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

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2 DoD-GEIS Headquarters AI/PI Management and Support Activities I n February 1999 the assistant secretary of defense for health affairs issued a memorandum outlining the operations of the Department of Defense’s influenza surveillance activities. This memorandum directed the Department of Defense Global Emerging Infections Surveillance and Re- sponse System (DoD-GEIS) headquarters to provide professional guidance, direction, and oversight of DoD influenza surveillance efforts, with the U.S. Air Force as the lead agency for laboratory-based surveillance (Bailey, 1999). Between 1999 and 2005, DoD-GEIS headquarters coordinated a variety of DoD-conducted influenza surveillance activities at the Air Force Institute for Operational Health (AFIOH), the Naval Health Research Cen- ter (NHRC), and sites within the Military Health System (MHS) as well as the overseas laboratories. While DoD-GEIS headquarters directed a number of influenza projects, its primary role was as a funding source. On January 2, 2005, the 109th Congress passed H.R. 1815, Sec. 748, “Pandemic Avian Flu Preparedness,” which listed DoD-GEIS by name and called upon the secretary of defense to address “. . . surveillance efforts domestically and internationally.” Subsequently, the DoD-GEIS was tasked   Institute of Medicine (IOM) Committee members visited DoD-GEIS headquarters in April 2007. Prior to this meeting DoD-GEIS headquarters provided the full committee with detailed background information on DoD-GEIS and the pandemic/avian influenza activities being sup- ported by the headquarters. These materials were used in the writing of this chapter and are available from the IOM in the public access file. 33 

34 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS by the assistant secretary of defense for health affairs to take the lead on the following activities laid out in Sec. 748, H.R. 1815: • Surveillance efforts domestically and internationally, including those utilizing the Global Emerging Infections Systems (GEIS), and how such efforts are integrated with other ongoing surveillance systems • Integration of pandemic and response planning with those of other federal departments, including the Department of Health and Human Ser- vices (HHS), Department of the Veterans Affairs, Department of State, and U.S. Agency for International Development • Collaboration (as appropriate) with international entities engaged in pandemic preparedness and response The supervisory role of DoD-GEIS headquarters in Avian Influenza/ Pandemic Influenza (AI/PI) activities was further reinforced in 2006 when the U.S. Army Surgeon General designated DoD-GEIS as the oversight agency for the 2006 congressional AI/PI supplemental funding and as the responsible agency for “monitoring and reporting execution and outcomes . . . to improve pandemic and avian influenza surveillance for DoD” (Kiley, 2006). In the fall of 2005, DoD-GEIS headquarters began to assess the gaps in DoD influenza surveillance and response activities in anticipation of the expansion of its influenza surveillance capability. The DoD-GEIS director submitted to the DoD-GEIS-supported laboratories and DoD agencies a December 22, 2005, memorandum, “Fiscal Year 2006 Special Supplemental Budget for Pandemic Influenza Preparedness,” requesting the partners to submit surveillance proposals to carry out the mandate of the $39.28 mil- lion congressional supplemental appropriation that was soon to be distrib- uted (Malone, 2005). In addition, DoD-GEIS headquarters worked closely with decision makers at the Office of the Assistant Secretary of Defense for Health Affairs, the Force Health Protection Council, the Army Executive Agency, and the Commander of U.S. Army Medical Research and Materiel Command to develop a strategy for handling the AI/PI funding and coor- dinate AI/PI activities across DoD. Upon receipt of the AI/PI supplemental funds in March 2006, the re- cently appointed DoD-GEIS director reorganized the headquarters to create a separate influenza and zoonoses divisions, and, with the advice and con- sultation of the existing professional staff, the director developed an AI/PI emergency preparedness plan (AI/PI EPP) program concept of operations, outlining program priorities. In addition, the DoD-GEIS headquarters es- tablished a core staff of professional public health and scientific personnel to properly and responsibly execute these funds. The staff was to include an individual to serve as the leader of the supplemental influenza oversight 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 35 team, and avian and pandemic emergency preparedness plan program, a communications center chief, a senior epidemiologist, an information sys- tems analyst, a program manager, and a program assistant (see Box 2.1 for details on each position’s role and responsibilities). Qualified candidates were sought, recruited, and interviewed with the assistance of the Henry M. Jackson Foundation (HJF) human resources section, and they were hired during the subsequent six months. A total of nine positions were developed, six of which have been filled to date. To fill the three remaining positions, DoD-GEIS Headquarters would like to add a communications analyst, a junior epidemiologist, and a health education specialist to the staff. These additions are currently pending future funding and assessment of need for FY08. DoD-GEIS AI/PI FUNDING Because of the fiscal year 2006 supplemental funding, the AI/PI ac- tivities have become the largest component of the DoD-GEIS surveillance and response efforts. In fiscal year 2006, the total DoD-GEIS budget was $50.289 million, of which 78 percent—approximately $39 million—came from the fiscal year 2006 congressional supplemental for AI/PI. This repre- sented a significant increase in DoD-GEIS funding from under $5 million in the program’s first year of funding in fiscal year 1997 (see Figure 2.1). At the time of this report 99.5 percent of the fiscal year 2006 supple- mental funds had been obligated (see Table 2-1). The increase for fiscal year 2007 is also substantial though less, with a total estimated DoD-GEIS budget of $36.4 million, of which 69 percent, or $25 million, is expected to be AI/PI surveillance funding. All of these DoD-GEIS funds are directly appropriated from Defense Health Program dollars out of the Tricare Man- agement Activity MHS. While these AI/PI funds represent a substantial increase in the over- all budget of DoD-GEIS in both fiscal year 2006 and fiscal year 2007, DoD-GEIS received less funding than was requested to carry out all of the proposed AI/PI activities. In fiscal year 2006, of $48 million requested, $39 million was approved. Similarly, in fiscal year 2007, of $50 million requested only $25 million was approved. Subsequently, in order to provide some consistency in influenza funding, a minimum level of funding was established, with a total of $40 million for fiscal year 2008 and $35 million for fiscal year 2009 being set during the DoD’s early funding reviews, con-   The Henry M. Jackson Foundation (HJF) for the Advancement of Military Medicine, Inc. is a private, not-for-profit organization dedicated to improving military medicine and public. HJF manages more than 60 endowments and 800 education funds that support military medi- cal education and training (http://www.hjf.org/about/index.html). 

