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Capacity-building efforts by the AFHSC-GEIS program
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Permanent Link: http://ufdc.ufl.edu/AA00010683/00001
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Title: Capacity-building efforts by the AFHSC-GEIS program
Series Title: BMC Public Health
Physical Description: Archival
Language: English
Creator: Sanchez, Jose L.
Johns, Matthew C.
Burke, Ronald L.
Vest, Kelly G.
Fukuda, Mark M.
Yoon, In-Kyu
Lon, Chanthap
Quintana, Miguel
Schnabel, David C.
Pimentel, Guillermo
Mansour, Moustafa
Tobias, Steven
Montgomery, Joel M.
Gray, Gregory C.
Saylors, Karen
Ndip, Lucy M.
Lewis, Sheri
Blair, Patrick J.
Sjoberg, Paul A.
Kuschner, Robert A.
Russell, Kevin L.
Blazes, David L.
AFHSC-GEIS Capacity Building Writing Group
Publisher: BioMed Central
Publication Date: 2011
 Notes
Abstract: Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.
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Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution.
Resource Identifier: doi - :10.1186/1471-2458-11-S2-S4
System ID: AA00010683:00001

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REVIEW OpenAccessCapacity-buildingeffortsbytheAFHSC-GEIS programJoseLSanchez1*,MatthewCJohns1,RonaldLBurke1,KellyGVest1,MarkMFukuda1,2,In-KyuYoon2, ChanthapLon2,MiguelQuintana3,DavidCSchnabel4,GuillermoPimentel5,MoustafaMansour5,StevenTobias6, JoelMMontgomery7,GregoryCGray8,KarenSaylors9,LucyMNdip10,SheriLewis11, PatrickJBlair12,PaulASjoberg13,RobertAKuschner14,KevinLRussell1,DavidLBlazes1, theAFHSC-GEISCapacityBuildingWritingGroup14,15,16,17,18,19,20,21,22,23,24,25AbstractCapacity-buildinginitiativesrelatedtopublichealtharedefinedasdevelopinglaboratoryinfrastructure, strengtheninghost-countrydiseasesurveillanceinitiatives,transferringtechnicalexpertiseandtrainingpersonnel. TheseinitiativesrepresentedamajorpieceoftheArmedForcesHealthSurveillanceCenter,DivisionofGlobal EmergingInfectionsSurveillanceandResponseSystem(AFHSC-GEIS)contributionstoworldwideemerging infectiousdisease(EID)surveillanceandresponse.Capacity-buildinginitiativeswereundertakenwithover80local andregionalMinistriesofHealth,AgricultureandDefense,aswellasothergovernmententitiesandinstitutions worldwide.Theeffortssupportedatleast52nationalinfluenzacentersandothercountry-specificinfluenza, regionalandU.S.-basedEIDreferencelaboratories(44civilian,eightmilitary)in46countriesworldwide.Equally important,referencetesting,laboratoryinfrastructureandequipmentsupportwasprovidedtoover500fieldsites in74countriesworldwidefromOctober2008toSeptember2009.Theseactivitiesallowedcountriestobettermeet themilestonesofimplementationofthe2005InternationalHealthRegulationsandcomplementedmanyinitiatives undertakenbyotherU.S.governmentagencies,suchastheU.S.DepartmentofHealthandHumanServices,the U.S.AgencyforInternationalDevelopmentandtheU.S.DepartmentofState.BackgroundCapacitybuilding,asitappl iestohealthinthiscontext, canbeaccomplishedthroughstrengtheninghealth systemsfordeliveryofmedicalcare,pursuingmedical researchinitiativestoanswerimportantlocalorregional healthquestions,orsupportingpublichealthdiseasesurveillancetoprioritizewhichdiseasesareaffectingrelevantpopulations.Withinthiscontext,globalpublic healthcapacitybuildingcanbedefinedasdeveloping laboratoryinfrastructure,strengtheninghost-countrydiseasesurveillanceinitiatives,transferringtechnicalexpertiseandtrainingpersonnel.Diseasesurveillanceisoften thefirststepinimprovingpublichealthbecauseit attemptstoquantifyneedsa ndallocatescarceassetsin resource-limitedsettings,inadditiontodetectingpotentialoutbreaksofdisease. Thoughnotanewconcept,capacitybuildinghas enjoyedrenewedprominenceastheworldendeavorsto meetrequirementsofInternationalHealthRegulations 2005(IHR(2005))[1].Article5oftheregulationsrequires thatallcountriesbeableto detect,assess,notifyand reportonpublichealthissuesofinternationalsignificance andcontrolanypotentialpublichealtheventofinternationalconcernby2012.Somecountriesarecapablenow, butmostarenotandwillnotbecompliantbythedeadline unlessasignificantimprovementinlocalcapacityoccurs. Ingeneral,forcapacitybuildingtobesuccessfulinthe longterm,effortsmustnotbeundertakenquicklyand needtobeimplementedthroughaconcertedunified effort,achievingsteady,sustainableandmeasurableprogressovertime,withtheeventualgoalbeingindependence fromtheproviderofthecapability. *Correspondence:Toti.Sanchez@us.army.mil1ArmedForcesHealthSurveillanceCenter,503RobertGrantAvenue,Silver Spring,MD20910,USA FulllistofauthorinformationisavailableattheendofthearticleSanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 2011Sanchezetal;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited.

