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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by Contract No. DAM17-00-P-0412. The views presented in this report are those of the Institute of Medicine Committee to Review the Department of Defense Global Emerging Infections Surveillance Response System and are not necessarily those of the funding agencies.
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THE NATIONAL ACADEMIES
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Institute of Medicine
National Research Council
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COMMITTEE TO REVIEW THE DEPARTMENT OF DEFENSE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM
PHILIP S.BRACHMAN (Chair), Professor,
Department of International Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
RUTH L.BERKELMAN, Professor,
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
DONALD S.BURKE, Professor,
Department of International Health and
Director of the Center for Immunization Research,
Johns Hopkins School of Public Health, Baltimore, Maryland
KATHLEEN F.GENSHEIMER, State Epidemiologist,
Bureau of Health, Maine Department of Human Services, Augusta, Maine
C.JAMES HOSPEDALES, Director,
Caribbean Epidemiology Center, Pan American Health Organization, World Health Organization, Port of Spain, Trinidad, West Indies
ANN MARIE KIMBALL, Professor,
Health Services and Epidemiology, Adjunct in Medicine, University of Washington, Seattle, Washington
GUÉNAËL R.RODIER, Director,
Department of Communicable Disease Surveillance and Response, World Health Organization, Geneva, Switzerland
RONALD K.ST. JOHN, Executive Director,
Center for Emergency Preparedness and Response, Health Canada, Ottawa, Ontario, Canada
RICHARD N.MILLER, Study Director
HEATHER C.O’MAONAIGH, Program Officer
PAMELA RAMEY-McCRAY, Administrative Assistant
ANDREA COHEN, Financial Associate
The U.S. Department of Defense (DoD) has historically defined its interest in infectious diseases almost exclusively in terms of “battle-stopper” illnesses—those resulting in acute effects that can directly affect military operations. Although this approach remains central to the U.S. military’s infectious disease doctrine, development of the DoD Global Emerging Infections Surveillance and Response System (GEIS) is part of an important transition in the way that the threat of infectious diseases— and, more specifically, the threat of emerging infectious diseases—is perceived and addressed by the U.S. military.
Emerging infectious disease surveillance is sustained globally through a network of activities maintained through the collective efforts of numerous governmental and nongovernmental agencies. It is through the contributions of many partners that surveillance for emerging infectious diseases is possible. The DoD possesses valuable resources that can be brought to bear in this effort. It maintains an extensive, diverse array of laboratory facilities, both within the United States and overseas. These DoD laboratories can perform routine diagnostic testing, but they also possess rare, sometimes unique, diagnostic capabilities. DoD overseas laboratories are located throughout the world in areas where the potential for the emergence of infectious diseases is high. Often, laboratories operate in regions where alternative laboratory resources are sparse or nonexistent (e.g., sub-Saharan Africa). No other organization or government in the world maintains such extensive or capable laboratory facilities and staffing internationally. DoD laboratory facilities represent medical re-
search, public health, and diplomatic resources that serve U.S. military, U.S. civilian, and global interests alike.
For more than a decade, formal DoD participation in emerging infectious disease surveillance has been encouraged by many in the U.S. public health community and within the DoD. In 1996, Presidential Decision Directive NSTC-7 (NSTC is the National Science and Technology Council of the Executive Office of the President) transformed these recommendations into a mandate. Thereafter, the National Intelligence Council declared emerging infectious diseases to be a threat to the national security of the United States, underscoring the importance of DoD participation in disease surveillance efforts. This role is not an altogether new one, as the DoD has been conducting various infectious disease surveillance projects (e.g., for influenza) for many years. Accommodation of its expanded role has led the DoD to implement GEIS. The committee recognizes this effort as a responsive and effective step toward addressing the problem of emerging infectious diseases.
We would like to thank the staff of the DoD laboratories, both domestic and overseas, and the staff of the GEIS Central Hub for the time and effort that they have invested in sharing with us information about the GEIS operations that they support. This review effort was very much a collegial one, and the report benefited from the openness of all those who provided us with documentation, presentations, and conversations. This study was also enriched by the insights that GEIS collaborators and associates provided regarding their views of GEIS from the outside looking in. Lists of the laboratory staff and GEIS collaborators and associates who shared their time with the committee can be found at the ends of Chapters 2 through 7 of this report. Any omissions are strictly the result of oversight.
The support provided by Institute of Medicine staff was instrumental in keeping this study moving apace. We extend our thanks to Richard Miller, Heather O’Maonaigh, and Pamela Ramey-McCray of the Institute of Medicine’s Medical Follow-Up Agency and to National Academies Travel staff, particularly Ann-Marie Walko, for their assistance. This study also benefited from the attention of Andrea Cohen, financial associate; Michael Hayes, consulting editor; and Linda Kilroy, contracting officer. Medical Follow-Up Agency staff members Phillip Bailey, Salem Fisseha, Lois Joellenbeck, and Karen Kazmerzak also helped along the way.
