Review of the DoD-GEIS Influenza Programs: Strengthening Global Surveillance and Response (2008)

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4 Armed Forces Research Institute of Medical Sciences Thailand Avian and Pandemic Influenza Activities T he Armed Forces Research Institute of Medical Sciences (AFRIMS) in Bangkok, Thailand was established in 1958 through an agree- ment between the governments of the United States and Thailand. The original laboratory was created as the Cholera Research Laboratory of the Southeast Asia Treaty Organization (SEATO). 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 medi- cal research laboratory run jointly by the Royal Thai Army and the U.S. Army under the overall command of a Royal Thai Army officer of flag rank. Historically, AFRIMS has been closely linked with a Royal Thai Army laboratory and also collaborates with various other national institutions, including the Thai Ministry of Health (Department of Medical Sciences, National Institute of Health, Department of Communicable Disease Con- trol, and the Office of the Permanent Secretary and its Field Epidemiology Training Program) and the Ministry of Agriculture (Department of Live- stock Development). For many years, AFRIMS was devoted exclusively to applied research in support of its medical mission. It has successfully developed research pro- grams with a special emphasis on the development of diagnostic tests and therapeutic products for malaria and other tropical febrile illnesses. AFRIMS research programs in infectious diseases, including diarrheal disease, malaria vaccine and drug research, viral diseases (specifically, dengue fever and hepa- titis), entomology and disease vector research, and retrovirology (including 81 

82 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS human immunodeficiency virus infection and AIDS), existed long before the introduction of the Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS). In some ways DoD-GEIS represented a departure for AFRIMS, although in other ways DoD-GEIS is a natural extension of the field research that has been AFRIMS’s mainstay. For example, the DoD-GEIS malaria pillar complements ongoing surveillance for antimalarial drug resistance, whereas surveillance for acute febrile illness is a somewhat new area of involvement. On July 4, 2005, AFRIMS was also designated a World Health Orga- nization (WHO) Collaborating Center for Diagnostic Reference, Training, and Investigation of Emerging Infectious Diseases. The projects undertaken by AFRIMS using the fiscal year 2006 AI/PI supplemental funding included increasing the laboratory infrastructure and capabilities of AFRIMS labo- ratories in Bangkok, Thailand, as well as performing regional influenza surveillance, particularly for highly pathogenic avian influenza (see Figure 4-1). A site visit team of the Institute of Medicine (IOM) Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs visited AFRIMS from March 12-17, 2007. The IOM site visit team spent two days in Bangkok and two and a half days in Kathmandu, Nepal, visit- ing the laboratories and reviewing surveillance projects supported by the DoD-GEIS supplemental funding. A list of the people with whom the site visit team met and the itinerary that was followed can be found at the end of this chapter. INFLUENZA IN THAILAND In January 2004, Thailand issued its first report of highly pathogenic avian influenza virus of the H5N1 subtype in poultry and humans (WHO, 2007a). Since that time Thailand has had a total of 25 human cases of avian influenza, 17 of which were fatal, but it has reported no human infections since September 2006 (although it did confirm H5N1 in poultry during rou- tine intensive surveillance in January 2007) (WHO 2007a, WHO 2007b). In addition to its human and poultry infections, Thailand has also had a number of domestic cats, captive tigers, and leopards die of the H5N1 virus (Tiensin et al., 2005). Other novel findings related to avian influenza in Thailand have been documented, dating back to July 2004, when a report described an atypi- cal human H5N1 infection that lacked the usual respiratory symptoms   Prior to the committee’s AFRIMS visit, the laboratory staff provided the committee with detailed background information on AFRIMS and the pandemic/avian influenza activities it was supporting. These materials are available from the IOM in the Public Access File. 

