strengthened. The inadequacies of the central DoD-GEIS strategy with respect to the role of laboratories’ surge capacities in their areas of responsibility, especially in the case of a pandemic, will leave the laboratories unprepared in the efforts to best assist host governments and multilateral partners. While it is useful to understand how the DoD laboratories could con- tribute in a pandemic, in many countries there are no estimates of needed laboratory surge capacity with which to put the DoD laboratories’ con- tribution into context. In the event of a pandemic, the DoD laboratory network will serve as only one piece of the required surge capacity, and at the current time it is unclear what role each laboratory will play. RECOMMENDATION 10-10. The DoD-GEIS influenza surveillance programs in the overseas laboratories should be complementary to the host-country laboratory system and help to increase surge capacity at the host country levels. DoD-GEIS should work with CDC, WHO, the U.S. Department of Agriculture, the Food and Agricultural Organiza-

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS tion, and other entities at the headquarters and in-country levels to develop a plan to handle an increased number of influenza samples from humans or animals. Information Sharing An effective surveillance network detects cases of disease, collects and analyzes the data, and disseminates the findings to people and organizations that use the information. For influenza, rapid and effective communication of information is essential for public health partners positioned to respond, such as ministries of health, U.S. partner agencies, and international organi- zations. Strategies for sharing information with public health partners have not been formally developed, although in most laboratories good practices have evolved. Methods and needs for sharing data vary greatly within the DoD-GEIS consortium, but information needs must be assessed and communication channels identified and opened. Equally important are the needs for the DoD-GEIS headquarters to collect surveillance data and other information from consortium members in a systematic, timely manner, analyze this in- formation as appropriate, and report this information back to consortium members and other relevant DoD personnel, public health partners, and the public. Each of the domestic and overseas laboratories has developed slightly different methods of sharing results among stakeholders (Table 10-5). Current DoD-GEIS efforts to communicate influenza virus surveillance and other information within the DoD-GEIS consortium, within the DoD, to public health partners, and to the public are improving but remain insuf- ficient. Of particular concern is the need for effective communication and dissemination of results as well as isolates at both the executive-agent and in-country levels. There must be a clear understanding of how and when information and specimens are to be communicated from the laboratories to WHO through the host country government and to the U.S. public health system via DoD. There is an established international system organized by WHO for flow of information and of influenza virus isolates from humans and animals. It was unclear in some places how DoD-GEIS laboratories were working with host governments to ensure that information was being fed into the WHO system. The channels of information flow from DoD- GEIS-supported activities and isolate distribution must be clearly under- stood by the host country and relevant international organizations. RECOMMENDATION 10-11. DoD-GEIS influenza surveillance pro- grams in the overseas laboratories in each host country should have a written understanding among all national and international partners

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 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS delineating the reporting of influenza virus detections and the appro- priate channels for exchanging isolates and communicating virological results. Such a document should include a clear statement of the labora- tory designated by WHO as the reference laboratory for isolates from the host country. COORDINATION OF EFFORTS WITH THE CENTERS FOR DISEASE CONTROL AND PREVENTION, THE WORLD HEALTH ORGANIZATION, AND LOCAL GOVERNMENTS Addressing emerging infectious diseases is an issue of global importance and shared responsibility. It is crucial to the success of a global influenza surveillance system that all of the relevant partners work together to plan and prepare for a possible pandemic. To this end, DoD-GEIS is working to TABLE 10-5 Information Sharing at DoD Domestic and Overseas Laboratories DoD Laboratory Description of Laboratory Data Sharing Practices NAMRU-2 Isolates are sent from NAMRU-2 to the Indonesian Ministry of Health and subsequently to CDC-Atlanta for analysis as part of its annual influenza vaccine development activities. AFRIMS Isolates are provided from AFRIMS to the Thai Ministry of Public Health according to Thai regulations and for subsequent reporting to the WHO. NAMRU-3 All isolates are forwarded to the CDC and/or Mill Hill (United Kingdom) as WHO collaborating centers. Results are reported to the Ministry of Health, WHO, and NAMRU-3 or other influenza partners as appropriate (i.e., DoD-GEIS, NMRC, CDC, etc.). USAMRU-K Isolates are provided from USAMRU-K to the Kenya Medical Research Institute. NMRCD Monthly reporting to the Ministry of Health, participating physicians, and the Air Force Institute for Operational Health in San Antonio, Texas. NHRC NHRC sends out a weekly newsletter that updates influenza activity seen in all its surveillance programs to many DoD stakeholders. Influenza viral sequence information is reported to the CDC. AFIOH AFIOH provides select isolates and all sequence data to the CDC and WHO for further subtyping and antigenic characterization for detection of variance from the vaccine component strains. SOURCE: DoD laboratories, DoD-GEIS annual report.

