Review of the DoD-GEIS Influenza Programs

Strengthening Global Surveillance and Response

Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs

Board on Global Health

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs Board on Global Health

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. W81XWH-06-C-0381 (DoD-7741) between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-11010-5 International Standard Book Number-10: 0-309-11010-6 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: Institute of Medicine (IOM). 2008. Review of the DOD-GEIS influenza programs: Strengthening global surveillance and response. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE FOR THE ASSESSMENT OF DOD-GEIS INFLUENZA SURVEILLANCE AND RESPONSE PROGRAMS MYRON M. LEVINE, M.D., D.T.P.H. (Chair), Professor and Director, Simon and Bessie Grollman Distinguished Professor, Center for Vaccine Development, University of Maryland School of Medicine CAROL CARDONA, D.V.M., Ph.D., Associate Veterinarian, Associate Specialist in Cooperative Extension, Veterinary Medicine Extension, University of California, Davis WALTER DOWDLE, Ph.D., The Task Force for Child Survival and Development TIMOTHY GERMANN, Ph.D., Technical Staff Member, Applied Science & Methods Development Group, Los Alamos National Laboratory MARY GILCHRIST, Ph.D., Director, Bureau of Laboratory Sciences, State Laboratory Institute, Department of Public Health, The Commonwealth of Massachusetts JAMES M. HUGHES, M.D., Director, Program in Global Infectious Disease, Center for Global Safe Water, School of Medicine and Rollins School of Public Health, Emory University K. MILLS McNEILL, Ph.D., M.D., Director, Public Health Laboratory, Mississippi State Department of Health PETER PALESE, Ph.D., Professor and Chair Department of Microbiology, Mount Sinai School of Medicine KENNEDY FRANCIS SHORTRIDGE, Ph.D., D.Sc., Emeritus Professor, The University of Hong Kong and Honorary Professor, Department of Micobiology, The University of Hong Kong, Hong Kong SAR, China, Honorary Professor, Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand JAMES TIBENDERANA, M.B.CH.B., M.Phil., Ph.D., Drug Policy Change Specialist/Epidemiologist Malaria Consortium, Uganda Board Liaison PHILIP K. RUSSELL, M.D., (Board on Global Health Liaison) Former Director, Office of Research and Development Coordination, Office of the Assistant Secretary for Public Health Emergency Preparedness, U.S. Department of Health and Human Services v

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Project Staff PATRICK W. KELLEY, M.D., Dr.P.H., Director, Boards on Global Health and African Science Academy Development RICK ERDTMANN, M.D., M.P.H., Director, Boards on Military and Veterans Health and Medical Follow-up Agency J. ALICE NIXON, M.A., Study Director KIMBERLY WEINGARTEN, Research Assistant ANGELA MENSAH, Senior Program Assistant (November 2006–April 2007) EMILY S. MEYER, Intern (February 2007–May 2007) vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical com- ments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Donald S. Burke, Graduate School of Public Health, University of Pittsburgh Philip E. Coyle III, Science Strategies, LLC Kathy Edwards, Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine Benson Estambale, College of Health Sciences, University of Nairobi Institute of Tropical and Infectious Diseases, Alison P. Galvani, Division of Epidemiology of Microbial Diseases, Yale University School of Medicine Kathleen F. Gensheimer, Medical Epidemiology Section, Division of Infectious Diseases, Maine Department of Health and Human Service Lance Jennings, Canterbury Heath Laboratories, Christchurch, New Zealand vii

