DTIC ADA538744: A Growing Global Network's Role in Outbreak Response: AFHSC-GEIS 2008-2009

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REVIEW Open Access
’
A growing global network s role in outbreak
response: AFHSC-GEIS 2008-2009
Matthew C Johns1*, Ronald L Burke1, Kelly G Vest1, Mark Fukuda1, Julie A Pavlin2, Sanjaya K Shrestha3,
David C Schnabel4, Steven Tobias5, Jeffrey A Tjaden6, Joel M Montgomery7, Dennis J Faix8, Mark R Duffy9,
Michael J Cooper10, Jose L Sanchez1, David L Blazes1,
the AFHSC-GEIS Outbreak Response Writing Group2,3,4,5,6,8,9,10
Abstract
A cornerstone of effective disease surveillance programs comprises the early identification of infectious threats and
the subsequent rapid response to prevent further spread. Effectively identifying, tracking and responding to these
threats is often difficult and requires international cooperation due to the rapidity with which diseases cross
national borders and spread throughout the global community as a result of travel and migration by humans and
animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department of Defense’s (DoD) Armed Forces Health
Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) identified
76 outbreaks in 53 countries. Emerging infectious disease outbreaks were identified by the global network and
included a wide spectrum of support activities in collaboration with host country partners, several of which were in
direct support of the World Health Organization’s (WHO) International Health Regulations (IHR) (2005). The network
also supported military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With
IHR (2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas
research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to
emerging disease threats.
Background standardized and well-maintained global surveillance
A central objective of disease surveillance systems is the system with a flexible framework for identifying and
early identification of infectious disease outbreaks to responding to such events.
facilitate rapid implementation of effective control mea- In 1997, the U.S. Department of Defense (DoD) estab-
sures for minimizing disease transmission and morbid- lished the Global Emerging Infections Surveillance and
ity. Although outbreak response has come a long way Response System (GEIS) in response to the Presidential
since John Snow’s investigation of cholera and the Decision Directive NSTC-7, which identified the need
Broad Street pump in 19th century London [1], effective for more robust global disease surveillance [2]. In 2008,
outbreak response continues to be challenging. Today, a GEIS was integrated into the newly formed Armed
particular challenge is the interconnected nature of our Forces Health Surveillance Center [3]. As the name
global society. Diseases cross international borders and implies, the primary mission of AFHSC-GEIS is global
present themselves in unique ways through a continu- disease surveillance and response. A large portion of
ously changing landscape, making it difficult to rapidly this mission is accomplished through DoD overseas
identify, analyze and respond to disease outbreaks. research laboratories, which were initially established
Appropriate and effective monitoring of newly recog- within partner host countries to conduct research on
nized disease clusters requires an established, infectious diseases of bilateral concern [4]. This capacity
has subsequently been leveraged by AFHSC-GEIS for
the purpose of disease surveillance and response.
*Correspondence:[email protected]
Currently, five DoD overseas research laboratories
1ArmedForcesHealthSurveillanceCenter,11800TechRd,SilverSpring,MD
20904,USA serve in this capacity: the Armed Forces Research
Fulllistofauthorinformationisavailableattheendofthearticle
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1. REPORT DATE 3. DATES COVERED
2011 2. REPORT TYPE 00-00-2011 to 00-00-2011
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
A growing global network’s role in outbrek response: AFHS-GEIS
5b. GRANT NUMBER
2008-2009
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
Armed Forces Health Surveillance center,11800 Tech Rd,Silver REPORT NUMBER
Spring,MD,20904
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11. SPONSOR/MONITOR’S REPORT
NUMBER(S)
12. DISTRIBUTION/AVAILABILITY STATEMENT
Approved for public release; distribution unlimited
13. SUPPLEMENTARY NOTES
14. ABSTRACT
A cornerstone of effective disease surveillance programs comprises the early identification of infectious
threats and the subsequent rapid response to prevent further spread. Effectively identifying, tracking and
responding to these threats is often difficult and requires international cooperation due to the rapidity with
which diseases cross national borders and spread throughout the global community as a result of travel
and migration by humans and animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department
of Defense?s (DoD) Armed Forces Health Surveillance Center Global Emerging Infections Surveillance
and Response System (AFHSC-GEIS) identified 76 outbreaks in 53 countries. Emerging infectious disease
outbreaks were identified by the global network and included a wide spectrum of support activities in
collaboration with host country partners, several of which were in direct support of the World Health
Organization?s (WHO) International Health Regulations (IHR) (2005). The network also supported
military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With IHR
(2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and
overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing
and responding to emerging disease threats.