36 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS BOX 2-1 DoD-GEIS Avian and Pandemic Influenza Emergency Preparedness Plan Program Staff’s Role and Responsibilities Team leader—provide direct scientific and medical support to the DoD-GEIS leadership; serve as epidemiology and public health subject matter expert for AI/PI related matters at DoD and other USG working groups and committees; provide technical and scientific consultative support to US military personnel and DoD officials; assist in the definition of relevant programmatic issues and decision- making process at the strategic, interagency, planning, and programmatic levels; assist DoD-GEIS management in the planning and direction, as well as improving the efficiency and effectiveness of, AI/PI activities; and prepare decision briefs, scientific manuscripts and presentations containing a variety of programmatic technical and funding information Communications center chief—serve as the lead officer in charge of the communi- cations center which will provide day-to-day support in information sharing activi- ties with other DoD-GEIS partners and key stakeholders; responsible for the initial set-up and subsequent operation of all communications and information sharing capabilities; and directly responsible for the continuity of operation of the commu- nications center and the day-to-day maintenance of electronic information Senior epidemiologist—responsible for analyzing a variety of medical surveillance and field/lab epidemiologic data using statistical methods and computer hardware/ software; draft research papers for peer-reviewed journals; assess the feasibility of proposed studies; evaluate data sources for other researchers; evaluate the suc- ducted from October to December 2006. This permanent funding was coor- dinated and obtained on behalf of DoD-GEIS by the Office of the Assistant Secretary of Defense for Health Affairs (DoD-GEIS HQ, 2007a) through the inclusion of influenza funding in the program operation memorandum (POM) for the next two years. It is still unclear if this POM status will be extended beyond 2009.   The Program Objectives Memorandum (POM) is the annual estimating framework utilized by the Department of Defense. Department planning is then translated into programs/projects necessary to fulfill requirements and implement the plan. At the same time, cost estimates for requirements associated with said programs/projects are generated. 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 37 cess of policies and identify the need for other policies; provide assistance in the conduction of field epidemiologic and outbreak investigations; provide surveillance summaries and reports to the AI/PI program newsletter Information systems analyst—plan, develop, test, and document highly complex applications programs. Generate new code and correct, convert, and/or modify existing code to meet specifications; confer with end-users to analyze specified methods and procedures, identify problems, and document specific requirements; Prepare reports on analyses, findings, and project progress, and present results to management and/or customer personnel; perform research on emerging technolo- gies to determine impact on application execution Program manager—Monitor and track costs, revenue, modifications, and billing for contracts performed by assigned office; compile and analyze complex contract, program, and financial data, and prepare monthly status reports based on the results; responsible for coordination of personnel travel, clearances, orders, set-up of video and teleconferences, and responsible for the administrative organization of DoD-GEIS sponsored meetings and symposia; serve as point of contact for the office on issues related to accounting, human resources, purchasing, and other departments, as well as external contacts such as customers, vendors, and subcontractors and security-related paperwork Program assistant—responsible for travel requests, clearances, budgetary man- agement and general office management support; collect and process purchasing requisitions, invoices for consultants and subcontractors, and travel and expense reports; provide work leadership to less experienced clerical and administrative personnel HEADQUARTERS MANAGEMENT OF DOD-GEIS AI-PI ACTIVITIES Based on the appropriations legislation and DoD directives mentioned above, DoD-GEIS headquarters is currently responsible for a variety of AI/ PI tasks, including collaborating with U.S. and international AI/PI partners, disseminating information and data generated by DoD-GEIS AI/PI activities, and overseeing and providing support to AI/PI projects run by the domestic and overseas laboratories and other DoD facilities. Thus the majority of the DoD-GEIS headquarters AI/PI supplemental funds ($1,634,100) are dedicated to managing multi-service DoD AI/PI programs and ensuring that available resources are utilized rapidly and effectively. In order to achieve this goal, DoD-GEIS headquarters has established an AI/PI EPP Manage- ment Office and Communications Center and created a cadre of dedicated personnel in AI/PI matters to enable the effective administration of a $30-40 million/year program. The establishment of management centers and the 

38 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS $45,000 $40,000 DoD-GEIS Funding $35,000 (in thousands) $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 97 98 99 00 01 02 03 04 05 06 FY FY FY FY FY FY FY FY FY FY Fiscal Year DoD-G EIS PO M DoD-G EIS AI/PI Fu nding FIGURE 2-1  DoD-GEIS funding from fiscal year 1997 to 2006. SOURCE: DoD-GEIS HQ, 2007b. Figure 2-1 TABLE 2-1  DoD-GEIS Avian Influenza/Pandemic Influenza Supplemental Funding in Fiscal Year 2006 Dollar Amount Dollar Amount Organization Approved Obligated Percent Funded (in thousands) (in thousands) Obligated DoD-GEIS HQ $5,447 $5,447 100.0% NAMRU-2 $2,665 $2,622 98.4% AFRIMS $6,140 $6,110 99.5% NAMRU-3 $3,988 $3,986 99.9% USAMRU-K $2,634 $2,634 100.0% NMRCD $1,741 $1,741 100.0% NHRC $3,164 $3,164 100.0% AFIOH $4,182 $4,182 100.0% Other Organizationsa $9,084 $8,967 98.7% Total $39,045 $38,853 99.5% a“Other Organizations” include USAMRIID ($394,000), LRMC (Germany) ($835,000), 18th MEDCOM (Korea) ($89,000), AFIP ($63,000), BAMC ($117,000), CDHAM/USUHS ($263,000), USACHPPM ($3,347,000), VETCOM ($15,000), PACAF ($45,000), NEHC ($954,000), NEPMU-5 ($14,000), WRAIR (PM Div) ($1,940,000), and ASD(HA)-FHP&R ($900,000). SOURCE: DoD-GEIS, 2007b. 