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viii REVIEWERS Daniel Lavanchy, Epidemic and Pandemic Alert and Response, Office for Alert and Response Operations, World Health Organization Graeme Laver, Australian National University, Professor Emeritus Mark Miller, Fogarty International Center, National Institutes of Health Frederick A. Murphy, Galveston Department of Pathology, University of Texas Medical Branch Douglas M. Watts, Department of Pathology, Center for Biodefense and Emerging Infectious Diseases, University of Texas Medical Branch Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Dr. David R. Chal- loner, Vice President for Health Affairs, Emeritus, University of Florida, and Charles C.J. Carpenter, the Miriam Hospital and Brown University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface I nfluenza in humans is an acute respiratory disease caused by RNA viruses that continually undergo genetic change, allowing seasonal epi- demics as the viruses evolve in subtle ways that permit them to evade preexisting immunity in portions of the human population. During seasonal epidemics, the very young and the elderly bear the brunt of mortality from influenza. However, every few decades a fundamental antigenic shift occurs in the virus, resulting in the emergence of a strikingly new influenza viral strain to which most of the human population is susceptible. If the new virus is particularly virulent, as well as antigenically distinct and readily transmissible between humans, a pandemic can ensue that represents a public health emergency with likely severe human and economic repercus- sions. The two most recent pandemics (1957 and 1968) are known to have resulted from a human influenza virus acquiring genes from an avian virus, resulting in a “reassorted” virus. Three pandemics caused by influenza A viruses occurred in the 20th century, including 1918-1919 (H1N1 virus), 1957 (H2N2 virus), and 1968 (H3N2 virus). Among these, the 1918-1919 pandemic stands out because of the particularly severe clinical disease observed and the unusual epide- miologic behavior that ensued in which healthy young adults, in addition to the very young and elderly, suffered high mortality. During the 1918-1919 pandemic, U.S. armed services personnel on military installations in the United States experienced unprecedented fatality rates. Fundamental strategies to minimize the impact of the next pandemic include the maintenance of a global surveillance system to detect emerging ix

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x PREFACE shifted influenza viruses, the rapid development of vaccines based on the newly emerged “shifted” strains, and use of stockpiled antiviral drugs. As both the 1957 and 1968 pandemic viruses apparently originated in East Asia, a critical component of current global influenza surveillance is based on the early detection of influenza-like disease and collection of influenza viruses from Asia. In 1997 an outbreak of influenza in chickens in Hong Kong due to a highly lethal H5N1 avian influenza A virus also caused 18 human cases, of which six were fatal. Since 2004, other avian H5N1 viruses have wreaked havoc among domestic poultry in East and Southeast Asia and have also caused more than 300 human cases (among close human contacts of poul- try), of which 60 percent were fatal. Thus far H5N1 viruses have not attained the capacity to transmit readily from human to human but the United States must be vigilant. In 1996, the Executive Office of the President of the United States issued a Presidential Decision Directive declaring that national and inter- national capabilities for infectious disease surveillance, prevention, and response were insufficient to protect the health of U.S. citizens from emerg- ing infectious diseases and called on U.S. federal agencies to remedy the situation. The Department of Defense (DoD) Global Emerging Infections Surveillance and Response System (GEIS), established in 1997, represents the DoD’s response to that Presidential Decision Directive. GEIS’s focus is primarily on sentinel surveillance of indigenous and expatriate populations for certain infectious disease targets, including influenza. For many decades the DoD has maintained a series of overseas medical research facilities in Asia, Africa, and Latin America that have been well poised to participate in the detection of emerging infectious disease threats. Collectively, these DoD facilities constitute an extraordinary array of surveillance assets. In 2006, through the National Defense Authorization Act, Congress provided a $39 million supplement to GEIS, specifically to expand sur- veillance and response capabilities with respect to the threat of pandemic influenza of avian virus origin. An IOM Committee was assembled at the request of the DoD to evaluate how the GEIS pandemic influenza surveil- lance and response program utilized the supplemental funds, strengthened influenza surveillance efforts domestically and internationally, integrated DoD efforts with those of other Federal agencies, coordinated activities with host countries (and neighboring countries in regional efforts), and collaborated with the World Health Organization and other international agencies engaged in influenza pandemic preparedness. Toward this end, a Committee was assembled with expertise in influenza, epidemiology, public health laboratory management, virology, veterinary and human medicine, global health and military preventive medicine. The Committee made site visits to the DoD overseas medical research units where GEIS-supported

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xi PREFACE projects are under way, as well as to key military medical laboratories within the United States involved in influenza surveillance. The findings of the Committee are summarized in this report, along with a series of recommendations. The Committee found that the DoD’s overseas medical research units constitute an impressive network that has laudably utilized the supplemen- tal funding to strengthen influenza surveillance, in addition to continuing their historically primary research activities. Perhaps the Committee’s most overarching recommendation is that DoD-GEIS headquarters should be formally charged with providing overall managerial and technical oversight (quality assurance, safety, etc.) and interagency communication for the multi-service influenza and respiratory disease surveillance program and the revised coordination structure. Part of this should be a codified chain of accountability to include timely reporting of findings. If the full set of recommendations are acted upon, the Committee is confident that the DoD- GEIS’s key role in global surveillance will be further strengthened and its effectiveness enhanced. Myron M. Levine, M.D., D.T.P.H. Chair