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In2007,theGovernmentAccountabilityOffice issuedareportdescribingtheglobalinfectiousdisease capacity-buildingeffortsofU.S.government(USG) entities[2].Atthetime,threeUSGentitieswereidentifiedasprovidingcapacitybuildingforemerging infectiousdiseases(EID),includingtheU.S.Centers forDiseaseControlandPrevention(CDC),theU.S. AgencyforInternationalDevelopmentandtheDepartmentofDefense sGlobalEmergingInfectionsSurveillanceandResponseSystem(DoD-GEIS).Theirefforts includedlaboratory-baseddiseasesurveillance,developmentandtestingofdiagnostics,andtrainingsuchas FieldEpidemiologyTrainin gPrograms,theinternationalversionofthefamedEpidemicIntelligenceService[3].Currently,manyotherUSGagenciesare engagedinbuildingdisea sesurveillancecapacity, includingtheU.S.DepartmentofState,theDefense ThreatReductionAgencyandtheU.S.NationalInstitutesofHealth[4].Inaddition,numerousstate,nonstateandnon-governmentalorganizations,suchasthe BillandMelindaGatesFoundation,theWorldBank andMdecinssansFrontires,contributesubstantially tocapacity-buildingeffortsaroundtheworld[5-7]. WiththeestablishmentoftheArmedForcesHealth SurveillanceCenter(AFHSC)inlate2008,theDoDGEISprogramwastransitionedtoadivisionand renamed AFHSC-GEIS ;however,itsmissionofworkingtopromoteandfacilitatenationalandinternational preparednessforEIDwasmai ntained.Strengtheningof U.S.militaryandhost-countrydiseasesurveillanceand publichealthlaboratorycapacityrepresentsacritical stepforcontributingtocompliancewiththeIHR(2005) detection,reportingandresponserequirements.During 2009,capacity-buildingeffortswereundertakenina varietyofformats,includingenhancementofdiagnostic capabilities,expansionofsurveillanceformilitarilyrelevantinfectiousandtropicaldiseases,anddeploymentof electronicsurveillanceplat forms.Theseeffortswere coordinatedwithlocalhost-c ountryhealthofficialsand geographicCombatantCommandstoensurethey addressedcountryandregionalmedicalprioritiesas wellastoensurebettersurveillanceandresponsetodiseaseoutbreaksandEIDthreatstoU.S.forcesabroad. Theseeffortsfocusedoninfluenzaandotherrespiratory diseases,malaria,dengueandothervector-borneillnesses,acutediarrhealdiseases,antimalarialandantimicrobialresistance,sexuallytransmitteddiseases,and bacterialwoundinfections.AccomplishmentsLaboratoryinfrastructuredevelopmentCapacity-buildinginitiativ escontinuedtorepresenta majorcomponentofAFHSC-GEIScontributionstoworldwideEIDsurveillanceandresponseactivities.Inadequate laboratorycapacityindevelopingcountrieshasbeen termedthe Achilles heel ofglobaleffortstocombat infectiousdiseases[8].T hus,manyAFHSC-GEISsponsoredactivitiesincapacitybuildingweredirectedat improvingexistinginfrastructurebyrenovatingcurrent laboratoryfacilities,furnishingnewscientificequipment, andprovisioningneworenhanceddiagnostictestingsystemsatoverseasU.S.DoDfacilities,aswellasU.S.-based, DoDinfluenzareferencelaboratories,whichserveasregionalreferencelaboratories,andhost-countrylaboratories. Effortswerecoordinatedwithover80localandregionalMinistriesofHealth,AgricultureandDefense,as wellasothergovernmentofficialsandinstitutions worldwidein74countries.Atotalof52NationalInfluenzaCenters(NICs)andothercountry-specificinfluenzaandEIDreferencelaboratories(44civilian,eight military)weresupportedin46countries(Table1).The effortsincludedsupporttolaboratoriesineightregions oftheworld.Sub-Saharan(east,centralandwest)Africa weretheregionswiththemostmajorlaboratorycapacity-buildingefforts(in14countries),consistentwith