15. SUBJECT TERMS
16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF
ABSTRACT OF PAGES RESPONSIBLE PERSON

a. REPORT b. ABSTRACT c. THIS PAGE Public Release 9
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Institute of Medical Sciences (AFRIMS) in Bangkok, partnerships between the United States and host coun-
Thailand; the U.S. Army Medical Research Unit-Kenya try militaries (mil-mil) partnerships that have developed
(USAMRU-K)inNairobi,Kenya;theU.S.Naval Medical over the years have served to empower the host country
Research Center Detachment (NMRCD) in Lima, Peru; military’s role in supporting outbreak response activities
theU.S.NavalMedicalResearchUnitNo.2(NAMRU-2) within their own countries [6].
in Jakarta, Indonesia; and the U.S. Naval Medical Inlate2006, Chretienetal.,providedadetailedbreak-
ResearchUnitNo.3(NAMRU-3)inCairo,Egypt.Addi- downofhowthebroad-rangingDoD’sglobaldiseasesur-
tionally, the AFHSC-GEIS network includes substantial veillance network could potentially serve as a model for
contributionsfromthreeU.S.-basedresearchlaboratories other global public health entities to adequately identify
and a major regional medical center in Europe. The and respond to these complex threats [7]. This paper
Naval Health Research Center (NHRC) in San Diego, describeshowtheAFHSC-GEISnetworkhassignificantly
California, conducts population-based surveillance contributed toward effective outbreakidentification and
among basic military trainees at eight of the 10 major responseandcapacitybuildingwithinpartnerhostcoun-
trainingcentersintheUnitedStates;diseasesurveillance tries[8]undertheguidingprinciples oftheWHO’sIHR
among shipboard service membersinthe 2nd (Atlantic), (2005)[9].Forclarityandforthepurposesofthisassess-
3rd (Pacific), and 7th (Far East) U.S. Naval fleets; and ment, we will describe the accomplishments of the
infectiousdiseasesurveillanceinsixclinicsandtwohos- AFHSC-GEIS network during fiscal year 2009 (Oct. 1,
pitals along the United States-Mexico border [in colla- 2008 through Sept. 30, 2009) through two categories:
boration with the U.S. Centers for Disease Control and respiratory disease outbreaks and non-respiratory EID
Prevention (CDC) and the County of San Diego Health outbreaks.
Department]. The U.S. Air Force School of Aerospace
Medicine (USAFSAM) in San Antonio, Texas, which Accomplishments
servesastheAirForce’sclinicalreferencelaboratoryand General
publichealthcenter,istheleadorganizationfortheU.S. The AFHSC-GEIS network responded to 76 outbreaks
military’s installation-based, influenza sentinel surveil- (Table1,Figure1) in53countriesduringthe2009fiscal
lance program. The Walter Reed Army Institute of year (FY09), several indirect support ofthe IHR (2005).
Research’s Division of Viral Diseases (WRAIR-DVD) in The most common diseases investigated were influenza
SilverSpring,Md.,providesfull-lengthgenomicsequen- (47), cholera (four), dengue fever (four) and hepatitis
cing capability and conducts surveillance among U.S. (three). Human disease was present in all but one of
civiliansassignedtoDepartmentofStateembassiesover- theseoutbreaks,andspecificcausativeagentswereiden-
seas. Additionally, Landstuhl Regional Medical Center tifiedin69(92percent)ofthem.Thepopulationaffected
(LRMC) and the United States Army Public Command rangedfromlessthan10individualstoseveralthousand,
Health Region-Europe (PHCR-Europe) in Landstuhl, and support efforts were often ongoing engagements
Germany, function as a regional military medical center beyond the initial investigation. The type of population
and support surveillance for respiratory pathogens and supportedalsovaried,dependingontherelationshipand
other emerging infectious diseases(EID)within the U.S. the nature of the mission ofthe laboratory partner.