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 39 expansion of relevant staff has increased the ability of DoD-GEIS headquar- ters to collaborate with relevant partners, communicate vital information to other DoD facilities as well as to national and global organizations, and oversee and manage the AI/PI projects being conducted at all DoD domestic and overseas laboratories (DoD-GEIS HQ, 2007a). Oversight and Management Although the DoD-GEIS headquarters has no command or control over the assets and personnel of any of the DoD-GEIS-supported laboratories or DoD agencies, DoD-GEIS uses influence derived from its centralized control of AI/PI activities funding and close coordination with the office of the as- sistant secretary of defense for health affairs to oversee and manage a large program across multiple commands (see Figure 2.2). DoD-GEIS headquarters staff guided the establishment and develop- ment of influenza and AI/PI surveillance and response activities. In addition, the staffs of the influenza and zoonoses division and the epidemiology and health systems division have had ample opportunity to interact with DoD- GEIS-supported laboratories and DoD agencies in addressing program priorities and problems by exchange of information, provision of guidance, and periodic telephone conferences and site visits. The principal activities and functions of the DoD-GEIS headquarters staff in support of AI/PI sur- veillance and response activities are as follows (DoD-GEIS HQ, 2007a): (1) Provide scientific and administrative oversight of DoD influenza surveillance efforts as well as of AI/PI EPP program initiatives to include, but not limited to, the following: (a) Initial development and scientific, merit-based evaluation of AI/PI control program-related surveillance and research proposals (b) Establishment of monitoring guidelines and formats for routine, periodic monthly status situation reports and status reports on AI/PI control program-related proposals (c) Centralized management of budgetary and contract management activities (d) Coordination of facilities infrastructure, maintenance and other program management activities with supporting agencies such as the HJF (2) Provide centralized subject matter expertise to DoD-GEIS partners in the areas of influenza and other acute respiratory infection (ARI) and AI/PI control. (3) Establish and maintain a central communications center capability for coordination of influenza and other ARIs and AI/PI EPP program and other DoD-GEIS activities with special emphasis toward key information 

Secretary of Defense 40 Assistant Secretary of Defense (Health Affairs) DoD-GEIS Headquarters Joint Chiefs of Staff Army Navy/ Marines Air Force (DoD-GEIS Executive Agent) Army SG/MEDCOM Navy SG/NMRC Air Force SG (DoD Influenza Executive Agent) Medical Research Materiel Command Walter Reed Army Center for Health Navy Navy Medical Research Navy Health Air Force Institute for Institute of Research Promotion and Environmental Center (NMRC) (Silver Research Center Operational Health (Silver Spring) Preventive Medicine Health Center Spring) (NHRC) (San Antonio) (CHPPM/APG MD) (Norfolk) (San Diego) Army Overseas Labs Defense Medical Environmental and Navy Overseas Labs AFRIMS (Bangkok) Surveillance System Prev Med Units NAMRU-2 (Jakarta) USAMRU-K (Nairobi) (Norfolk, Sigonella, NAMRU-3 (Cairo) San Diego, Hawaii) NMRCD (Lima) FIGURE 2-2  DoD-GEIS organizational chart. fig 2-2 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 41 and updates on DoD AI/PI EPP program-related activities in strategic areas of the world. (4) Provide specialized AI/PI EPP-related epidemiological, laboratory, and communications expertise in support of exercises and real-time out- breaks of influenza or other emerging infectious diseases (EIDs) in coordi- nation with the office of the assistant secretary of defense for health affairs, the Office of the Army Surgeon General, the Naval Bureau of Medicine and Surgery, the Air Force Surgeon General’s office, and the Combatant Com- mand (COCOM) surgeons’ offices. (5) Assist in the development and facilitation of tabletop emergency- preparedness exercises as well as in the support of ongoing medical train- ing and education activities in AI/PI control program-related matters in coordination with the Uniformed Services University of the Health Sciences (USUHS), COCOM surgeons, and other DoD-GEIS partners. (6) Provide an integrated and standardized methodology for clinical laboratory testing of patient samples suspected of infection with influenza and other militarily relevant EIDs, consistent with the World Health Orga- nization (WHO) and the Centers for Disease Control and Prevention (CDC) systems in coordination with DoD influenza reference centers in the United States (AFIOH and NHRC) as well as with the respective services clinical laboratory consultants and major medical centers. DoD-GEIS headquarters staff maintains constant supervision and over- sight of AI/PI efforts through review and feedback in monthly reports submitted to the AI/PI EPP program staff, which includes statements of performance and status of funding obligations by each partner. Metrics reviewed within these monthly reports include, but are not limited to, the number of specimens collected and processed, the number of sites partici- pating in isolate collection, the number of countries participating in isolate collection, and the number of Biosafety Level 3 (BSL-3) labs completed and functioning (DoD-GEIS HQ, 2007a). Constant feedback is being provided when deficiencies are identified, and subsequent funding—provided on a quarterly basis—is contingent on progress made by DOD-GEIS-supported laboratories and DoD agencies. AI/PI supplemental funding obligations are monitored centrally, and subsequent allocation of funding is adjusted based on performance—or lack thereof. Based on these measures, DoD- GEIS headquarters sees the execution of the fiscal year 2006 congressional supplement for AI/PI, the efficient obligation of funds, and the accomplish- ment of project goals by the DoD-GEIS headquarters staff and DOD- GEIS-supported laboratories and DoD agencies (99.5 percent obligation of fiscal year 2006 funds) as positive indications of the program’s capacity for utilization of limited, one-year funding. An additional component of oversight and management is the provi- 