AFRIMS THAILAND 83 FIGURE 4-1 DoD’s regional presence in influenza surveillance (South East Asia), 2007. SOURCE: DoD-GEIS, 2007b. and therefore indicated that the clinical spectrum of disease was perhaps broader than originally thought (Apisarnthanarak, et al. 2004). Six months later, in January 2005, the first account of a probable secondary human 3-1 and 4-1 transmission of avian influenza resulting in severe disease was published after a young girl in Thailand was believed to have fatally infected her mother with H5N1 (WHO, 2004). In addition to Thailand, eight countries in South and Southeast Asia have reported highly pathogenic avian influenza among poultry: Bangla- desh, Cambodia, India, Indonesia, Laos, Malaysia, Myanmar, and Vietnam. Bangladesh and Myanmar both reported their first outbreaks of highly pathogenic H5N1 in poultry in early 2007. Indonesia, on the other hand, reported its first human case of H5N1 avian influenza in July 2005 and 

84 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS has had the highest number of AI cases worldwide (WHO 2007a, WHO 2007c). MANAGEMENT AND PLANNING AFRIMS’s overall strategy integrates DoD-GEIS activities into tradi- tional research streams in order to leverage AFRIMS’s resources and exper- tise that are already in place so as to reduce program overhead costs and to complement the activities of the Thai government. This integration results in more than 80 percent of DoD-GEIS funds being allocated to program implementation rather than overhead costs. In addition, this integration complements and reflects the activities of the Thai government. Staffing AFRIMS employs more than 400 personnel, including 25 Americans, twelve of whom are scientists. The DoD-GEIS program is coordinated by a full-time military public health/preventive medicine officer as well as a full-time influenza program manager (Henry Jackson Foundation contract). Together they oversee the work of DoD-GEIS staff (24 in Thailand and 23 in Nepal). In addition to laboratory expertise, staff members have expertise in training (both in Bangkok and the regional countries), public relations, data processing, database design, and secretarial support. Overall the IOM team found DoD-GEIS staff members to be capable, enthusiastic about their work, and eager to develop their influenza surveillance program. Conclusions While AFRIMS made appropriate use of the supplemental funding, the site visit team concluded that a minimum of two years of funding for supplemental influenza surveillance is desirable, and a five-year funding package would be ideal. Ideally, a novel, modest, and stable funding stream would be created to allow for proper planning and program implementa- tion as well as for surge capacity in the face of an unexpected outbreak situation. This would require a different approach to the proposal process structure, an approach that would ideally be applied to all OCONUS (out- side of the Continental U.S.) and CONUS (Continental U.S.) laboratories. SURVEILLANCE AFRIMS has been involved in specimen collection as part of the DoD Influenza Surveillance Program since 1996 (AFRIMS, 2007a). Approxi- mately one-third of the samples submitted have been positive for at least 

AFRIMS THAILAND 85 one respiratory virus in the testing panel (adenovirus, herpes simplex virus, enterovirus, influenza A and B, and parainfluenza 1, 2, and 3). Approxi- mately 45 percent of the isolates were influenza B and 46 percent influenza A. The hemagglutinin of one of the H3 isolates submitted to the Air Force Institute for Operational Health (AFIOH) from the field site in Sangklaburi early in 2007 had an unusual amino acid change at position 142, from a glycine to arginine; this change has been noted only twice in the past two years, one in a fatal case (AFIOH, 2004). In fiscal year 2006, AFRIMS’s department of virology was able to expand its surveillance network to a total of 13 sites in five countries. It processed 490 samples (AFRIMS, 2006). These included specimens received from two influenza outbreaks in Nepal, confirmatory testing for the WHO influenza surveillance program in Nepal, and results from the U.S. embassy surveillance project. AFRIMS’s situation in Thailand has required a complementary ap- proach as the country has its own influenza virus surveillance program and its response to the introduction of AI has been substantial. The Thai laboratory, which is affiliated with the Ministry of Public Health (MoPH), has sophisticated methodology to serve the country and is backed up at 14 remote sites across the country, all of which are also equipped with rapid testing technologies. Its internet-based reporting system will eventu- ally merge with another AFRIMS-supported project, linking MoPH and the Ministry of Agriculture and Cooperatives to allow sharing of data on zoonotic illnesses between ministries at the provincial and national levels. Therefore, AFRIMS’s capacity for AI must be directed at less well resourced countries in the region and at supplying services that are complementary to those available in Thailand. Sentinel surveillance projects are of two types, those directed toward detection of disease in personnel of 14 regional U.S. embassies and those aimed at detecting disease in populations in Southeast Asia. In the case of the former, specimen transport has been expensive and burdensome, with small numbers tested. However, the program should have a stabilizing func- tion should PI threaten employees. Within Thailand, AFRIMS is expanding influenza surveillance programs through its relationship with the Royal Thai Army (AFRIMS, 2007a). In these locations, previously unaddressed by the MoPH, AFRIMS’s DoD- GEIS funding supports the capacities of ten military and two civilian hos- pitals to detect and report influenza primarily among refugee populations and non-Thai citizens along the western border with Myanmar. This work supplements the surveillance system of the MoPH in Thailand. In the Philippines the purpose of the AFRIMS work is to develop an ac- tive influenza surveillance program in the Cebu Province (AFRIMS, 2007a). The Philippines is beginning to incorporate this network into the national 