European Command. Additionally, AFHSC-GEIS has Thirty-six (48 percent) of the outbreak investigations
been a member institution and contributing partner in involvedpartnerssupportingcivilianentitiesthroughfor-
the WHO’s Global Outbreak Alert and Response mal bilateral requests or as part of their role as a WHO
Networksince1999. regional reference laboratory (NAMRU-3, AFRIMS and
Rapid identification of outbreaks and support of timely USAMRU-K). In the majority of these instances, testing
response efforts are key components of complying with of samples from civilian populations was performed.
the World Health Organization’s (WHO) International Twenty-four (32 percent) of the partner responses
Health Regulations (IHR) (2005), and are core focus involved outbreaks among U.S. troops stationed in the
areas and strategic goals of the AFHSC-GEIS network continental United States (CONUS) or at overseas loca-
[5]. Support for these efforts, provided in response tions, while 15 (20 percent) of the responses involved
to host country requests for assistance with new or investigationsincollaborationwithforeignmilitarypart-
ongoing outbreaks, consists of a wide range of functions, ners and multinational forces involved in peacekeeping
such as field team support, epidemiology or consultative activities or exercises. One investigation involved influ-
support, and laboratory diagnostic support. These efforts enzatestingofU.S.expatriatesthroughtheU.S.Embassy
and collaborative exchanges strengthen relationships, clinicinJakarta,Indonesia.
build and maintain trust, and are a critical component Response activities included a range of efforts from
of the long-standing relationships between the network the provision of simple consultative services to com-
partners and their sponsor host countries. Many of the prehensive outbreak packages that included field
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Table 1Diseases andagents investigated throughout support, epidemiologic consultation and laboratory
2009amongAFHSC-GEIS globalpartner laboratories and diagnostic support. In 27 (36 percent) of the outbreaks,
institutions personnel were provided for field support, 44 (59 per-
DiseaseorAgent NumberofOutbreaks cent) outbreaks received epidemiologic or clinical con-
Adenovirus 1 sultative support, and laboratory diagnostic and testing
Campylobacter 1 support was provided to 68 (91 percent) of the out-
Chikungunya 1 break support requests. Many AFHSC-GEIS partner
Cholera 4 responses were a combination of the above and
Cyclospora 1 27 (36 percent) of the outbreak investigations provided
Denguefever 4 a fully comprehensive response effort with support
Hepatitis(viral) 3 from all three categories.
Influenza
Pandemic(2009)H1N1 42
Respiratory disease outbreaks
SeasonalInfluenza 4
Beginning in 2006, the DoD’s global disease surveillance
AvianInfluenza(H5N1) 2
network has worked to enhance the existing surveillance
Malaria 1
infrastructure to prepare for a potential influenza pan-
Norovirus 1
demic. The goals of these expansion efforts included
Rickettsiosis 1
broadening the network to monitor and detect increas-
RiftValleyfever 1
ing numbers of avian (H5N1) influenza outbreaks
Salmonellatyphi 1
around the world and identify new infectious disease
GroupAStreptococcal(GAS)pneumonia 1
threats [10]. This expansion of capacity and function
Syphilis 1
was both appropriate and fortuitous as AFHSC-GEIS
Unknownetiology
network partners at NHRC and USAFSAM were the
Conjunctivitis 1
first in the world to detect the novel influenza A/H1N1
Gastrointestinalsyndrome 2
strain in April 2009 in San Diego, California, and San
Respiratorysyndrome 1
Antonio,Texas.Thisrapiddetectionduringtheendofthe
Hemorrhagicsyndrome 1
influenza season allowed the appearance of this novel
Vampirebatbites 1
strain to be identified and reported as a Public Health
Total 76
EmergencyofInternationalConcernbytheCDC,aWHO
Figure1GlobalSnapshotofEmergingInfectiousDiseasesandRespiratoryDiseasesOutbreaks.October2008toSeptember2009.
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Collaborating Center, in compliance with IHR (2005). specimensarestoredinliquidnitrogenor-80°Cfreezers.