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS coordinate and integrate its efforts with national and international surveil- lance and response-planning partners, such as CDC, HHS, the Pan Ameri- can Health Organization (PAHO), WHO, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service. At the time of the site visits, DoD-GEIS surveillance activities were integrated with those of U.S. government, host country, and multilateral partners to various degrees often dependent on how long each program had been underway. However, DoD-GEIS headquarters and all of the domestic and overseas laboratories were working to improve the levels of coordination and integration using AI/PI supplemental funds. International Partners Congress, as expressed in Sec. 748, H.R.1815, and the DoD strategic plan both call for DoD-GEIS to collaborate with international partners, such as WHO, and with governmental agencies in foreign countries, such as ministries of health. With the supplemental funding, DoD-GEIS has been working on expanding its influenza activities in coordination with international partners. At the headquarters level, the assignment of a full- time U.S. military medical officer to WHO in Geneva, Switzerland, has bolstered coordination and integration of efforts between DoD-GEIS and WHO (Fukuda, 2006). In addition, DoD-GEIS seeks external advice and consultation for AI/PI surveillance and control activities on a project-by- project basis from outside consultants, such as key offices at PAHO, WHO, and the Food and Agricultural Organization, as needed. DoD-GEIS has 260 influenza surveillance sites in 56 countries around the world (see Figure 10-2). A number of these countries represent col- laborations with WHO national influenza centers and other international partners. The DoD laboratories also play a significant role in the establishment of collaborative relationships with international partners and governmen- tal agencies in foreign countries. At a number of DoD laboratories the implementation of the supplemental funding has lead to the strengthening of these relationships. The DoD overseas laboratories have developed and significantly improved relationships with a variety of global and host- country partners working in the fields of avian and pandemic influenza (see Table 10-6). In addition, a number of the DoD overseas laboratories have increased international collaboration and coordination by serving dual functions as U.S. DoD laboratories as well as WHO collaborating centers or reference laboratories (Table 10-7). While significant effort has been put into strengthening the coordina- tion of avian and pandemic influenza activities, the overseas laboratories

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 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS FIGURE 10-2 DoD’s worldwide presence in influenza surveillance, 2007. SOURCE: DoD-GEIS, 2006. TABLE 10-6 International Partners of DoD Overseas Laboratories DoD Laboratory Global and Host-Country Partners NAMRU-2 Indonesian Ministry of Health, Indonesian Ministry of Figure 10-2 Agriculture and Fisheries, Indonesian National Institutes of Health Research and Development (Litbangkes), WHO, FAO, other partner governments in the region AFRIMS Royal Thai Army, Thailand Ministry of Public Health, Thai Ministry of Agriculture and Cooperatives, WHO, other partner governments in the region NAMRU-3 Egyptian ministries of health, environment, and agriculture, WHO EMRO, FAO, APHIS, other partner governments in the region USAMRU-K Kenya Medical Research Institute (KEMRI), AFIOH, and Kenya Ministry of Health (KMoH) Ministry of Livestock and Fisheries, ornithology department of the National Museums of Kenya, Kenya Wildlife Service, WHO, GTZ, FAO, other partner governments in the region NMRCD Peruvian Ministry of Health, Ministry of Agriculture, and Military, PAHO, other partner governments in the region SOURCE: DoD laboratories, DoD-GEIS annual report.