86 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS surveillance program. As in Nepal and Thailand, the protocol for influ- enza-like illnesses (ILI) that is employed here involves local rapid testing and followup testing by PCR (polymerase chain reaction) in Bangkok, with confirmatory testing at AFIOH in San Antonio, Texas, and selected isolates sent to the WHO Influenza Reference Laboratory at CDC in Atlanta. Conclusions The Committee concluded that AFRIMS’s influenza surveillance pro- tocol activities and initiatives expanded with supplemental funding repre- sented a significant contribution to the influenza surveillance network in the region. In addition, the committee concluded that AFRIMS would greatly extend its contribution to knowledge of the H5N1 influenza virus with ad- ditional protocols focused on seasonal influenza and novel findings. RECOMMENDATION 4-1. AFRIMS should establish more intensi- fied surveillance for seasonal and novel strains of influenza at sites in temperate and tropical/subtropical parts of Nepal, in locales with com- mercial poultry production units, and at migratory bird resting sites. LABORATORY In Bangkok, AFRIMS occupies a total of six separate buildings at two sites approximately one kilometer apart (DoD-GEIS, 2007a). Relevant to the DOD-GEIS work, these buildings house laboratory space as well as a veterinary animal wing and a veterinary medicine building. AFRIMS is in the process of constructing a Biosafety Level 3 (BSL-3) laboratory suite. A significant deficit in the region is the availability of sufficient biosafety capacity. Funding was made available in fiscal year 2006 for AI/PI, and AFRIMS took advantage of this to build infrastructure in the form of this BSL-3 laboratory. Real-time PCR using the RotoGene system has been established at the AFRIMS respiratory pathogen section and at the Department of Veterinary Medicine BSL-3 laboratory. AFIOH and the CDC have provided probes, primers, and training. Current capabilities include universal A and B, H1, H3, and H5 detection. Mass-tag PCR assays have also been established at AFRIMS for the identification of a range of respiratory pathogens. Study personnel and other interested personnel (both the Royal Thai Army and U.S. Army Materiel Command) will receive training on the standard operat- ing procedures for these PCR assays. AFRIMS is playing an important role outside of Thailand as well, pri- marily through the Walter Reed/AFRIMS Research Unit Nepal (WARUN). WARUN was formally established in August 1995 and currently provides 