theidentifiedneedsofthisregionrelativetotheworld, especiallyasitrelatestoinfluenza[9,10].Amongall infrastructureandcapacity-buildingprojects(Table2), themajoritysupportedprimarilyhumanhealthentities (in67countries);however,projectsalsosupportedanimalhealthentitiesforzoonoticdiseasesineightcountries.Trainingeffortsarementioned,butarepresented indetailelsewhereinthissupplement[11]. OneofthemostnotableAFHSC-GEISaccomplishments infiscal2009wastheestablishmentoftwonewbiosafety level-3(BSL-3)laboratorysuiteswithinDoDreference laboratories.TheArmedForcesResearchInstituteof MedicalSciences(AFRIMS)inBangkok,Thailand,completedthefirstlaboratory,whichtheUnitedStatescertifiedandcommissionedonJuly8,2009.Thesuitewas officiallyinauguratedSeptember16,2009andbegan immediatelysupportingworkinavianandpandemicinfluenzamonitoring,includingcultureandmolecularsequencingcapability(Figure1). ThisBSL-3laboratory constitutesthefirstDoD-certifiedlaboratoryofitskindin theregionandprovidestheWorldHealthOrganization (WHO),ThailandandothercountriesinSoutheastAsia withamuch-neededhigh-containmentcapabilitytoconductresearchandassistwithoutbreaksinvolvingselect humanandanimalbacterialandviralstrains. TheNavalHealthResearchCenter(NHRC)openeda secondBSL-3(agriculture-en hanced)laboratorysuitein late2009.ThefacilityallowsworkwithzoonoticinfluenzastrainssubmittedbyAFHSC-GEISpartnersaround theworld,includingdevelopmentofnewvirusneutralizationtestingcapabilitiesagainstH5N1andotherhighly pathogenicavianinfluenza strains.Additionally,two BSL-2laboratorieswerealsoestablishedattheCameroonSanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page2of9

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ArmyMilitaryHealthResearchCenter,supportedby GlobalViralForecastingInitiativeinYaoundandatthe UniversityofBuea(Figure2).Bothfacilitieswillgreatly improvetheabilitytoconductinfluenzaandEIDdiagnosticwork,aswellaspotentiallyadvancedpathogendiscoveryworkinhard-to-reachlocationsinAfrica. Effortswerealsoundertakentoimprovelaboratory capabilityforglobalinfluenzasurveillanceanddiagnosis, especiallyregardingtheno velA/H1N1influenzapandemic.Tothisend,AFRIMSes tablishedviral/bacterial pathogencultureandmoleculardiagnosticcapabilityin theirNepaldetachmenttosupporttheNationalPublic Table12009MajorLaboratoryCapacity-BuildingInitiativesbyGeographicRegionGeographicRegionMajorLaboratoryCapacityBuildingInitiative CountriesSupported SoutheastAsiaNIC&militaryinfluenzalabequipment,reagent&trainingsupport;EID laboratorydiagnostics&diseasesurveillancesystems Bhutan,Cambodia,LaoPeople sDemocratic Republic,Nepal,Singapore,Thailand FarEast NIC&militaryinfluenzalabequipment&reagentsupport;EIDlab proficiency&equipmentsupport Japan,Korea,Philippines East&CentralAfricaNIC&VHFlabequipment,reagent&trainingsupport;EIDlaboratory diagnostics Cameroon,Kenya,Tanzania,Uganda WestAfrica NIC&MoHinfluenzalabequipment,reagent&trainingsupport;VHFlab diagnostics&militaryEIDlabdiagnostictestingcapacity Benin,BurkinaFaso,Coted Ivoire,Ghana, Liberia,Mali,Niger,Nigeria,SierraLeone,Togo NorthAfrica,Middle East&SouthwestAsia NIClabequipment,reagent&trainingsupport Afghanistan,Egypt,Iraq,Jordan,Kuwait,Oman, Pakistan,Sudan,Syria CentralAsia EID&influenzalabequipment,reagent&trainingsupport Azerbaijan,Georgia,Mongolia Europe Military&academicinfluenzalabequipment,reagent&trainingsupport Poland,Romania Central&South America NIC&MoHinfluenzalabequipment,reagent&trainingsupport; leishmaniamilitaryreferencelabequipment,reagent&trainingsupport