With the onset of this influenza A/H1N1 pandemic in This surveillance, conducted by NHRC, has facilitated
April2009,substantialeffortsweremadebyAFHSC-GEIS timelyspecimencollectionandpathogenidentificationin
networkpartnerstoassisttheglobalhealthcommunityin a number of shipboard respiratory outbreaks in recent
responding to this threat. Fifty-one (67 percent) of the years. The surveillance system detects a wide variety of
76 outbreaks responses involved respiratory diseases, circulatinginfluenzatypesastheseshipsmakenumerous
41 (80 percent) of which were due to novel influenza worldwideportstopsoverashorttimeperiod.Ingeneral,
A/H1N1. the specimens are saved and processed at the end of a
Beginning in April 2009, with the onset of the influ- ship’sdeployment,whichusuallylastssixmonths.How-
enza pandemic, disease surveillance and investigative ever,inthecaseofanoutbreak,febrilerespiratoryillness
support activities were dominated by novel influenza (FRI) specimens from immediately before the outbreak
A/H1N1-related responses. As with other investigations, onwardcan be processedonboardthe shipwithspecific
the activities for novel influenza A/H1N1 were wide- polymerasechainreaction(PCR)testingorshippedover-
rangingandinvolveddifferentpopulationsandsituations. nighttoNHRCfor12-to24-hourturnaroundmolecular
The AFHSC-GEIS network supported the diagnostic testingandculture.
confirmation (directly in DoDlab or throughsupportof Shipboard investigations ranged from simple identifi-
host-country laboratories) of the first cases in 14 coun- cation of the novel influenza A/H1N1 virus to detailed
tries (Bhutan, Cambodia, Colombia, Djibouti, Ecuador, epidemiologic investigation and testing [13]. NMRCD,
Egypt,Kenya,Kuwait,LaoPeople’sDemocraticRepublic, in partnership with the Peruvian Navy, investigated a
Lebanon,Nepal,Peru,RepublicoftheSeychellesandthe shipboard outbreak in June through July 2009 aboard a
United States), again demonstrating direct support for 355-crew Peruvian Navy ship at sea in the Pacific
increasing compliance with IHR (2005). The non-U.S. Ocean. During the four-week investigation, team mem-
activities were a result of the respective AFHSC-GEIS bers confirmed 78 of 85 (92 percent) febrile acute
partner laboratory’s roles as regional reference testing respiratory illness cases as novel influenza A/H1N1. The
centersandthebilateralcollaborationswithhost-country attack rate aboard the ship during the time of the out-
Ministries of Health. These bilateral relationships break was 22 percent. Early detection, through an active
resulted in support of 17 large-scale outbreaks among shipboard surveillance system modeled on the NHRC
civiliansin13countries. program, played an important role in the rapid detection
U.S. service members and beneficiaries were affected and subsequent control of the outbreak [14].
by the pandemic from the beginning. In the first wave The USS Boxer (LHD 4), with a complement of more
(April through August 2009), AFHSC-GEIS network than 2,200 U.S. Sailors and Marines, was docked at
partners actively investigated 18 different outbreaks on Phuket, Thailand, from June 23 through 29, 2009. On
U.S. military installations and among previously defined June 30, four of 14 patients with ILI tested positive for
high-risk groups [11]. These high-risk groups included influenza A by PCR. By July 9, 102 individuals had pro-
deployed or deploying personnel, shipboard personnel, vided respiratory specimens (throat swabs in viral trans-
new accessions (basic and advanced military trainees port media) that were sent to NHRC, where 69 were
and service academy students), health care workers, confirmed as novel influenza A/H1N1. Overall, more
children and staff in daycare centers, and pregnant than 200 cases were identified in a five-week period and
women. Stressful military environments, highly mobile 177 personnel were isolated with FRI for an average
missions and complex troop dynamics helped to propa- duration of 3.6 days (Figure 2) [15].