AFRIMS THAILAND 87 influenza diagnostic support and training to various entities in Nepal, such as the National Public Health Laboratory (NPHL), the Epidemiology and Disease Control Division (EDCD), and WHO Nepal. The WARUN laboratory has capacity for bacteriologic culture and will be fully functional in performing influenza virus PCR assays for AI/PI by June 2007. In this effort a study will be conducted with the MoPH and several clinical sites looking at ILI. Specimens will be tested at the site of collection using rapid tests, and companion specimens will be transported to WARUN for PCR testing. The results will be confirmed at the AFRIMS laboratory in Bangkok and further characterized at AFIOH in San Antonio, Texas. Conclusions AFRIMS has proposed a plan to rapidly accelerate its protocol for releasing PCR results in Nepal, the Philippines, and Thailand and for re- leasing cultures in Bangkok by January 1, 2008. Inherent in this is the need for AFRIMS to be entirely self-sufficient in its isolation and identification systems as soon as possible so that rapid and accurate results are imme- diately available for decision makers. AFRIMS’s proposed expansion of laboratory capacity and increased autonomy would also increase its status in Thailand, a country with significant influenza resources but lacking suf- ficient biosafety capacity. As the facilities move toward self-sufficiency it would be beneficial to have a safety officer, in lieu of a staff member, who is responsible for laboratory containment facilities, as well as an individual devoted to the oversight of quality assurance. RECOMMENDATION 4-2. AFRIMS should continue to work toward self-sufficiency in its isolation and identification systems in order to release PCR results more quickly to its national partners while tak- ing appropriate steps to ensure laboratory containment and quality assurance. RESPONSE CAPACITY Under routine conditions, the AFRIMS respiratory laboratory is capa- ble of performing molecular screening of 200 samples per week. Addition- ally, the field sites at the Kwai River Christian Hospital and in Kangphaeng Phet are each capable of screening an additional 100 samples per week, bringing the total capacity to 400 samples per week (AFRIMS, 2007b) (see Table 4-1). In a periepidemic situation, AFRIMS would be able initially to alter the current testing algorithm to test for influenza A first and then, if positive, 

88 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS TABLE 4-1 Summary of Surge Capability at AFRIMS AFRIMS Respiratory Condition Lab Field Site × 2 Total Samples Routine operation 200/week 200/week 400/week Altered algorithm, 300/week 300/week 600/week influenza A and H5 first Target only specific gene 1,000/week 1,000/week 2,000/week 24-hours-a-day, seven- 3,000/week 2,000/week 5,000/week days-a-week operations SOURCE: AFRIMS, 2007b. H5. This would allow screening of an additional 100 samples per week at the respiratory laboratory and an additional 50 per week at each field site, for a total of 600 samples per week. Further refinement of the screening process, targeting only the gene required to rule in or out the strain of interest, would allow screening of up to 1.000 samples per week at the respiratory laboratory and 500 per week at each field site, for a total of 2,000 samples per week, without reassigning personnel. The limiting factor here would not be the laboratory, but data entry and quality assurance. If required, AFRIMS could convert to a 24-hours–a-day, seven-days- a-week operation at the respiratory laboratory, thus trebling its sample processing capabilities. Such a surge would not be possible at the field sites, although a doubling of work hours is feasible. The best estimates of their short-term surge capabilities would be that the respiratory section could process 3,000 samples per week and each field site could process 1,000 samples per week, bringing AFRIMS’s total molecular screening capabilities to 5,000 samples per week (AFRIMS, 2007b). This would require reas- signing staff from other research activities and departments to maintain 24-hours-a-day, seven-days–a-week operations and would require equip- ment to be on stand-by in case of primary equipment failure. Additionally, AFRIMS does not stock enough reagents to accomplish these sample loads (nor would it be cost-effective), so reagents would have to be acquired quickly in order to carry out work at this volume. Conclusions AFRIMS has developed a plan and a chain of command to convert ex- pendable research and other laboratory activities to support enhanced sur- veillance should human-to-human transmission by a novel avian influenza 