Colombia,Ecuador,ElSalvador,Guatemala, Honduras,Nicaragua,Panama,Paraguay,PeruAcronyms:NIC,nationalinfluenzacenter;EID,emerginginfectiousdiseases;VHF,viralhemorrhagicfever;MoH,MinistryofHealth. Table22009Capacity-BuildingInitiativesbyMajorRegionalAFHSC-GEISSupportedPartnersandTypePartner (seetext) TypeofInfrastructure/CapacityBuilding*Centers/ Hospitals Field Sites Countries* AFRIMSInfluenza&malaria/MDRlabs(KH,PH);enteric&influenzalabupgrade(NP,TH);bloodculture (NP);influenzatesting(BT);influenzaantiviralresistance(TH) 22515 NAMRU-2Malaria,FVBI,enteric,bloodculture&AMRtesting(KH);influenza&AFItesting(ID,KH,SG); surveillancedatamanagement(LA) 4734 NAMRU-3Influenza,bloodculture&AMRtesting(EG,JO);InfluenzaPCR/culture&antiviralresistancetesting (32countries);JointBiologicalAgentIdentification&DetectionSystem(5deployedUSmilitary sites-CENTCOM**);zoonoticdisease&entomology(EG,DJ);AFI,blood/cerebrospinalspinalfluid culture&serologytesting(AZ,GE);LeishmaniaPCR&culture(EG,LR);rotavirustesting(6 countries);cholera&otherADDtesting(7countries);FVBItesting(EG,DJ,AZ,GE) 374234 NMRCDPeru InfluenzaPCR/culture&antiviralresistancetestingsupport(10countries);AFI&viralculture& serologytesting(PE,BO,EC,PY);LeishmaniaPCR,MDR,urine/vaginalPCR-STIs,RickettsialPCR& culture(PE);entericculture,PCR&AMRtesting(PE,EC,PY);Alertaelectronicdiseasesurveillance system(PE,PA,EC) 2310211 USAMRUKenya Malaria/MDR,microscopy&PCR,rotavirus,cholera&otherADDtesting,arboviral/VHFPCR& culture,AFIs,bloodculture&serologytesting,STIsculture(KE);influenzaPCR,culture&genotyping (KE,UG,CM);influenza,AFI,FVBI,cholera&otherADDs(KE,TZ,NG) 7695 PHCR-SouthInfluenzaPCR,culture&indirectimmunofluorescenceassay(US,HN,SV,NI,GT,PA);malaria, Leishmania,&denguePCRtesting(HN) 476 UnivIowa CEID Respiratory&otherzoonoticrespiratoryEIDtesting&epidemiology(US,TH,KH,NG,RO,MN)6~306 JHU/APLInfluenzamilitarytreatmentfacilities(PIPM)modeling(US);SMStext&ESSENCEDesktopedition system(PH);OpensourceInteractiveVoiceRecognitionsoftwaresurveillance(PE);OpenESSENCE websitesoftwaresurveillance(US,PE);SMStext(PH) 1~1253Acronyms:MDR,multidrugresistance;FVBI,febrile&vector-borneillnesses;AMR,antimicrobialresistance;AFI,acutefebrileillnesses(suchasdengue, leptospirosisandzoonoticinfections);PCR,polymerasechainreaction;ADD,acutediarrhealdiseases(suchastraveler sdiarrhea,campylobacter,shigellosis, salmonellosis);STIs,sexuallytransmittedinfections,including Neisseriagonorrhea ;EID,emerginginfectiousdiseases;PIPM,PandemicInfluenzaPrevention Modeling;SMS,ShortMessageService;ESSENCE,ElectronicSyndromicSurveillanceforEarlyNotificationofCommunity-basedEpidemics. *CountrynamesaredisplayedinparenthesisusingtheInternationalOrganizationforStandardization(ISO3166)two-charactercode(URL: http://www.commondatahub.com/live/geography/country/iso_3166_country_codes?gclid=CPSnst2e5KQCFQqP5god3xzd8A);Countriescolumnrepresentsthe numberwhereactivitieshavebeenimplemented;U.S.militarydeploymentsites(suchasIraq,Afghanistan)orU.S.DepartmentofStateembassiesdonot contributetoseparatecountrycounts,sincetheyrepresentoverseaslocationswhereU.S.forcesand/orciviliansaredeployedorstationed. **CENTCOM,U.S.CentralCommand(forwardU.S.troopdeploymentsites).Sanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page3of9