42 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS sion of influenza-related guidance, mentoring, and analytic support to entities executing the DoD-GEIS AI/PI program. DoD-GEIS headquarters currently relies on information sharing and posting of data and key event information within the GEIS website as part of the communications center functions (DoD-GEIS HQ, 2007a). Mentoring is conducted on a project- by-project basis; input and comments are provided on project execution. Data collection, analysis, and assistance are provided in final write-ups of project results for publication or presentation. Joint meetings to present project updates and to discuss future directions are held periodically, such as the DoD Joint Influenza Surveillance Working Group held annually in May, the Force Health Protection Conference held annually in August, the International Conference on Emerging Infectious Diseases held every other March, and the State of the DoD-GEIS meeting, which was held most re- cently in December 2005. In addition, DoD-GEIS headquarters staff make periodic visits to the overseas laboratories and other working partners at least twice a year to discuss priorities and plan future activities. Best products and practices are also shared between DoD-GEIS partners, such as the transplantation of the Early Warning Outbreak Recognition System (EWORS) from the Naval Medical Research Unit No.2 (NAMRU-2) in Indonesia to the Naval Medical Research Center in Peru (DoD-GEIS HQ, 2007a). Expertise is also transferred between laboratories as a result of medical scientist career management by the Army and Navy; personnel are often reassigned from one DoD-GEIS partner to another, providing addi- tional “cross fertilization.” The DoD-GEIS headquarters seeks to maximize the analytic capacities and expertise within the DoD-GEIS network to assist DoD-GEIS-supported laboratories and DoD agencies instead of developing separate and independent analytic activities or resources. Limited technical assistance is provided to certain projects by drawing on the epidemiology and data analysis resources at the U.S. Army’s Medical Surveillance Activ- ity co-located with DoD-GEIS headquarters at the Linden Lane location in Silver Spring, Md. (DoD-GEIS HQ, 2007a). Collaboration DoD-GEIS is working to coordinate and integrate its efforts with na- tional and international surveillance and response-planning partners, such as CDC, HHS, the Pan American Health Organization (PAHO), WHO, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service. DoD-GEIS staff participates in a number of DoD-run influenza collabo- rating bodies, including annual DoD Joint Influenza Surveillance Working Group meetings (Embrey, 2006). This meeting is typically sponsored by 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 43 NHRC or AFIOH and brings together domestic and international influ- enza-surveillance efforts from within DoD. While this primarily involves DoD working groups, non-DoD agencies such as the CDC and the U.S. Agency for International Development also participate. During these meet- ings the various organizations share surveillance data and identify poten- tial surveillance gaps that can be and need to be addressed. Additionally, DoD-GEIS headquarters staff hosts a biweekly teleconference with service epidemiology centers and key partners to exchange timely information on infectious threats to U.S. forces and to coordinate outbreak response; it is referred to as the EpiChiefs Teleconference. Participants include the Navy Environmental Health Center, the U.S. Army Center for Health Promotion and Preventive Medicine, the Armed Forces Institute of Pathology, the U.S. Northern Command, and the Assistant Secretary of Defense for Health Af- fairs, among others (DoD-GEIS HQ, 2007a). DoD-GEIS staff also participate in two HHS-coordinated influenza- related groups. The first is a quarterly meeting with both the influenza division and the Office of Global Health at HHS. DoD-GEIS’s participation in this group allows for ongoing feedback regarding influenza and AI/PI surveillance and control activities. These meetings focus upon the identifi- cation and evaluation of potential gaps in surveillance efforts in an effort minimize duplication as well as on the review of spending plans related to pandemic influenza activities. Another purpose of these meetings is to enhance surveillance capabilities and the reporting of timely information through coordination and cooperation between the two organizations. DoD-GEIS was designated by the Assistant Secretary of Defense for Health Affairs as the DoD point of contact and the meeting coordinator for this endeavor. DoD-GEIS and representatives from other DoD Offices are also mem- bers of the HHS Pandemic and Seasonal Influenza Risk Management Group. This group has met monthly since its creation in September 2006. Representatives from HHS, the National Institutes of Health (NIH), the U.S. Department of Agriculture, the Food and Drug Administration (FDA), the State Department, and CDC participate in this meeting and its related topic-driven focus area groups. Surveillance of pandemic influenza is one of the many focus areas of this group, along with research and develop- ment, animal models, manufacturing capacity, regulatory and legal issues, and stockpile issues. Currently two of the three working groups, vaccine prioritization and influenza diagnostics, have DoD representation (DoD- GEIS HQ, 2007a). DoD representatives also collaborate with many of these same part- ners at the annual meetings of the FDA-sponsored Vaccines and Related Biological Products Advisory Committee. This advisory committee meets once a year to discuss the globally circulating strains of influenza viruses 