AFRIMS THAILAND 89 virus occur. More specifically, its plan describes how the lab will suspend certian activities and divert staff and resources to rapid around-the-clock PCR and diagnostic activities. This requires a limited amount of exposure of research staff to influenza work in order to train and prepare them. In- cluded in this plan is the flexibility to send relevant staff to outbreak sites. In addition, AFRIMS’s support of tabletop simulation exercises would help to identify areas of the national plans that need strengthening and direct future investments of pandemic preparedness funding in the region. CAPACITY BUILDING AFRIMS funded a significant number of capacity-building activities with the supplemental AI/PI funding from fiscal year 2006. The labora- tory hired and trained core DoD-GEIS personnel to coordinate influenza surveillance at AFRIMS as well as laboratory and data entry personnel to work in the respiratory pathogen section in the department of virology. In addition, AFRIMS designed and awarded a contract to construct a BSL-3 laboratory facility. In order to improve its existing laboratory capacities, AFRIMS acquired real-time PCR and Mass Tag PCR technologies to per- form respiratory pathogen identification as well as characterization and real-time PCR for the veterinary BSL-3 laboratory. Virus culturing requires higher levels of biosafety because it produces higher concentrations of virus than are generally present in human nasal, throat, or other respiratory specimens. Importantly, culture is valuable be- cause it affords greater capacity to characterize the virus and detect changes in antigenicity and nucleic acid sequences. These changes may further sug- gest that the virus is evolving to become more resistant to antiviral agents, more likely to cause severe disease, or more readily transmissible from hu- man to human. Additionally, strains with similar sequences may be traced to a common origin, and this may suggest the source of infection. The design and construction of a BSL-3 laboratory is under way and expected to be completed by early 2008. The cost of this biosafety capacity is approxi- mately $2 million, all of which comes from the supplemental funding. The respiratory laboratory in Bangkok will have the capability for mo- lecular diagnosis as well as subtyping strains to distinguish significant vari- ants among the seasonal influenza isolates and to recognize strains that may emerge as candidate pandemic strains. An innovative capacity using mass tag spectroscopy to detect a wider range of respiratory pathogens, ranging from influenza to human metapneumovirus to mycoplasma, will be installed and evaluated in collaboration with a group at Columbia University. The viability of this technology is very much dependent on sound spectroscopy support. This venture may yield new information about pathogens that are currently unrecognized but that affect nationals, refugees, and military 

90 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS personnel alike. This respiratory laboratory will be greatly enhanced when the BSL-3 capacity is available for the virus isolation work. As mentioned earlier, the major effort in Nepal involves WARUN, which has capacity for bacteriologic culture and will be fully functional in performing PCR assays for AI/PI by June 2007. In this effort a study will be conducted with the MoPH and several clinical sites looking at ILI. Speci- mens will be tested at the site of collection using rapid tests, and companion specimens will be transported to WARUN for PCR testing. The results will be confirmed at the AFRIMS laboratory in Bangkok and further character- ized at AFIOH in San Antonio, Texas. Training is an important element of the AFRIMS work, and it has been provided to U.S. embassies in the region as well as to public health agencies in Thailand, Nepal, and the Philippines; the training has covered such areas as specimen collection and transport, epidemiology, laboratory techniques, and AI recognition and response. In some cases the training sessions involved collaborations with other U.S. agencies or organizations within the countries where the training was conducted. While in Kathmandu the site visit team met with the dean of the university’s Institute of Medicine, himself a pediatrician, who expressed support for the DoD-GEIS-funded surveillance projects, emphasizing the importance of local technological understanding and improvements. The team saw great opportunities in Nepal to put into effect AFRIMS’s skills as a WHO training center. Conclusions The IOM site visit team feels it a wise decision for AFRIMS to expand its diagnostic capabilities as this will allow it to culture H5N1 and other highly pathogenic strains of avian influenza virus as well as strains that may evolve or be recognized in the future. In conjunction with the expansion of the laboratory capabilities, AFRIMS will need to increase the number of trained personnel. RECOMMENDATION 4-3. AFRIMS should continue to provide rel- evant training, including epidemiological training, to U.S. and local personnel to enable its expansion of laboratory capabilities. COLLABORATION AND COORDINATION AFRIMS collaborates on influenza virus surveillance with various or- ganizations in Thailand as well as in the wider region (e.g. Nepal and the Philippines) and also has strong links with the Naval Medical Research Unit No. 2 (NAMRU-2) in Jakarta. 