gate pandemics in the past and have drawn the atten- As part of the deployment process, troops usually
tion of the military’s operational leadership and leaders transition through pre-deployment training at what the
of civilian sectors within host countries. These investi- U.S. Army refers to as power projection platforms
gations involved from a few dozen cases to more than (PPP). These are usually large installations with thou-
1,000 cases tested. sands of individuals transferring to the deployed setting
Shipboard investigations involved a number of each year [16]. The first wave of novel influenza
responding units and included ships at sea in the A/H1N1 included outbreaks among deploying service
AtlanticandPacificOceans,andthePersianGulf,aswell members from nine of the 15 PPPs and subsequently
as vessels in port in major cities around the world. resulted in two large-scale outbreaks in the operational
Shipboard investigations have benefitted from the theatre (Iraq and Kuwait). The most notable PPP out-
ongoing surveillance ofrespiratory disease onlarge U.S. breaks were at Fort Riley, Kansas (n=33), Fort Hood,
Navy ships [12]. Patients meeting the case definition of Texas (n=44), Fort Lewis, Washington (n=144), and
febrile respiratory illness (FRI), temperature > 100.4°F Fort Bliss, Texas (n=188). Response activities at each
and cough or sore throat, undergo throat swabs andthe of the PPPs varied based on the reality on the ground
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Figure2Epicurveofcases,isolatedpatientsduringA/H1N1outbreakaboardtheUSSBoxer.Summer2009.
and timing in the pre-deployment process. Sites with from illness onset and from asymptomatic patients
large numbers of individuals in the latter stages of pre- (≥24 hours) contained cultureable virus in 24 percent
deployment were forced to take much more aggressive and 19 percent of the samples, respectively. The USAFA
steps to screen and monitor the symptoms of illness for investigation made a significant and novel contribution
departing troops. to the general public health knowledge on the transmis-
Military service academies were particularly hard hit sion dynamics of this disease and demonstrated a high
by novel A/H1N1 outbreaks during the first wave. Nota- proportion of asymptomatic, sub-clinical disease among
ble outbreaks requiring outside assistance and support cadets in this setting.
took place at the U.S. Air Force Academy (USAFA) [17] Remarkably, while notable novel influenza A/H1N1-
(Figure 3), U.S. Coast Guard Academy, U.S. Military related outbreaks occurred at all of the basic military
Academy and U.S. Naval Academy. Response efforts training centers, overall, military recruits were only
ranged from diagnostic support for cadets and midship- minimally affected during the first wave of the pandemic
men in isolation to comprehensive outbreak support. (Figure 5). Subsequently, the burden of disease shifted
The response effort for USAFA was unique because it almost entirely to recruits at these installations in early
was the first to provide information on the different fall (August-October) 2009, although the disease burden
aspects of the disease in such a high-risk setting. The of novel influenza A/H1N1 among recruits during the
USAFA investigation team conducted retrospective and entire time was significantly smaller than the ongoing
prospective surveillance to describe the epidemiology of epidemic of adenovirus respiratory diseases among U.S.
the outbreak and to define and implement effective con- military recruits [18].
trol measures. Extensive education and hygiene efforts In addition to the novel influenza A/H1N1 outbreaks,
were implemented and ill cadets were isolated from four seasonal influenza outbreak investigations were
non-ill cadets to decrease transmission. The team docu- undertaken:oneamongdeployedU.S.troopsinDjibouti,
mented confirmed (n=134) and suspected (n=34) novel oneinarefugeecampinNepal,oneonboardaU.S.Navy
influenza A/H1N1 cases among basic cadet trainees, submarine, and one among newly arrived Japanese
with an outbreak period incidence rate of 11 percent. military trainees in Camp Pendleton, California.
The peak of the outbreak occurred on July 6 and was TwoH5N1-relatedinvestigationsoccurred,alongwithan
likely propagated by a Fourth of July social-mixing event ongoinginvestigationofhumanH5N1casesinEgyptand
(Figure 4). The investigation team obtained serial nasal assistancewithhumantestingduringanoutbreakofinflu-
wash samples from patients and published the first enzainbirdsinNepalinNovemberof2008.Additionally,
report of virus shedding duration determined by virus two respiratory illness outbreak investigations occurred
culture. Follow-up nasal wash samples taken seven days amongbasicmilitarytrainees,whiletheU.S.ArmyPublic
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Figure3U.S.AirForceAcademyswearing-inceremony(PhotoCourtesyofOfficialU.S.AirForceAcademywebsite).