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Figure1 AFRIMSBSL-3LaboratoryCommissioning .OnSeptember16,2009(fromlefttoright),MajorGeneralKrisadaDuangurai,director generalofAFRIMS;U.S.AmbassadorEricJohn,togetherwithColonelJamesBoles,commanderofAFRIMS,officiatedtheribbon-cutting ceremonyfortheAFRIMSBSL-3laboratory.Thisfacilitysignificantlycontributestothecountry scapacitytoconductresearchandinvestigate outbreakscausedbyagents,suchasavianinfluenza,chikungunyavirusandotherendemicdiseasesthroughoutSoutheastAsia. Figure2 InfluenzaSurveillanceCapacity-BuildingInitiativewithGlobalViralForecastingInitiativeandUniversityofBuea,Cameroon. Twobiosafetylevel-2laboratorieswererenovatedattheCameroonArmyMilitaryHealthResearchCenterinYaoundandattheUniversityof Buea,incooperationwiththeCameroongovernmentandmilitary.Theselaboratorieshavethecapacitytoisolateandcharacterizehumanand animalinfluenzaviruses,aswellasotherEIDpathogensofunknownorigin. Sanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page4of9

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HealthLaboratoryandalsoestablishedreal-timereverse transcriptasepolymerasechainreaction(rRT-PCR)diagnosticcapacityforinfluenzaatamaintertiary-carehospitaloftheDepartmentofHealthwithintheVisayas regionofthePhilippines. Developinginfluenzadiagnosticcapabilitiesatother NICswasalsosupportedbytheU.S.NavalMedical ResearchUnitNo.3(NAMRU-3)inAfghanistan,Iraq andJordan;bytheU.S.NavalMedicalResearchCenter DetachmentinPeru(NMRCD-Peru)inthecountriesof Colombia,Ecuador,ParaguayandVenezuela;andin Kenya,bytheU.S.ArmyMedicalResearchUnit-Kenya. Finally,inconjunctionwiththeCDC sCentralAmerica andPanamacenter,theU.S.ArmyPublicHealthCommandRegion-South(PHCR-South)providedlaboratory technicalassistance,reagentsandsuppliestotheMinistriesofHealth(MoHs)inElSalvador,Guatemala,Honduras,NicaraguaandPanama,resultinginthe certificationoftheGuatemalanNICandthetestingof over5,000specimensfornovelA/H1N1. IncollaborationwiththePeruvianNavy,NMRCDPeruhasbuiltarobustshipboarddiseasesurveillance infrastructurewithdetectioncapabilitymodeledvery closelyontheNHRCshipboardsurveillancesystem. Theearlydetectionaspectofthissysteminvolves equippingparticipatingsh ipswithreal-timePCRdiagnosticcapabilityforemerging infectiousdiseases,such asinfluenzaoradenovirus.Short-termstorageofsamplesallowsformorein-depth,follow-uptestingatthe laboratoryinLimaoratothercollaboratingregional laboratories.Since2007,thissystemhassuccessfully identifiedandrespondedtonumerousoutbreaksof respiratory,gastrointestinalandsexuallytransmitted infectionsamongactive-dutyPeruvianpersonnel aboardships[12].Morerece ntly,thiscapabilitywas instrumentalinidentifyingandrespondingtoalarge outbreakofnovelA/H1N1onboardalargedeckship inthePacific[13]. Thisinvestmentinlaboratoryinfrastructuredevelopmenthasdirectlyimpactedthenumberofoutbreak investigationsthattheA FHSC-GEISnetworkhasbeen abletosupport.Thecapacity-buildingeffortscontributedtooutbreakresponsesin76instancesin53countries,representingeverymajorpopulatedregionofthe world,includingsupportfortheconfirmationofthe firstcasesofnovelA/H1N1in14countries(United States,Bhutan,Cambodia,Colombia,Djibouti,Ecuador, Egypt,Kenya,Kuwait,LaoPeople sDemocraticRepublic (PDR),Lebanon,Nepal,PeruandtheRepublicofthe Seychelles)[12].Thelaboratoryinfrastructureallowsfor acuteresponsecapabilityandtheabilitytomonitor ongoingepidemicsorshiftingEIDpatterns,suchasthe identificationandcontinued monitoringofartemisininresistantmalariainSoutheastAsiabypartnersfrom AFRIMS[14]andattheU.S.NavalMedicalResearch UnitNo.2(NAMRU-2)orthesearchforgeneticmutationswithininfluenzavirusesthatmayindicateresistancetoantiviralmedications.TrainingItisimportanttorecognizethatcapacitybuildingnot