AFRIMS THAILAND 91 AFRIMS personnel are well aware of the importance of building trust- ing relationships with their partners and, as such, are careful and patient when establishing themselves in the various areas in which they work. In the interest of developing appropriate and sustainable projects, they work to find areas of mutual interest and aim to address the specific requests and needs of their partners. For example, the leadership understood that the ways in which it could assist the already established and fully functional influenza surveillance system of Thailand’s MoPH were limited. The leader- ship therefore asked the MoPH what could be done to assist its efforts and, as a result, supported the development of the electronic reporting system for avian influenza. Because AFRIMS is a relative newcomer in its AI/PI surveillance pro- grams, relationships with organizations in the area doing similar work, such as U.S. Agency for International Development (USAID) and CDC, are also in their early stages of development. It is important to note, however, that these organizations are highly interested in future collaborations with AFRIMS. During the IOM team’s meeting with the International Emerg- ing Infections Program (IEIP), it was explained that two of the program’s planned influenza studies intend to include a collaboration with AFRIMS. The team similarly heard during its meeting with representatives from USAID that increased interaction with AFRIMS is desired. It is believed that the completion of AFRIMS’s BSL-3 laboratory will help to increase its collaborations with both existing partners and potential partners, such as IEIP. In addition, AFRIMS projects could also benefit from increased col- laboration with personnel at DoD-GEIS headquarters to provide influenza- specific guidance and assistance. The Nepal MoPH affirmed its relationship with WARUN and AFRIMS but noted that it expects to receive funding from the World Bank to build its own BSL-3. More specifically, the World Bank is giving Nepal $18 million, 60 percent of which will be allotted to the veterinary efforts and 40 percent to the human programs. When the IOM team visited WHO, officials there proposed to develop a model public health laboratory system in Nepal, working with the Nepal MoPH and personnel from AFRIMS/WARUN. This would require significant human resources input. Conclusions The support that AFRIMS provided for the Thai MoPH to develop a web-based reporting system should be a model for other AI/PI programs, and the development and use of similar systems in other countries or re- gions should be promoted. In an emergency there will be little opportunity to communicate critical information to those who need it most, and the web system will fill that void. The committee felt that Nepal would also 