44 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS in an attempt to decide which strains to include in the annual seasonal in- fluenza vaccine administered in the Northern Hemisphere. At this meeting, DoD-GEIS presents annual influenza surveillance data collected through its related activities. Representatives from the FDA, HHS, NIH, academia, and vaccine manufacturers also attend this meeting and make presentations (DoD-GEIS HQ, 2007a). In addition to formalized working groups, DoD and other government agencies, including HHS, the Department of Homeland Security (DHS), 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). Pro- fessional relationships with key individuals in these organizations provide DoD-GEIS staff with unique and invaluable opportunities to seek, share, and receive advice about incorporating best methods and practices. DoD- GEIS also has considerable ongoing professional contact with senior scien- tists and program managers from other federal agencies through its regular participation with, and membership in, major activities such as the Institute of Medicine’s Microbial Threat Forum, the U.S. Medicine Institute’s round- table policy meetings, and the Infectious Diseases Society of America. External advice and consultation for AI/PI surveillance and control activities is received on a project-by-project basis from outside consultants such as key offices at PAHO, WHO, and the Food and Agricultural Or- ganization. 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). DoD-GEIS has also used the supplemental funding to create and fund a number of coordinating mechanisms and events related to AI/PI, including • development of DoD-GEIS biweekly EpiChiefs and other ad hoc executive summary reports distributed to key DoD military and civilian health officials; • development of training efforts and coordinating AI/PI prepared- ness workshops in support of five combatant commands in conjunction with the USUHS Center for Disaster and Humanitarian Assistance officials; and • oversight and coordination of the CDC-DoD Working Group on Influenza and Emerging Infectious Diseases, which AI-PI EPP program of- fice staff assumed in October 2006 (DoD-GEIS HQ, 2007a). 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 45 Communication The DoD-GEIS headquarters communications center, established in October 2006, is the centerpiece of DoD-GEIS’ communication strategy. The DOD-GEIS headquarters is now able to quickly distribute informa- tion and disease updates to its various partners and key stakeholders via an electronic forum. Information is gathered through open sources and regular communication channels and then widely disseminated. Although many recipients of this material are DoD personnel, other government agencies are included, such as the State Department, DHS, CDC, HHS, and the Office of the Vice President, in addition to the international WHO and PAHO. Currently, 139 individuals representing key offices from seven U.S. government agencies, various international health organizations, and many DoD health commands receive information on a daily basis regard- ing infectious diseases (primarily influenza), surveillance updates, and new disease outbreaks (DoD-GEIS HQ, 2007a). DoD-GEIS headquarters and the AI/PI surveillance and response efforts office have recently relocated, and a functional DoD-GEIS communications center has been established on-site with video teleconferencing and telecom capabilities and a DoD-GEIS communication center e-mail resource for the centralized distribution of information to the director of DoD-GEIS, the Assistant Secretary of Defense for Health Affairs, and other relevant service components and government partners, such as the CDC and DHHS as it becomes available. The communications center is also capable of providing 24 hours a day, seven days a week communications between all DoD-GEIS partners during a pandemic if the DoD determined this action necessary. The DoD-GEIS communications center complements the outreach and re- porting role of AFIOH and other organizations within DoD that perform critical influenza surveillance, such as NHRC and the U.S. Army Center for Health Promotion and Preventive Medicine-Europe. In an emergency pandemic influenza situation, the communications center will be available for operations 24 hours a day, seven days a week and will coordinate all communications dealing with influenza surveillance and response provided by DoD-GEIS partners (DoD-GEIS HQ, 2007a). In addition to the new office space and the communications center, DoD-GEIS headquarters has plans to initiate an AI/PI EPP Program Management Office which will pro- vide overall management and oversight of the routine ARI surveillance and newly developed AI/PI-related surveillance projects at the DoD-GEIS. The key stakeholders with whom the headquarters communicates in- clude, but are not limited to, the following (DoD-GEIS HQ, 2007a): 

46 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS a. The Office of the Assistant Secretary of Defense for Health Affairs b. Surgeons General for the U.S. Army, U.S. Navy and U.S. Air Force c. Unified Combatant Command surgeons’ offices; d. U.S. military medical treatment facilities in the United States and overseas e. Domestic U.S. military medical reference laboratories (AFIOH, NHRC) f. International reference laboratories for influenza (such as specific offices at DHS, WHO, and the CDC) g. DoD overseas medical research laboratories h. The U.S. Army Center for Health Promotion and Preventive Medicine i. The Armed Forces Medical Intelligence Center j. The DHS’s National Biosurveillance Integration Center k. The U.S. Army Medical Research and Materiel Command and applicable associated activities (such as the Walter Reed Army Institute of Research and NMRC) One of the objectives of this communications center is to be a central, single source of accurate, timely information on global influenza for stake- holders within various U.S. government agencies. Documents that are dis- seminated are subsequently posted on the DoD-GEIS website, either on the public or the secure site, depending on the level of sensitivity of the infor- mation. DoD-GEIS partners regularly report on outbreaks occurring within their host countries and regions. Laboratory confirmation of the presence of novel viruses (e.g., H5N1) is also considered a priority communication to DoD-GEIS headquarters from the field. DOD-GEIS HEADQUARTERS AND OTHER MILITARY HEALTH SYSTEM INFLUENZA SURVEILLANCE AND RESPONSE ACTIVITIES DoD-GEIS Headquarters Influenza Activities In addition to managing projects being carried out by other DoD partners, DoD-GEIS headquarters works directly with the Johns Hopkins University Applied Physics Laboratory (JHU/APL) to manage and execute several influenza-related projects. Two of these projects funded with AI/PI supplemental funding are an evaluation of the Early Warning Surveillance/ 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 47 BOX 2-2 Early Warning Outbreak Recognition System (EWORS) The Early Warning Outbreak Recognition System (EWORS) was developed by NAMRU-2 to detect disease outbreaks early throughout Indonesia without rely- ing on slower and often nonexistent laboratory methods. EWORS is based on a simple computer program that allows a remote clinic to enter basic demographic data on the patient and document whether they have symptoms such as fever, diarrhea, breathing difficulty, cough, or