In addition, we are grateful to GEIS Central Hub staff members, particularly Joel Gaydos, Steve Gubenia, Patrick Kelley, Jennifer Rubenstein, and James Writer for their tireless assistance in preparing and compiling background documents and for helping to plan and negotiate the logistics of site visits. Likewise, we offer special thanks to Roxana Lescano, Lucy Rubio, and Trueman Sharp, Naval Medical Research Center Detachment,
Peru; Andrew Corwin and John Sisson, Naval Medical Research Unit 2, Indonesia; Gaye Ruble, Armed Forces Research Institute of Medical Sciences, Thailand; Cole Church, Naval Medical Research Unit 3, Egypt; Ronald Rosenberg, U.S. Army Medical Research Unit, Kenya; and Leslie Henry, Naval Health Research Center, San Diego, for their help in putting site visits together.
This report is a testament to the hard work, patience, and resolve of many. We extend to all involved our appreciation and gratitude.
Philip S.Brachman (Committee Chair)
Ann Marie Kimball
Ronald K.St. John
This 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 comments 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:
JAMES BANTA, Adjunct Professor, International Public Health, International Health Policy, The George Washington University Medical Center
KENNETH BART, Director, Graduate School of Public Health, San Diego State University
DAVID BRANDLING-BENNETT, Deputy Director, Pan American Health Organization
SCOTT HALSTEAD, Adjunct Professor, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences
ROBERT HOLZMAN, Professor of Clinical & Environmental Medicine, New York University School of Medicine
JOSHUA LEDERBERG, Raymond and Beverly Sackler Foundation Scholar, The Rockefeller University
JAMES W.LEDUC, Acting Director, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention
STEPHEN B.THACKER, Assistant Surgeon General and Director, Epidemiology Program Office, Centers for Disease Control and Prevention
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 Adel A.F. Mahmoud, President, Merck Vaccine Division, Merck & Co. Appointed by the National Research Council and Institute of Medicine, he was 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.
Acronyms and Abbreviations
automated data processor
Armed Forces Epidemiology Board
acute febrile illness
Air Force Institute for Environmental Safety and Occupational Health Risk Analysis
Armed Forces Institute of Pathology
Armed Forces Research Institute of Medical Sciences
African Medical and Research Foundation
Air Force Reportable Events Surveillance System
Acquired Immunodeficiency Syndrome
Caribbean Epidemiology Center
Centers for Disease Control and Prevention (United States)
Department of Defense Composite Health Care System (I and II)
Center for Health Promotion and Preventive Medicine
Commander-in-Chief, Unified Combatant Command
Committee on International Science, Engineering, and Technology
Cooperative Research and Development Agreement
Department of Defense (United States)
Department of Medical Services
Defense Medical Surveillance System
emerging infectious disease
enzyme linked immunosorbent assay
Eastern Mediterranean Regional Office, World Health Organization
El Niño/Southern Oscillation
Early Warning Outbreak Response System
Electronic Surveillance System for Early Notification of Community-Based Epidemics
foreign service national
Field Epidemiology Training Program
WHO’s influenza surveillance system
Global Emerging Infections Surveillance and Response System
geographic information system
Gonococcal Isolate Surveillance Project
Human Immunodeficiency Virus
International Livestock Research Institute
Institute of Medicine
Instituto Nacional de Salud (Peru)
Japanese International Cooperative Agency
Kenya Medical Research Institute
Laboratory Information Tracking System
U.S. Multinational Forces and Observers
Military Health System
Military Infectious Disease Research Program
Ministry of Health
Ministry of Health and Population (Egypt)
Médicins Sans Frontières; Doctors without Borders
Naval Medical Research Institute Detachment
Naval Medical Research Unit 2
Naval Medical Research Unit 3
National Aeronautics and Space Administration
Naval Disease Reporting System
Naval Environmental Health Center
Navy Environmental and Preventive Medicine Unit
Naval Health Research Center
National Institute of Allergy and Infectious Diseases
Naval Medical Research Center Detachment
National Institutes of Health
National Science and Technology Council, Executive Office of the President, Presidential Decision Directive NSTC-7
National Security Decision Directive
Oficina General de Epidemiologia (Ministry of Health Office of Epidemiology, Peru)
Office of Science and Technology Policy
Pan American Health Organization
Public Health Laboratory Information System
Research Sciences Department
Southeast Asia Treaty Organization
sexually transmitted disease
Theater Area Medical Laboratory
Training in Epidemiology and Public Health Intervention Network
Tricare Management Area
United States Agency for International Development
United States Agency for International Development-project Addressing Threats of Emerging and Re-emerging Infectious Diseases
United States Army Medical Research Institute of Infectious Diseases
United States Army Medical Research Unit, Kenya
United States Centers for Disease Control and Prevention
United States Uniformed Services University of the Health Sciences
Venezuelan Equine Encephalitis
Addressing Threats of Emerging and Re-Emerging Infectious Diseases project
Virtual Public Health Laboratory
Voice Over Internet Protocol
very small apperature terminal
World Health Organization
Walter Reed Army Institute of Research