Outbreak recognized
40
35 Suspect
Confirmed
30 4th of July Event
25
s
e
s
a 20
C Transmission building

.
o
N
15
10
5
0
5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4
6/2 6/2 6/2 6/2 6/2 6/3 7/ 7/ 7/ 7/ 7/ 7/ 7/ 7/ 7/ 7/1 7/1 7/1 7/1 7/1 7/1 7/1 7/1 7/1 7/1 7/2 7/2 7/2 7/2 7/2
Date of symptom onset
Figure4Confirmed,suspectcasesofA/H1N1virusinfectionatU.S.AirForceAcademy,2009[17].
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Figure5A/H1N1epicurve,timelineforoutbreaksandclustersamongU.S.servicemembersandbeneficiaries.
Health Command (Provisional) investigated anoutbreak organisms. Outbreaks involving all five pathogen/illness
of Group A Streptococcus at Fort Leonard Wood, categories occurred in the one-year timeframe of this
Missouri.AnadenovirustypeB14wasinvestigatedatthe report.Globalsurveillancenetworkpartnersrespondedto
U.S.CoastGuardTrainingCenterinCapeMay,N.J.Both 20 outbreaks involving non-respiratory EIDs where the
outbreaks took placeinMarch 2009 andwere supported diseaseagentswereidentified,includingfourdenguefever,
bythelaboratoryatNHRC. fourcholera,threeviralhepatitis,twogastrointestinalsyn-
Overall, the AFHSC-GEIS global disease surveillance drome, and one each of Campylobacter, chikungunya,
network response remained strong through the end of Cyclospora, malaria, Norovirus, rickettsiosis, Rift Valley
the first wave and well into the second fall wave of the fever,Salmonellatyphiandsyphilis.Additionally,partners
pandemic. At that point, efforts across the network pri- conductedindividualoutbreakinvestigationsofconjuncti-
marily shifted from outbreak response to systematic sur- vitisandviralhemorrhagicsyndrome,whileoneresponse
veillance (monitoring and representative sampling) of activity examinedbitesfromvampire bats. Overall,these
affected sites, along with more complex characterization responseactivitiestookplacein14countries.
of the viruses and close tracking of the global circulation From May to September 2009, a diarrheal disease out-
patterns of all influenza viruses. break occurred in western Nepal, with reports of nearly
70,000patientstreatedandover350deaths.TheNational
Non-respiratory, emerging infectious disease outbreaks Public Health Laboratory of the Ministry of Health and
TheAFHSC-GEISEIDsurveillanceprogramincludesfive PopulationforNepalrequestedassistancefromtheWalter
programpillarsordiseasefocusareas:respiratorydiseases, Reed/AFRIMS ResearchUnit Nepal (WARUN) indeter-
febrileandvector-borneillnesses,entericdiseases,sexually miningtheetiology.WARUNreceived158stoolsamples
transmitted infections and antimicrobial resistant from eight districts in western Nepal; 45 percent from
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children <15 years and 61 percent from female patients. been faster, currently receiving reports from 120 units
WARUNinNepalandAFRIMSinThailandanalyzedthe throughout the country.
samples using real-time PCR and culture. Eighty-two of Within the one-year period of review, the 76 outbreaks
the outbreak samples were positive for Vibrio cholerae identified by the AFHSC-GEIS network spanned the
(01/0139)byPCR.ManyofthePCRpositivesamplessub- clinical disease spectrum and involved efforts of interna-
sequentlygrewV.choleraeserogroup01serotype Ogawa tional significance. The U.S. DoD has established a
inculture.AntibioticsensitivityanalysisoftheV.cholera robust and flexible global response framework through
isolates showed universal resistance to nalidixic acid, open collaborations with long-standing host country
colistin, streptomycin, sulfisoxazole, and trimethoprim/ partners, other global health institutions and agencies
sulfamethoxazolebutsensitivitytothecommonlyrecom- such as the WHO, the CDC and Institute Pasteur. In
mendedantibioticsazithromycin,ciprofloxacin,ampicillin doing so, AFHSC-GEIS, through its global network of
and tetracycline. The National Public Health Laboratory partners, is addressing the specific milestones for build-
performed the initial culture onthese stool samples,and ing sustained capacity for early detection and rapid
theWARUNandAFRIMSlaboratorieseventuallyverified response as prescribed by the IHR (2005).
and confirmed the cause of the outbreak. The effort
enabled local health authorities to institute appropriate
Conclusions
treatmentandpreventionmeasuresinatimelymanner.