onlyinvolvesrenovatinglaboratoriesandprovidingdiagnosticequipmentandsupplies,butmostimportant, buildinghumancapacity.Throughtrainingpublichealth andlaboratorypersonnel,thephysicalinfrastructure couldbeproperlyleveragedforoptimalsupportofIHR (2005)compliance.During2009,AFHSC-GEISsupported18partnerorganizationsthatconducted123 traininginitiativesin40c ountriesinvolvingatleast 3,130people,includingmanyhost-countrypersonnel,in directsupportofassistingwithcompliancewithIHR (2005).Significantexpansionoftrainingactivitieswas attainedintheareasofpandemicpreparedness,outbreakinvestigationandresponse,EIDsurveillance,and pathogendiagnostictechniques. Byengaginglocalhealthandothergovernmentofficialsandcivilianinstitutionsintrainingendeavors,the U.S.military sroleasakeystakeholderinglobalpublic healthhasimproved;andmanyopportunitiesforEIDrelatedsurveillance,researchandcapacity-building initiativeshavebeenleveragedtoprovideaplatformfor publichealthtraining,descr ibedelsewhereinthissupplement[11].ElectronicsurveillanceinitiativesElectronicdiseasesurveilla nce,anotherimportantcomponentofacomprehensiveglobalpublichealthdisease preventionandcontrolstrategy,contributessignificantly tocapacitybuildingandsup portforIHR(2005)complianceinpartnercountries.Usingelectronicmethodsfor datacollectionandanalysishasthepotentialtoimprove theaccuracyandtimelinessofoutbreakdetection,aswell astoprovidesituationalawarenessduring,orinthe aftermathof,anoutbreakorpandemic.TheAFHSCGEISnetworkhassupportednumerousinitiativesin electronicdiseasesurveillanceduringthepastseveral years,inpartnershipwithseveralDoDoverseaslaboratories,host-countryMinistriesofHealthandDefense andourtechnicalpartner,theJohnsHopkinsUniversity AppliedPhysicsLaboratory(JHU/APL). AFHSC-GEIShasreliedontheextensiveexperience thatJHU/APLacquiredint hedesignandimplementationoftheElectronicSyndromicSurveillanceforEarly NotificationofCommunity-basedEpidemics(ESSENCE) system[15].Thiselectronicdiseasesurveillancesystem, usedworldwideatallDoDmilitarytreatmentfacilities (MTFs),theU.S.VeteransHealthAdministrationsystem andatleast12statesintheUnitedStates,servedasaSanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page5of9

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modelforatoolkitapproachtodeployingelectronic surveillancewithintheAFHSC-GEISnetwork.Tools havebeencreatedtoenabledatacollectionfromthe mostsophisticateddatasourcestoremotesettings wheredatahavetraditionallybeendifficult,ifnot impossible,tocollect.Thesetoolshavefar-reaching applicabilityinanyresour ce-limitedsetting,whether overseasorafteradisasterintheUnitedStates.Thefollowingdescribessomeoftheeffortsthathavefocused onadaptingelectronicorsyndromicsurveillancetechniquestoresource-limitedsettings. Twoelectronicsurveillanceeffortsweredevelopedat AFRIMSinSoutheastAsiaandoptimizedin2009,includingaprojectwiththeRoyalThaiArmy(RTA)inremote borderareas,aswellasapilotshortmessageservice (SMS)-basedprojectinthePhilippines,partofajoint effortwithJHU/APLandtheCebuCityHealthOffice (CHO).TheThaiUnit-BasedSurveillance(UBS)project commencedin2001andoriginallycoveredareasalongthe Thai-CambodiaborderwheretheThaiMoHdidnothave diseasesurveillancecapabilities.Theproject,developedby theRTAwithsupportfromAFRIMSandAFHSC-GEIS, reportsdiseasesinbothmilitaryandlocalcivilianpopulationsbyfaxingreportsorbyvoiceviamilitaryradio.In 2009,theThai-Myanmarborderareawasaddedandan additional497personnelweretrained.Version2.0ofthe