vomiting. These data are downloaded daily from remote sites around the country to a central location such as the ministry of health. Either remotely or locally, data can then be graphed based on variables such as date, age, race, and symptoms and presented geographically by area of residence to determine clustering by location. It is now also being used in Peru as well to collect surveillance data on a symptoms associate with influenza. Response System (EWORS) and an expansion of the Pandemic Influenza Policy Model (PIPM). Early Warning Surveillance/Response System Strengthening DoD-GEIS headquarters is using $460,000 in fiscal year 2006 AI/PI supplemental funding to strengthen DoD-GEIS’s existing EWORS system (see Box 2-2). In collaborating with overseas DoD-GEIS partners, such as DoD overseas laboratories, DoD-GEIS will use the surveillance/response system evaluation framework, results from the modeling/simulation studies, and field evaluations (all conducted with supplemental funds) to implement early warning surveillance/response systems targeted for pandemic influ- enza but applicable to other emerging infections as well. The seven-person team at JHU/APL working on this project draws heavily on collaborations with NAMRU-2 in Jakarta and NMRCD in Lima, both of which have developed electronic syndromic surveillance systems with host-country ministries of health with previous funding from DoD-GEIS and other agencies. DoD-GEIS headquarters hopes to pilot the next-generation EWORS system using data gained during this project, including a comprehensive evaluation of existing EWORS systems. Key EWORS staff members from NAMRU-2 and NMRCD participate in an ongoing working group with JHU/APL and DoD-GEIS headquarters staff to guide enhancement of existing EWORS networks and planning for new systems (DoD-GEIS HQ, 2007a). DoD-GEIS anticipates that this AI/PI- funded project will greatly enhance existing EWORS systems and will guide 

48 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS future investment by DoD-GEIS and other agencies and governments in early warning systems in resource-poor countries. Pandemic Influenza Policy Model Expansion DoD-GEIS headquarters is also supporting the expansion of the Pan- demic Influenza Policy Model with $460,000 in supplemental funding. PIPM is a modeling project initiated to provide information on influenza preparedness to military installations in order to allow them to plan for various pandemic scenarios. The expansion of the PIPM is expected to provide the means to examine the effect of changing disease and opera- tional parameters on a wider range of DoD installations and organizations, including basic-training installations of the U.S. Navy and U.S. Air Force, installations with high operational tempo, installations with high logistical throughput, installations undergoing large-scale mobilization or demo- bilization operations, and installations within large metropolitan areas. Methods will be applied from operations research theory, including linear and dynamic programming along with other optimization techniques as applicable, to expand the PIPM model. In addition, the expanded PIPM model will incorporate and expand aspects of existing models, such as CDC’s FluAid and FluSurge and DoD’s Joint Medical Planning software, in order to address requirements that are unique to the military (DoD-GEIS HQ, 2007a). DoD-GEIS and the project team from JHU/APL have divided the work into three phases. In the first phase, data will be collected on a variety of types of military installations to understand how the PIPM needs to be ex- panded to accommodate the inclusion of those installations in the model. Then the project team will focus on identification and prioritization of per- tinent disease and operational parameters that will affect the DoD medical response to pandemic influenza. In the second phase, information gathered from the various sources will be collated, and estimated DoD-specific values for the parameters will be identified. The project team will also construct and evaluate a decision-analysis model that optimizes DoD public health response to pandemic influenza. In the last phase, the web-based and user- friendly PIPM computer interface will be extended to allow DoD personnel to plan for, evaluate, and train on different disease scenarios for a wide range of military installations and organizations (DoD-GEIS HQ, 2007a). DoD-GEIS headquarters expects that this project will provide military medical and operational commanders and policy makers with the first fine- grained, military-specific simulation tool for testing pandemic influenza surveillance and response strategies. Given that the 1918 pandemic severely affected military populations, the ability to evaluate preparedness and pre- ventive measures against a H5N1 pandemic model is seen as important. 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 49 Influenza Activities Elsewhere in the Military Health System United States Army Medical Research Institute of Infectious Diseases In fiscal year 2006, GEIS supplemental funding for pandemic and avian influenza was the only source of funding for work done at the U.S. Army Medical Research Institute of Infectious Diseases with highly pathogenic avian influenza (DoD-GEIS, 2007). The institute conducted a number of activities supported by supplemental influenza funds, including analysis of influenza molecular diagnostics, generation of an influenza A reference panel, and development of immunodiagnostic reagents for influenza diag- nosis (DoD-GEIS, 2007). To support the influenza activities, the institute purchased specialized equipment for highly pathogenic avian influenza work, and personnel were trained in biosafety practices. As a result, the institute now provides DoD and GEIS with a unique high-containment laboratory capable of supporting work with highly pathogenic avian influ- enza (DoD-GEIS, 2007). United States Army Center for Health Promotion and Preventive Medicine Serosurveillance for avian and pandemic influenza  In fiscal year 2006, work was initiated to develop a Center for Epidemiology and Serosurveil- lance of Pandemic Influenza associated with the DoD Serum Repository. The primary objectives of this center were to be assessing the prevalence of exposure to avian influenza strains among military service members, pro- viding serologic data to support investigations of geographically localized avian and pandemic influenza outbreaks, and investigating the prevalence