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS TABLE 10-7 DoD Laboratories Serving as WHO Collaborating Centers and Reference Laboratories DoD Laboratory WHO Role NAMRU-2 WHO Collaborating Centre for New, Emerging and Reemerging Infectious Diseases AFRIMS WHO Collaborating Center for Diagnostic Reference, Training, and Investigation of Emerging Infectious Diseases NAMRU-3 WHO Regional Influenza Reference Laboratory and WHO reference laboratories for diagnosis of influenza A/H5 infection SOURCE: DoD laboratories, DoD-GEIS annual report. must continue their efforts to work within each country’s national plan, thereby increasing national capacity and avoiding unintentionally working against the national plan. DoD influenza protocols should be executed in such a way that they cause a net strengthening of national and international capacity. As part of these collaborations, the overseas laboratories should also take opportunities to assist the host country in the development and implementation of disease-control guidelines and pandemic preparedness where appropriate and necessary. In some countries, for example, the com- mittee found a lack of evidence of influenza pandemic preparedness at the local hospital level. RECOMMENDATION 10-12. Overseas laboratories, with the stra- tegic guidance of DoD-GEIS headquarters, should coordinate with national and regional influenza pandemic and enzootic response plans to establish the role for each laboratory in country and regionally. Where possible, DoD-GEIS laboratories should engage in host-country influenza coordinating activities, including tabletop response exercises and distribution of testing capacity, in concert with WHO and other international agencies. An important goal will be to strengthen linkages between laboratories and entities with key resources. U.S. Government Partners The DoD is also one of several U.S. government agencies with a signifi- cant interest in and responsibility for addressing emerging infectious dis- eases such as influenza. Each agency fills a particular niche and contributes important resources while also having certain limitations. The DoD, for its part, possesses unique laboratory capabilities, many situated in diverse

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0 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS forward locations, and has a vested interest in addressing emerging infec- tious diseases as a matter of national security (NIC, 2000). While the DoD will have limited public health role in the event of a pandemic in the U.S. according to the National Strategy for Pandemic Influenza, Implementation Plan (see Box 10-1), the influenza surveillance activities being conducted at the DoD’s domestic and overseas laboratories are producing valuable information on the location and variations of the circulating influenza viruses which can help prepare both U.S. military and civilian populations. In order to ensure coordinated U.S. government planning and imple- mentation of influenza activities, DoD-GEIS-supported personnel work to coordinate influenza-related activities with other U.S. government agen- cies both at headquarters and at the laboratory level. At the headquarters level, DoD-GEIS staff participates in a number of influenza-coordinating BOX 10-1 National Strategy for Pandemic Influenza, Implementation Plan Roles and Responsibilities The Secretary of Homeland Security will be responsible for coordination of the federal response as provided by the National Strategy for Pandemic Influenza (Strategy), and will support the Secretary of Health and Human Services’ coordi- nation of overall public health and medical emergency response efforts. The Secretary of Health and Human Services will be responsible for the over- all coordination of the public health and medical emergency response during a pandemic. The Secretary of Defense will be responsible for protecting American interests at home and abroad. The Secretary of Transportation will be responsible for coordination of the transportation sector. The Secretary of Agriculture will be responsible for overall coordination of vet- erinary response to a domestic animal outbreak of a pandemic virus or virus with pandemic potential and ongoing surveillance for influenza in domestic animals and animal products. The Secretary of the Treasury will be responsible for monitoring and evaluating the economic impacts of the pandemic and will help formulate the economic policy response and advise on the likely economic impacts of containment efforts. Other cabinet heads will retain responsibility for their respective sectors and will be responsible for developing pandemic.

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS bodies, including annual DoD Joint Influenza Surveillance Working Group meetings as well as a number of HHS-coordinated influenza-related groups (Embrey, 2006). DoD representatives also participate with other U.S. gov- ernment partners at the annual meetings of the FDA-sponsored Vaccines and Related Biological Products Advisory Committee. DoD and other gov- ernment agencies, including HHS, the Department of Homeland Security, the State Department, and CDC, have exchanged full-time medical liaison officers to help provide situational awareness of ongoing missions and to implement initiatives of mutual interest (Bresee and Jernigan, 2006). DoD domestic and overseas laboratories have been working to improve their collaborations with other relevant U.S. agencies working in the same locations, including other DoD entities, CDC, the U.S. Agency for Interna- tional Development (USAID), the U.S. Department of Agriculture (USDA), and the National Aeronautics and Space Administration. (See Table 10-8 for a list of DoD laboratories and their U.S. government partners.) The roles of various DoD laboratories in the event of a pandemic are less clear in the host country setting. The responsibilities of each U.S. government agency should be agreed upon by each U.S. agency and outlined by the host country government. The relationship between the CDC and the DoD warrants particular attention. The CDC now has a presence in almost all of the countries where the overseas laboratories are located. In the past the DoD and the CDC have provided each other with backup support and entered into collabora- tive relationships on an as-needed basis. As influenza activities evolve, col- laboration between the CDC and the DoD will be of utmost importance if TABLE 10-8 U.S. Government Partners of DoD Domestic and Overseas Laboratories DoD Laboratory US Agency Partners NAMRU-2 CDC, USAID, NASA, U.S. Embassy, AFRIMS AFRIMS CDC, USAID, NAMRU-2, AFIOH NAMRU-3 CDC, USAID USAMRU-K CDC, USAID, AFIOH, NAMRU-3 NMRCD CDC, USAID, AFIOH, USDA NHRC CDC, AFIOH, NAMRU-2, NAMRU-3, USDA AFIOH CDC, AFRIMS, USAMRU-K, NMRCD, NHRC, USCHPPM, SOURCE: DoD laboratories, DoD-GEIS annual report.