UBSsimplifieddatacollectionfrom216symptomsand categorizationinto12syndromesthatareconsistentwith theThaiMoH sreportingrequirements.Thisupdated systemaddedquestionsaboutpoultryexposure,leptospirosis,novelA/H1N1infectionandchickungunyavirus infection.Althoughnomajoroutbreaksofdiseasewere detectedbythissystemin2009,itcontinuedtoprovide situationalawarenessfortheRTAandThaiMoH. Denguefeverposesasignificanthealththreatinthe Philippines.Currenthospital-basedsurveillanceishighly valid,butpoorlysuitedforrapididentificationofdengue hotspots becauseofdelaysassociatedwithlaboratory confirmation.Tocapturethisimportantdataforthe purposesofsurveillance,amorerapid,butlessspecific surveillancemethodwasimplementedandcomparedto thestandardsentinelsurveillancesystem.Thispilot studyimplementsandevaluatesasimpledenguesurveillanceprotocolusingSMStextmessagestosenddaily, person-baseddenguesurveillancedatafromlocalBarangayHealthCenters(BHCs)tothecityhealthoffice (CHO)inCebuCity.Thepilo tactivitywasoriginally establishedinfiveclinicsasofMarch2009,butwas sooninstitutedinallBHCsinthecity.BeginningJuly1, 2009,allBHCshavebeenidentifyingallpatientsreportingtoclinicwithfever.Eachday,BHCpersonnelsend thisinformationtotheCHO,creatingatextmessage foreachpatientwithfever.TheSMSmessagecontains thedateandclinicname,aswellasthepatient sname, age,genderandsymptoms.Themessageistransferred intoaMicrosoftAccessdatabase,cleaned,andstarting July2010,reviewedintheESSENCEDesktopEdition applicationtoidentifystatisticallysignificantincreasesin reportedfevercases. Meanwhile,NAMRU-2continuedtosupporttheoptimizationoftheEarlyWarningOutbreakRecognition System(EWORS)at11referenceandprovincialhospitalsintheLaoPDRallowinglocalMoHofficialsto monitortheimpactandburdenoftropicalandinfectiousdiseasesinthecountryinrealtime.TheCDCcurrentlyfundsmostoftheoperatingbudgetforEWORS inLaoPDR.Thesystem,jointlydevelopedbytheIndonesianMoHandNAMRU-2withAFHSC-GEISfunding, isalsobeingusedinIndonesiaasthenationalreporting system.EWORShasadditionallybeenusedinCambodia, PeruandVietnam,althoughitisnolongerinusein thesecountriesbecauselocalhealthauthoritiesfavored othersurveillancesystems. InSouthAmerica,NMRCD-Perusupportedmajor effortsinelectronicdiseasesurveillance,includingcontinuationandoptimizationofAlerta,apublic-private initiativethathasrevolutionizedsurveillanceforthePeruvianmilitaryduringthepastsevenyears.TheAlerta systemhasseenrecentexpansiontoallbranchesofthe Peruvianmilitary,aswellasadoptionbytheMoHofone othercountryintheregion Panama.Thissystemidentified17outbreaksduring2009,includinginfluenza,dengue,mumps,malaria,hepatitisAandrespiratorydisease. Finally,incollaborationwiththeJHU/APLgroup, NMRCD-Peruworkedtodevelopanelectronicsyndromicsurveillancesystembased onopen-sourcesoftware foruseinresource-limitedenvironments.Asaresult,the systemcanbesustainedwithoutcontinuedmajorinvestmentsorsoftwarelicensingfees.Thiseffortinvolvedthe developmentofinteractivev oiceresponsereporting,as wellasbuildingaweb-basedinfrastructureanddatabase onanopen-sourceversionoftheESSENCEsystem (OpenESSENCE)inuseintheU nitedStates.Additionally,NMRCD-Perusupportedthesystematicevaluation oftheseelectronicsurveillancesystemsandresearchon waystoimprovereportingviaelectronicsystems[16]. Theseelectronicsurveillanceinitiativesconstitutea vibrantportfoliothatcapitalizesontheexpertiseofthe JHU/APLgroupandnumerousAFHSC-GEISpartnersat overseaslaboratoriesandwithinhost-countryMinistries ofHealthandDefense.Manyofthelessonslearned,challenges,successesandfailureshavebeensharedwithin thisnetworkofcollaborators,andaharmonizedstrategy isemergingtodevelopandde ployanelectronicdisease surveillancesystemthatismodularandresponsiveto variousneedsfoundindevelopingsettings.This approachshouldassistmanycountriesincomplyingwith IHR(2005)bythe2012deadline.Sanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page6of9