Department of Defense resources have also been TheArmedForcesHealthSurveillanceCenter’sDivisionof
directed toward the investigation or characterization of GlobalEmergingInfectionsSurveillanceandResponseSys-
other phenomena that may threaten public health other temcontinuestoexpandinternationallytoeffectivelyiden-
than the disease incidence. For example, AFRIMS and tify and respond to threats from a wide range of disease
NAMRU-2 investigators were among the first worldwide agents and geography. The growth and enhancement of
to recognize that increases in Plasmodium falciparum thissurveillancesysteminanticipationofpandemic/avian
treatment failures to the powerful artemisinin combina- influenzaallowedtheDoDtoidentifythecurrentinfluenza
tion therapies signaled the onset of resistance to the last pandemic[20,21]andanumberofotherinfectiousdisease
remaining class of malaria treatments in widespread outbreaksincommunitiesthroughouttheglobe.Amulti-
deployment today. As a result of these findings, world- purposesystemwithdefinedgoalsandpillarsoffocus,the
wide efforts are under way to contain spread of drug- AFHSC-GEISnetworkhasevolvedtobecomeatruemodel
resistant forms of the parasite from what is hoped to be foremerginginfectioussurveillanceplatformsatthelocal,
a relatively constrained area in Southeast Asia along the regionalandinternationallevel.Byutilizingthisestablished
Thai-Cambodian border [19]. global system, the DoD isable to provide a commonand
Although many methods may be used to detect out- systematic approach to disease surveillance and a frame-
breaks, most often an astute clinician or laboratory workforeffectiveresponse.Asemergingandre-emerging
worker identifies an unusual occurrence or an increased threats develop in areas where partners work collabora-
frequency. However, syndromic or electronic surveil- tivelywithhostcountriesandglobalhealthinstitutions,the
lance may serve as another method to augment, but not AFHSC-GEISnetworkstandsreadytorespond.
replace, traditional disease surveillance efforts [8].
AFHSC-GEIS partners at NMRCD have implemented a
Acknowledgements
near real-time electronic disease surveillance system #AFHSC-GEISOutbreakResponseWritingGroup:SonamWangchuk2,Tandin
based on highly cost-effective and sustainable strategies Dorji2,RobertGibbons2,SoponIamsirithaworn2,JasonRichardson2,Rome
Buathong2,RichardJarman2,In-KyuYoon2,GeetaShakya3,VictorOfula4,
affordable in resource-constrained, developing countries.
RodneyColdren4,WallaceBulimo4,RosemarySang4,DukeOmariba4,Beryl
This system is called Alerta and was first implemented Obura4,DennisMwala4,MatthewKasper5,GaryBrice5,MayaWilliams5,Chad
in the Peruvian Navy population in 2002, the Peruvian Yasuda5,RobertVBarthel6,GuillermoPimentel6,ChrisMeyers8,Peter
Kammerer8,DarcieE.Baynes8,DavidMetzgar8,AnthonyHawksworth8,Patrick
Army three years later and more recently the Peruvian
Blair8,MelodyEllorin8,RobertCoon8,VictorMacintosh9,KristenBurwell9,
Air Force. Currently, Alerta covers 98 percent, 99 per- ElizabethMacias9,ThomasPalys10,KurtJerke10
cent and 95 percent of the Peruvian Navy, Army and Theauthorswishtothankthenumerousindividualswhoperform
surveillanceaspartoftheAFHSC-GEISglobalnetwork,includingall
Air Force population, respectively, and receives over
individualsintheMinistriesofHealthandMinistriesofDefenseofour
200 notifications per week. The system has been useful partnernationswhoseeffortshavecontributedtothesuccessofthe
in outbreak detection, identifying over 20 outbreaks in network.