92 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS benefit from AFRIMS’s assistance in establishing a model system in Nepal for optimizing the delivery of regional and national public health laboratory services in collaboration with WHO and the Nepal MoPH. The committee concluded that AFRIMS’s ongoing collaboration with NAMRU-2 allows for improved utilization of AI/PI resources as well as redundant coverage for each of the laboratories in the event of a crisis (political, geologic, etc.) that might close one and not the other during a pandemic. RECOMMENDATION 4-4. AFRIMS should continue to strengthen its relationship with NAMRU-2 in Indonesia and evaluate its roles in Asia and identify, where possible, critical geographic regions that are not covered by one or the other of these AI/PI programs. References Air Force Institute for Operational Health (AFIOH). 2004. DoD global influenza and other respiratory viral pathogens surveillance weekly update week 14 (4 Apr – 10 Apr). http:// www.geis.fhp.osd.mil/GEIS/SurveillanceActivities/Influenza/Reports/influenza_2004-04- 04.pdf (accessed September 5, 2007). AFRIMS (Armed Forces Research Institute of Medical Sciences). 2007a. AFRIMS influenza surveillance program—current and future (unpublished). AFRIMS. 2007b. Estimated laboratory surge capacity (unpublished). AFRIMS. 2006. AFRIMS human influenza isolate collection—current, prior to end FY07, and prior to end FY08 (unpublished). Apisarnthanarak, A., R. Kitphati, K. Thongphubeth, P. Patoomanunt, P. Anthanont, W. A ­ uwanit, P. Thawatsupha, M. Chittaganpitch, S. Saeng-Aroon, S. Waicharoen, P. Apisarnthanarak, G. A. Storch, L. M. Mundy, and V. J. Fraser. 2004. Atypical avian influenza (H5N1). Emerging Infectious Diseases 10(7):1321-1324. DoD-GEIS (Department of Defense Global Emerging Infections System). 2007a. Armed Forces Research Institute of Medical Sciences. http://www.geis.fhp.osd.mil/GEIS/­Training/ AFRIMS.asp (accessed July 30, 2007). DoD-GEIS. 2007b. Department of Defense influenza surveillance sites worldwide, 2007 (unpublished). Tiensin, T., P. Chaitaweesub, T. Songserm, A. Chaisingh, W. Hoonsuwan, C. Buranathai, T. Parakamawongsa, S. Premashthira, A. Amonsin, M. Gilbert, M. Nielen, and A. S ­ tegeman. 2005. Highly pathogenic avian influenza H5N1, Thailand, 2004. Emerging Infectious Diseases 11(11):1664-1672. WHO (World Health Organization). 2004. Avian influenza—situation in Thailand. http:// www.who.int/csr/don/2004_09_28a/en/print.html (accessed June 12, 2007). WHO. 2007a. H5N1 avian influenza: Timeline of major events. http://www.who.int/csr/­ disease/avian_influenza/Timeline_2007_03_20.pdf (accessed July 30, 2007). WHO. 2007b. Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO. http://www.who.int/csr/disease/avian_influenza/country/cases_table_ 2007_07_25/en/index.html (accessed July 30, 2007). WHO. 2007c. Avian influenza outbreaks in South-East Asia. http://www.searo.who.int/EN/ section10/section1027.htm (accessed June 12, 2007). 

AFRIMS THAILAND 93 List of Contacts DoD-GEIS AFRIMS Assessment: Thailand Rodney Coldren, GEIS Director, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand Robert V. Gibbons, Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand Richard Jarman, Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand Khir Saw Aye Myint, Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand Bonnie Smoak, Commander, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand Bryan Sweeney, Influenza Program Manager, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand In-Kyu Yoon, Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand Jim Waller, Economic Section, Embassy of the United States, Bangkok, Thailand Sudarat Damrongwatanapokin, Regional Development Mission, Asia/ United States Agency for International Development, Bangkok, Thailand Susan Maloney, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia Henry Baggett, International Emerging Infections Program, Centers for Disease Control and Prevention/Thailand Ministry of Public Health, Nonthaburi, Thailand Leonard F. Peruski, International Emerging Infections Program, Centers for Disease Control and Prevention/Thailand Ministry of Public Health, Nonthaburi, Thailand Wiwan Sanasuttipun, International Emerging Infections Program, Centers for Disease Control and Prevention/Thailand Ministry of Public Health, Nonthaburi, Thailand Somsak Thamthitiwat, International Emerging Infections Program, Centers for Disease Control and Prevention/Thailand Ministry of Public Health, Nonthaburi, Thailand Malinee Chittaganpitch, National Institutes of Health, Bangkok, Thailand Rungrueng Kitphati, National Institutes of Health, Bangkok, Thailand Krongraew Supawat, National Institutes of Health, Bangkok, Thailand 