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 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS both are to make efficient and effective use of limited resources. Similarly, strong relationships with other U.S. government partners such as USAID and USDA ensure most efficient use of U.S. funds. RECOMMENDATION 10-13. DoD-GEIS should further strengthen its coordination and collaboration on pandemic influenza and other emerging infectious diseases with all U.S. partners, both domestically and in its overseas operations. These partners include HHS, CDC, the National Institutes of Health, FDA, USDA, the Department of State, the U.S. Agency for International Development, the Department of Homeland Security, and other relevant U.S. government efforts. CONCLUSION Overall, the committee concluded that DoD-GEIS has effectively ex- ecuted and managed the fiscal year 2006 AI/PI supplemental funding, especially given condensed timeframes for planning and implementation. At DoD-GEIS headquarters, as well as at the domestic and overseas labora- tories, DoD-GEIS personnel absorbed the increase in funding into programs aimed at successfully building DoD and host-country laboratory and hu- man resource capacity, globally expanding information about avian influ- enza and acute respiratory diseases, benefitting the health of U.S. military personnel, and strengthening U.S. relations within the global community. The preceding sections describe the steps the committee feels that the pro- gram should take in order to achieve and strengthen a sustained DoD-GEIS influenza surveillance and response effort. With sustained funding and the implementation of these recommendations, DoD-GEIS has a unique op- portunity to further contribute to the evolving global knowledge of highly pathogenic avian influenza virus as well as continue to strengthen global emerging infectious disease surveillance and response. REFERENCES AFRIMS (Armed Forces Research Institute of Medical Sciences). 2007. AFRIMS influenza surveillance program—current and future (unpublished). Bresee, J., and D. Jernigan. 2006. U.S. government contributions to global influenza surveil- lance. PowerPoint presentation given at first meeting of the IOM Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs, December 19, Washington, DC. Chretien, J. P., D. L. Blazes, R. L. Coldren, M. D. Lewis, J. Gaywee, K. Kana, N. Sirisopana, V. Vallejos, C. C. Mundaca, S. Montano, G. J. Martin, and J. C. Gaydos. 2007. The im- portance of militaries from developing countries in global infectious disease surveillance. Bulletin of the World Health Organization 85(3):174-180.

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 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS DoD-GEIS (Department of Defense Global Emerging Infections System). 2006. DoD Global Emerging Infections Surveillance and Response System annual report fiscal year 00. Silver Spring, MD: Walter Reed Army Institute for Research DoD-GEIS. 2007a. DoD-GEIS website. http://www.geis.fhp.osd.mil/ (accessed August 7, 2007). DoD-GEIS. 2007b. Department of Defense influenza surveillance sites worldwide, 00 (unpublished). Embrey, E. P. 2006. U.S. government policy perspectives on global influenza. PowerPoint pre- sentation given at first meeting of the IOM Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs, December 19, Washington, DC. Fukuda, K. 2006. Global challenges of pandemic and avian influenza. PowerPoint presentation given at first meeting of the IOM Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs, December 19, Washington, DC. NIC (National Intelligence Council). 2000. The global infectious disease threat and its implica- tions for the U.S. http://www.fas.org/irp/threat/nie99-17d.htm (accessed July 24, 2007). NMRCD (U.S. Naval Medical Research Center Detachment). 2006. Influenza and disease surveillance summary (unpublished).

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