of a preexisting antibody against human influenza strains that may provide the potential for cross-reactive protection from avian influenza infection among service members in the event of an avian and pandemic influenza outbreak. The supplemental influenza funding was used to support the development of this center. Additional staff were hired to implement and oversee the project. Detailed programs were generated to identify service members deployed to or living in areas of H5N1 activity through the Defense Medical Surveillance System. The Southern Research Institute in Birmingham, Ala., was selected to perform both avian (H5N1 clades 1 and 2 subtypes) and human influenza (H3N2 and H1N1) seroprevalence testing on DoD serum repository specimens, using hemagglutination inhibition as- says with confirmatory microneutralization assays. Specimen testing began early in 2007. The U.S. Army Center for Health Promotion and Preventive Medicine expects that this work will provide a unique opportunity to gen- erate seroepidemiologic data to enable surveillance for H5N1 and related 

50 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS avian and pandemic influenza virus exposure and to permit rational vaccine or therapeutic selection in the event of an outbreak. Pandemic Influenza Workshop  On August 7-8, 2006, the U.S. Army Center for Health Promotion and Preventive Medicine and DoD-GEIS headquar- ters sponsored a training course aimed at improving preparedness and re- sponse to an influenza pandemic. The workshop, held in Albuquerque, N. Mex., was supported by the supplemental funding for pandemic and avian influenza. The target audience comprised military public health emergency officers and other public health practitioners. More than 300 participants from the Army, Navy, Air Force, Marines, and Coast Guard participated, as well as personnel from other U.S. government agencies, including the Departments of Veterans Affairs and Homeland Security, and also from the militaries of allied countries. The workshop covered lessons learned from previous pandemics and the swine influenza response in 1976, sur- veillance for influenza and emerging pathogens, and components of the national, DoD, COCOM, and U.S. Army Medical Command efforts to- ward preparedness. Other areas were also discussed, including community preparedness, incident command at the local level, pharmacological and nonpharmacological methods of preventing and slowing the spread of infec- tion, triage and treatment options, use of personal protective equipment, legal considerations involved in responding to a pandemic, communications during a pandemic, and the management of mass fatalities. Conclusions The committee has found that given condensed time frames for plan- ning and implementation, DoD-GEIS has effectively executed and managed the fiscal year 2006 AI/PI supplemental funding. The DoD-GEIS headquar- ters has facilitated the disbursement and utilization of the large increase in funding to influenza programs, building both DoD and host-country laboratory and human resources capacity. It has expanded the informa- tion being collected about avian influenza and acute respiratory diseases and has strengthened U.S. relations with the global community. DoD-GEIS headquarters has successfully managed the implementation of these AI/PI projects through the following activities: the addition of project manage- ment staff as well as the increase in relevant influenza surveillance and response expertise; the establishment of assessment mechanisms to track the progress of AI/PI projects; their participation in U.S. government working groups on influenza preparedness and response; and the establishment of the inter-DoD communication center to facilitate the sharing of influenza information across laboratory facilities. While the committee concludes that the execution of the fiscal year 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 51 2006 AI/PI supplemental funding has resulted in the implementation of valuable influenza surveillance and response activities and that the changes to DoD-GEIS headquarters have contributed to improvements to the DoD- GEIS influenza programs, there are a number of areas that should be strengthened in order to improve a sustained DoD-GEIS influenza surveil- lance and response effort. First, the AI/PI supplemental funding and the associated DoD direc- tives have led to strengthening the role of DoD-GEIS headquarters as the responsible agency for coordination, guidance, and oversight of DoD influenza activities. The committee has concluded that a strengthening of this leadership role in conjunction with a reexamination and revision of the functional operating structure of the DoD influenza and respiratory disease surveillance program to reflect the current needs of the program would improve the management and oversight of the program in general. Recommendation 2-1. In order to better manage the influenza program, DoD-GEIS headquarters should strengthen its leadership role in the execution of DoD-GEIS influenza activities through strategic planning and distribution of future funding. Second, while there have been attempts to improve inter-laboratory dialogue and information sharing, laboratories are still working in vary- ing degrees of isolation and would benefit from closer collaboration. Since the laboratories are relatively new to the influenza field, many of them have experienced a steep learning curve over the past fiscal year. Each laboratory has gained valuable lessons from implementing the first year of these supplemental AI/PI funds, and this knowledge, if shared, would greatly improve the continued program development of AI/PI activities at all DoD-GEIS sites. Thus, in order to most effectively improve DoD-GEIS’s influenza activities, there should be strategic planning done at DOD-GEIS headquarters based on lessons learned at the laboratories over the first year of supplemental funding. Recommendation 2-2. In order to assure the most effective use of the resources and varied expertise at the different DoD sites, mecha- nisms should be put into place to have systematic communication among the sites with respect to the various influenza-related projects and activities, including the development of a structured communica- tion mechanism within each laboratory that would interact with head- quarters to coordinate influenza activities, and the creation of regular opportunities for sharing of best practices facilitated by DoD-GEIS headquarters. 