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Contents ABBREVIATIONS AND ACRONYMS xix SUMMARY 1 1 INTRODUCTION 21 Background, 21 Charge to the Committee, 28 The Study Process, 29 References, 30 2 DOD-GEIS HEADQUARTERS AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 33 DoD-GEIS AI/PI Funding, 35 Headquarters Management of DoD-GEIS AI/PI Activities, 37 DoD-GEIS Headquarters and Other Military Health System Influenza Surveillance and Response Activities, 46 Conclusions, 50 References, 52 List of Contacts, 54 3 NAVAL MEDICAL RESEARCH UNIT 2 INDONESIA AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 55 Influenza in Indonesia, 56 Management and Planning, 57 xiii

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xiv CONTENTS Surveillance, 59 Laboratory, 63 Response Capacity, 66 Capacity Building, 70 Collaboration and Coordination, 72 References, 75 List of Contacts, 77 Schedule of Events, 78 4 ARMED FORCES RESEARCH INSTITUTE OF MEDICAL SCIENCES THAILAND AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 81 Influenza in Thailand, 82 Management and Planning, 84 Surveillance, 84 Laboratory, 86 Response Capacity, 87 Capacity Building, 89 Collaboration and Coordination, 90 References, 92 List of Contacts, 93 Schedule of Events, 95 5 NAVAL MEDICAL RESEARCH UNIT 3 EGYPT AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 97 Influenza in Egypt, 99 Management and Planning, 99 Surveillance, 102 Laboratory, 105 Response Capacity, 107 Capacity Building, 111 Collaboration and Coordination, 115 References, 119 List of Contacts, 120 Schedule of Events, 121 6 U.S. ARMY MEDICAL RESEARCH UNIT KENYA AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 123 Influenza in Kenya, 125 Management and Planning, 125 Surveillance, 128 Laboratory, 132 Response Capacity, 134

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xv CONTENTS Capacity Building, 136 Collaboration and Coordination, 137 Uganda, 139 References, 142 List of Contacts, 144 Schedule of Events, 145 7 NAVAL MEDICAL RESEARCH CENTER DETACHMENT PERU AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 147 Management and Planning, 149 Surveillance, 151 Laboratory, 154 Response Capacity, 155 Capacity Building, 156 Collaboration and Coordination, 158 References, 161 List of Contacts, 163 Schedule of Events, 164 8 NAVAL HEALTH RESEARCH CENTER SAN DIEGO AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 167 Management and Planning, 168 Surveillance, 169 Laboratory, 174 Response Capacity, 175 Collaboration and Coordination, 178 References, 179 List of Contacts, 180 Schedule of Events, 180 9 AIR FORCE INSTITUTE FOR OPERATIONAL HEALTH SAN ANTONIO AVIAN AND PANDEMIC INFLUENZA ACTIVITIES 183 Management and Planning, 184 Surveillance, 188 Laboratory, 190 Response Capacity, 193 Collaboration and Coordination, 195 References, 197 List of Contacts, 199 Schedule of Events, 200

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xvi CONTENTS 10 OVERARCHING CONCLUSIONS AND RECOMMENDATIONS 203 Consistency with Department of Defense and National Plans, 204 The Utility of Each Funded Project’s Contribution to a Comprehensive AI/PI Surveillance Program, 207 Adequacy of the Program in View of Evolving Epidemiologic Factors, 209 Coordination of Efforts with the Centers for Disease Control and Prevention, the World Health Organization, and Local Governments, 216 Conclusion, 222 References, 222 APPENDIX Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO, 11 July 2007 226 LIST OF FIGURES 1-1 Nations with confirmed cases H5N1 avian influenza, 24 2-1 DoD-GEIS funding from fiscal year 1997 to 2006, 38 2-2 DoD-GEIS organizational chart, 40 3-1 DoD’s regional presence in influenza surveillance (South East Asia), 2007, 56 4-1 DoD’s regional presence in influenza surveillance (South East Asia), 2007, 83 5-1 DoD’s regional presence in influenza surveillance (Africa), 2007, 98 5-2 NAMRU-3 avian influenza assessment missions and outbreak support, 103 6-1 DoD’s regional presence in influenza surveillance (Africa), 2007, 124 7-1 DoD’s regional presence in influenza surveillance (Latin America), 2007, 148 8-1 NHRC influenza surveillance sites and activities, 2006-2007, 170 9-1 AFIOH sentinel surveillance sites and activities, present and future, 2006-2007, 189 10-1 Department of Defense influenza surveillance sites worldwide, 2007, 205 10-2 DoD’s worldwide presence in influenza surveillance, 2007, 218