Disclaimer
the last year, six of which were for influenza. Eighty-six
Theopinionsstatedinthispaperarethoseoftheauthorsanddonot
reporting units operate nationwide, including border representtheofficialpositionoftheU.S.DepartmentofDefense,local
units, hospitals, infirmaries and ships incorporated in countryMinistriesofHealthorDefense,orothercontributingnetwork
partners.
the Peruvian Navy surveillance system. Due to this pre-
ThisarticlehasbeenpublishedaspartofBMCPublicHealthVolume
vious experience, the Peruvian Army’s expansion has 11Supplement1,2011:DepartmentofDefenseGlobalEmergingInfections
Johnsetal.BMCPublicHealth2011,11(Suppl2):S3 Page9of9
http://www.biomedcentral.com/1471-2458/11/S2/S3
SurveillanceandResponseSystem(GEIS):anupdatefor2009.Thefull H1N1InfluenzaaboardUSSBoxer,29June031July2009.MSMRMed
contentsofthesupplementareavailableonlineathttp://www. SurvMonthlyReport2009,16(9).
biomedcentral.com/1471-2458/11?issue=S2. 16. PowerProjectionPlatform.[http://www.globalsecurity.org/military/facility/
ppp.htm].
Authordetails 17. WitkopCT,DuffyMR,MaciasEA,GibbonsTF,EscobarJD,BurwellKN,
1ArmedForcesHealthSurveillanceCenter,11800TechRd,SilverSpring,MD KnightKK:NovelInfluenzaA(H1N1)outbreakattheU.S.AirForce
20904,USA.2ArmedForcesResearchInstituteofMedicalSciences,315/ Academy:epidemiologyandviralsheddingduration.AmJPrevMed
6RajavithiRd.,Bangkok,Thailand10400.3WalterReed/AFRIMSResearchUnit 2010,38(2):121-126.
Nepal,c/oU.S.Embassy,P.O.Box295,Kathmandu,Nepal.4U.S.Embassy, 18. KajonAE,MoseleyJM,MetzgarD,HuongHS,WadleighA,RyanMA,
Attn:MRU,UnitedNationsAvenue,P.O.Box606,VillageMarket RussellKL:Molecularepidemiologyofadenovirustype4infectionsinU.
00621Nairobi,Kenya.5NavalMedicalResearchUnitNo.2,Kompleks S.militaryrecruitsinthepostvaccinationera(1997-2003).JInfectDis
PergudanganDEPKESR.I.,JI.PercetakanNegaraIINo.23,Jakarta,10560, 2007,196(1):67-75.
Indonesia.6NavalMedicalResearchUnitNo.3,ExtensionofRamsesStreet, 19. SamarasekeraU:Countriesracetocontainresistancetokeyantimalarial.
AdjacenttoAbbassiaFeverHospital,PostalCode11517,Cairo,Egypt.7Naval Lancet2009,374(9686):277-280.
MedicalResearchCenterDetachment-Peru,CentroMedicoNaval“CMST,”Av. 20. SwineinfluenzaA(H1N1)infectionintwochildren—SouthernCalifornia,
VenezuelaCDRA36,Callao2,Lima,Peru.8NavalHealthResearchCenter, March-April2009. MMWRMorbMortalWklyRep2009,58(15):400-402.
140SylvesterRd.,SanDiego,Calif.92106,USA.9U.S.AirForceSchoolof 21. Update:swineinfluenzaA(H1N1)infections—CaliforniaandTexas,April
AerospaceMedicine,EpidemiologyConsultService,2513KennedyCircle, 2009. MMWRMorbMortalWklyRep2009,58(16):435-437.
Bldg180,BrooksCityBase,Texas78235,USA.10U.S.PublicHealthCommand
(Provisional)-PublicHealthRegion-Europe,Landstuhl,Germany. doi:10.1186/1471-2458-11-S2-S3
Citethisarticleas:Johnsetal.:Agrowingglobalnetwork’srolein
Competinginterests outbreakresponse:AFHSC-GEIS2008-2009.BMCPublicHealth201111
Tothebestknowledgeoftheauthors,therearenocompetinginterests. (Suppl2):S3.
Published:4March2011
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