52 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS Third, the committee concluded that the addition of relevant expertise at DoD-GEIS headquarters was benefiting the whole DoD-GEIS influenza program. Plans to further strengthen the headquarters personnel would al- low DoD-GEIS headquarters to more appropriately address the issues and challenges faced at the DoD-GEIS-supported laboratories. For example, DoD-GEIS headquarters is planning to add a communications analyst, a junior epidemiologist, and a health education specialist to the staff. These additions are currently pending future funding and assessment of need in fiscal year 2008. Recommendation 2-3. In order to improve the management of the DoD-GEIS influenza program, DoD-GEIS headquarters should continue to strengthen its in-house influenza expertise as necessary in order to give DoD laboratories and other relevant institutions the assis- tance needed to implement quality influenza surveillance and response activities. Finally, collaboration and coordination between DoD-GEIS and other partners helps to limit redundancies and to maximize resources for AI/PI activities. It is important that one of the primary occupations of the head- quarters be the active coordination and guidance of projects carried out across all DoD-GEIS-funded facilities with those activities being conducted by other U.S. agencies and international partners. Recommendation 2-4. DoD-GEIS headquarters should continue to work with U.S. and international partners to ensure coordination among global influenza efforts. References Bailey, S. 1999. Policy for DoD global, laboratory-based influenza surveillance. Memorandum for Surgeon General of the Army, Surgeon General of the Navy, Surgeon General of the Air Force, Deputy Director for Medical Readiness, J-4, the Joint Staff. U.S. Department of Defense, Health Affairs, Washington, DC, February 3, 1999. On file with the National Academies Public Access Records Office. 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. DoD-GEIS (Department of Defense-Global Emerging Infections System). 2007. Partnering in the fight against emerging infections: Annual report, fiscal year 2006. Silver Spring, MD: Walter Reed Army Institute for Research DoD-GEIS HQ. 2007a. Presentation on DoD-GEIS headquarters activities. Presented April 30, 2007 at DoD-GEIS Headquarters in Silver Spring, MD. 

AI/PI MANAGEMENT AND SUPPORT ACTIVITIES 53 DoD-GEIS HQ. 2007b. DoD-GEIS funding distribution to all GEIS partners from fiscal year 1997 to 2006 (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. Kiley, K. 2006. Oversight for supplemental funding for pandemic and avian influenza memo- randum. Memorandum for Surgeon General of the Army, Surgeon General of the Navy, Surgeon General of the Air Force. Signed March 16, 2006. Fukuda, K. 2006. Global challenges of pandemic and avian influenza. PowerPoint presenta- tion given at first meeting of the IOM Committee for the Assessment of DoD-GEIS Influenza Surveillance and Response Programs, December 19, Washington, D.C. Malone, J. L. 2005. Fiscal year 2006 special supplemental budget for pandemic influenza preparedness memorandum. Memorandum for DoD-GEIS-supported laboratories and DoD agencies. December 22, 2005. 

54 REVIEW OF THE DOD-GEIS INFLUENZA PROGRAMS List of contacts LT Jean-Paul Chretien, Coordinator, Overseas Research Laboratories, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Mario DaRocha, Program Assistant, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Dr. Tracy DuVernoy, Chief, Communications Center, Department of Defense Global Emerging Infections Surveillance and Response System headquarters COL Ralph Erickson, Director, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Dr. Joel Gaydos, Public Health Practice, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Steve Gubenia, Deputy, Finance and Administration, Department of Defense Global Emerging Infections Surveillance and Response System headquarters LtCol Victor MacIntosh, Director, Military Health System GEIS Programs, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Jay Mansfield, Information Systems Analyst/Programmer, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Robin Miliner, Program Manager, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Dr. Jean Otto, Senior Epidemiologist, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Dr. Jose Sanchez, Leader, Influenza Team, Department of Defense Global Emerging Infections Surveillance and Response System headquarters LTC Kelly Vest, Deputy Influenza and Zoonoses, Department of Defense Global Emerging Infections Surveillance and Response System headquarters Col Mark Rubertone, Chief, Army Medical Surveillance Activity Dr. Angelia Eick, Deputy Scientific Director, Center for Biosurveillance, Army Medical Surveillance Activity