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xvii CONTENTS LIST OF TABLES 1-1 Primary DoD Overseas and Domestic Laboratories Receiving DoD-GEIS AI/PI Funding, 25 2-1 DoD-GEIS Avian Influenza/Pandemic Influenza Supplemental Funding in Fiscal Year 2006, 38 3-1 Summary of Surge Capability at NAMRU-2, 68 4-1 Summary of Surge Capability at AFRIMS, 88 5-1 Summary of Surge Capability at NAMRU-3—Routine Operations, 109 5-2 Summary of Surge Capability at NAMRU-3—Altered Agorithm (Influenza A and H5 first), 109 5-3 Summary of Surge Capability at NAMRU-3—24-Hours-a-Day, Seven-Days-a-Week Operations and Altered Algorithm (Influenza A and H5 first), 110 5-4 Summary of Surge Capability at NAMRU-3—Outbreak Support, 111 6-1 Summary of Surge Capability at USAMRU-K, 135 8-1 Summary of Surge Capability at the NRDL, NHRC, 177 9-1 Summary AFIOH Surge Capacity, 194 10-1 Department of Defense Laboratories Funding for Fiscal Year 2006, 208 10-2 Animal Surveillance Activities at the DoD Overseas Laboratories, 211 10-3 Laboratory Capabilities at the DoD Domestic and Overseas Laboratories, 212 10-4 Estimated Laboratory Surge Capacity at DoD Domestic and Overseas Laboratories, 214 10-5 Information Sharing at DoD Domestic and Overseas Laboratories, 216 10-6 International Partners of DoD Overseas Laboratories, 218 10-7 DoD Laboratories Serving as WHO Collaborating Centers and Reference Laboratories, 219 10-8 U.S. Government Partners of DoD Domestic and Overseas Laboratories, 221 LIST OF BOXES S-1 Chapter 2 Recommendations DoD-GEIS Headquarters 13 S-2 Chapter 3 Recommendations Naval Medical Research Unit No. 2 Indonesia, 13 S-3 Chapter 4 Recommendations Armed Forces Research Institute of Medical Sciences Thailand, 14

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xviii CONTENTS S-4 Chapter 5 Recommendations Naval Medical Research Unit 3 Egypt, 15 S-5 Chapter 6 Recommendations U.S. Army Medical Research Unit Kenya, 16 S-6 Chapter 7 Recommendations Naval Medical Research Center Detachment Peru, 17 S-7 Chapter 8 Recommendations Naval Health Research Center San Diego, 17 S-8 Chapter 9 Recommendations Air Force Institute for Operational Health San Antonio, 18 2-1 DoD-GEIS Avian and Pandemic Influenza Emergency Preparedness Plan Program Staff’s Role and Responsibilities, 36 2-2 Early Warning Outbreak Recognition System (EWORS), 47 9-1 DoD Influenza Executive Agent Functions Identified by AFIOH, 196 10-1 National Strategy for Pandemic Influenza, Implementation Plan Roles and Responsibilities, 220

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Abbreviations and Acronyms AAALAC American Association for the Accreditation of Laboratory Animal Care AFCOM U.S. African Command AFIOH Air Force Institute for Operational Health AFIP Armed Forces Institute of Pathology AFMIC Armed Forces Medical Intelligence Center AFRIMS Armed Forces Research Institute of Medical Sciences, Thailand AFRO WHO Regional Office for Africa AI avian influenza AI/PI avian influenza/pandemic influenza AI/PI EPP Avian Influenza/Pandemic Influenza Emergency Preparedness Plan AMSA U.S. Army’s medical surveillance activity ARI acute respiratory infection ASD-HA Assistant Secretary of Defense for Health Affairs BSL-2 biosafety level 2 BSL-3 biosafety level 3 BSL-3E biosafety level 3 enhanced BUMED Naval Bureau of Medicine and Surgery CDC Centers for Disease Control and Prevention CDHAM Center for Disaster and Humanitarian Assistance CENTCOM U.S. Central Command xix