94 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS DoD-GEIS WARUN Assessment: Nepal Sanjaya Kr. Shrestha, Walter Reed AFRIMS Research Unit Nepal, Kathmandu, Nepal Mrigendra Pd. Shrestha, Walter Reed AFRIMS Research Unit Nepal, Kathmandu, Nepal Ruthanne Taylor, U.S. Embassy Medical Unit Chief, American Embassy, Kathmandu, Nepal James F. Moriarty, U.S. Ambassador to Nepal, Kathmandu, Nepal Scott Taylor, Defense Attaché, American Embassy, Kathmandu, Nepal Ramesh K. Adinkani, Institute of Medicine, Kathmandu, Nepal Manas Kumar Banerjee, Epidemiology and Disease Control Division of Department of Health Services, Kathmandu, Nepal Sarala Malla, Ministry of Health and Population, Department of Health Services, National Public Health Laboratory, Kathmandu, Nepal Jeetendra Man Shrestha, Epidemiology and Disease Control Division of Department of Health Services, Kathmandu, Nepal Sailesh B. Pradhan, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal Manohar Prasad Gupta, Tribhuvan University Teaching Hospital, Kathmandu, Nepal Yagya Laxmi Shakya, Tribhuvan University Teaching Hospital, Kathmandu, Nepal Prativa Pandey, CIWEC Clinical Travel Medicine Center, Kathmandu, Nepal Margarita Ronderos, World Health Organization Country Office for Nepal, Kathmandu, Nepal Kan Tun, World Health Organization Country Office for Nepal, Kathmandu, Nepal Prakash Ghimire, Programme for Immunization of Preventable Diseases, World Health Organization, Kathmandu, Nepal 

AFRIMS THAILAND 95 Schedule of Events DoD-GEIS AFRIMS and WARUN Assessments Bangkok, Thailand and Kathmandu, Nepal Participants: Mary J. R. Gilchrist Kennedy Francis Shortridge Kimberly Weingarten March 12–17, 2007 Monday, March 12, 2007 0830-0930 In-brief at Vet Med building Col. Smoak Lt. Col. Coldren Mr. Sweeney 0930-1030 Overview of GEIS program 1030-1045 Break 1045-1130 Briefing on BSL-3 1130-1215 Lunch 1215-1330 Tour of AFRIMS main building 1330-1345 Return to Vet Med 1345-1445 Overview of Department of Immunology and Medicine avian influenza program 1445-1545 Overview of RTA influenza surveillance Enterics department 1545-1615 Briefing on Department of Veterinary Medicine 1615-1700 Tour of Vet Med and BSL-3 suite construction site 1700-1730 Return to hotel Tuesday, March 13, 2007 0800-1000 Briefing on Department of Virology 1000-1015 Break 1015-1145 Meeting with USAID personnel and state department science and tech officer 1145-1230 Lunch 1230-1315 Travel to Ministry of Public Health (MoPH) 1315-1445 Meeting with IEIP staff and MoPH representatives 1445-1500 Break 1500-1645 Continued discussions with MoPH representatives 1645-1745 Return to hotel 

96 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS Wednesday, March 14, 2007 0730-1330 Fly to Kathmandu, Nepal 1400-1530 Facility tour and staff introductions 1530-1630 Presentation on WARUN activities Dr. Sanjaya Kr. Shrestha, Head of Station, WARUN 1600-1630 Return to hotel Thursday, March 15, 2007 0900-1030 Discussion of purpose of visit and importance of influenza surveillance program Mr. James F. Moriarty, U.S. ambassador to Nepal Lt. Col. Scott Taylor, defense attache Dr. Ruthanne Taylor, U.S. embassy medical unit chief 1030-1130 Discussion of purpose of visit, the influenza diagnostic support program, and future plans of the Department of Health Services Dr. Manas Kumar Banerjee, Director of EDCD  Jeetendra Man Shrestha, avian influenza coordinator Dr. of EDCD  Margarita Ronderos, WHO medical officer and UN Dr. influenza coordinator 1430-1550 Discussion of veterinary laboratory work  Rebati Man Shrestha, director of Central Veterinary Dr. Laboratory 1550-1630 Meeting about construction plans for laboratory Dr. Kan Tun, country representative to WHO Dr. Margarita Ronderos 1630-1700 Return to hotel Friday, March 16, 2007 1100-1600 Visit sentinel influenza sites (TUTH, CIWEC, KMC, BDRC) 1600-1630 Return to hotel Saturday, March 17, 2007 0900-1100 De-brief 1100-1200 Lunch 1200-1800 Departure