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xx ACRONYMS AND ABBREVIATIONS CHPPM U.S. Army Center for Health Promotion and Preventive Medicine COCOM Combatant Command CONOPS concept of operations CONUS continental U.S. CPE cytopathic effect DCM Deputy Chief of Mission DGE Directorate of General Epidemiology DHP Defense Health Program DHS U.S. Department of Homeland Security DoD U.S. Department of Defense DoS U.S. Department of State DSO Defense Science Organization EDCD Epidemiology and Disease Control Division EID emerging infectious disease EMRO Eastern Mediterranean Regional Office EUCOM U.S. European Command EWORS Early Warning Outbreak Recognition System FAO Food and Agricultural Organization FDA Food and Drug Administration FISC Fleet and Industrial Supply Center FRI febrile respiratory illness FSN foreign service nationals FTE full-time equivalent GAINS Global Avian Influenza Network Surveillance GEIS Global Emerging Infections and Surveillance Response System GLP good laboratory practice GOARN Global Outbreak Alert Response Network GTZ German Agency for Technical Cooperation HA hemagglutinin HAI human avian influenza HHS U.S. Department for Health and Human Services HIV human immunodeficiency virus HJF Henry M. Jackson Foundation HPAI highly pathogenic avian influenza ICEID International Conference on Emerging Infectious Diseases IDSA Infectious Diseases Society of America IEC information, education, and communication IEIP International Emerging Infections Program IF immunofluorescence ILI influenza-like illness

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xxi ACRONYMS AND ABBREVIATIONS INS Instituto Nacional de Salud Peru IOM Institute of Medicine IRB institutional review board ITI Idaho Technology Incorporated JHU/APL Johns Hopkins University Applied Physics Laboratory JISWG Joint Influenza Surveillance Working Group KEMRI Kenya Medical Research Institute LANL Los Alamos National Laboratory LES locally employed staff LRN Laboratory Response Network MAAIF Ministry of Agriculture, Animal Industry, and Fisheries MDCK Madin-Darby canine kidney MHS military health system MIDRP Military Infectious Diseases Research Program MoA Ministry of Agriculture MoE Ministry of Environment MoH Ministry of Health MoHP Ministry of Health and Population MoPH Ministry of Public Health MoU memorandum of understanding MTF Medical Treatment Facilities MUWRP Makerere University Walter Reed Project NAMRID Naval Medical Research Institute Detachment NAMRU-2 Naval Medical Research Unit No. 2, Indonesia NAMRU-3 Naval Medical Research Unit No. 3, Egypt NASA National Aeronautics and Space Administration NBIC National Biosurveillance Integration Center NCD Newcastle disease NCLE National Center for Laboratory and Epidemiology NEHC Navy Environmental Health Center NGO nongovernmental organization NHRC Naval Health Research Center, San Diego, CA NIC National Influenza Center NIH National Institutes of Health NMRC Naval Medical Research Center NMRCD Naval Medical Research Center Detachment, Peru NORTHCOM U.S. Northern Command NPHL National Public Health Laboratory NRDL National Respiratory Disease Laboratory NSTC-7 National Science and Technology Council, Executive Office of the President, Presidential Decision Directive NTF National Task Force

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xxii ACRONYMS AND ABBREVIATIONS OASDHA Office of the Assistant Secretary of Defense for Health Affairs OCONUS outside the continental United States OIE World Organization for Animal Health OTSG Office of the Army Surgeon General PAHO Pan American Health Organization PCR polymerase chain reaction PI pandemic influenza PIPM Pandemic Influenza Policy Model Extension POM Program Objective Memorandum PPE personal protective equipment QA/QC quality assurance/quality control RSD Research Sciences Department RSV respiratory syncytial virus RTA Royal Thai Army RT-PCR reverse transcription polymerase chain reaction RVF Rift Valley fever SARS severe acute respiratory syndrome SEATO Southeast Asia Treaty Organization SME subject matter expertise SOP standard operating procedure SOUTHCOM U.S. Southern Command TMA Tricare Management Activity USACHPPM U.S. Army Center for Health Promotion and Preventive Medicine USAID U.S. Agency for International Development USAMC U.S. Army Materiel Command USAMRIID United States Army Medical Research Institute for Infectious Diseases USAMRMC U.S. Army Medical Research and Materiel Command USAMRU-K U.S. Army Medical Research Unit, Kenya USDA U.S. Department of Agriculture USDAAPHIS U.S. Department of Agriculture’s Animal and Plant Health Inspection Service USG United States government USUHS Uniformed Services University of the Health Sciences UVRI Uganda Virus Research Institute VE vaccine effectiveness VRBPAC Vaccines and Related Biological Products Advisory Committee WARUN Walter Reed/AFRIMS Research Unit Nepal WHO World Health Organization WRAIR Walter Reed Army Institute of Research WRP Walter Reed Project