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Provisionoftechnicalexpertise/reference laboratorysupportInadditiontosupportinglaboratoryinfrastructure developmentandnewsurveillanceinitiatives,AFHSCGEISprovidedtechnicalexpertiseinsupportofcapacity-buildingefforts.In2009,oneofthelargestsuch effortswasthenetwork sglobalresponsetothenovel A/H1N1influenz apandemic.Forexample,NAMRU-3 providedtrainingonlaboratorytechniquesfor73scientistsandtechnicalpersonnelfrom32countriesinwesternandnorthernAfrica,theMiddleEast,andcentral Asia,aswellasequipmentandreagentsupporttoestablishedNICsinEgypt,Kuwait,Oman,Pakistan,Sudan andSyria.Supportforfurther viralcharacterizationby geneticsequencingandantiviralresistancetestingwas alsoperformedatNAMRU-3,withreferencetesting supportbytheCDCinAtlanta.Thisvirologydiagnostic-testingcapacitybuildingofnationalreferencelaboratoriesconstitutedanessentialstepinestablishingthe capabilityforH5N1andnovelA/H1N1detectionand rapidresponse,andresultedinabetterunderstanding oftheepidemiologicpatternsofrespiratoryvirusescirculatingintheregion.Italsorepresentedthefirststep towardNICaccreditationandcollaborationwiththe WHOGlobalInfluenzaSurveillanceNetworkinsupport ofinfluenzavaccinedevelopment.Bylinkingcountries inregionalandsub-regionalnetworksandbyfostering participationinWHOmissionstoassesslaboratorytestingcapacityneeds,NAMRU-3playedadirectrolein promotingIHR(2005)compliance. WorkingcloselywithU.S.CentralCommandandU.S. AfricaCommand,NAMRU-3andtheU.S.NavyEnvironmentalandPreventiveMedicineUnitNo.2(NEPMU-2) providedfocusedlaboratoryassessment,training,emergencysuppliesandqualityassurancesupporttofivemilitary,far-forwarddeployed,influenzatestinglaboratoriesin SouthwestAsiaandassistedwiththedeploymentofthe JointBiologicalAgentIdentificationandDetectionSystem (JBAIDS)platformforconfirmationofnovelA/H1N1 casesin-theater.ThiscapabilitysubsequentlyprovedcriticalwhenExpeditionaryMedicalForcesinKuwaitand Djiboutiwereabletoidentifyandrespondtonovel A/H1N1andseasonalinfluenzaoutbreaks,respectively. Networkexpertiseandcompetencewereimportantin supportingglobalinfluenzatestingefforts.Forinstance, theAFRIMS-supportedlaboratoryinthePhilippines wasdesignatedbythePhilippineNICastheonlyother facilityauthorizedtoconductnovelA/H1N1testing,in supportofcentralandsouthernregionsofthecountry (specifically,MindanaoandVisayas).Military-to-military(mil-mil)partnershipsGrowingcollaborativemilitary-militarypartnershipsand surveillanceexchangesamongglobalnetworkpartners andforeignmilitarycounterpartscontinuedtobean areaofhighinterestandpriorityforAFHSC-GEIS.The networkcurrentlysupportsactivemilitarypartnerships in14countries.Thesepartn ershipsresultedinanumberofcollaborativeresponseactivitiesthatsupported foreignmilitarypartners,multinationalpeacekeepers andobserversinjointexercisesandmissions. Thelatespringandsummeroutbreaksofnovel A/H1N1inmilitarytreatmentfacilitiesthroughout EuroperesultedincollaborationbetweenLandstuhl RegionalMedicalCenterandPHCR-Europeandthe GermanMilitaryReferenceLaboratory.Thelong-standingrelationshipbetweentheU.S.EuropeanCommand andtheGermanArmy sPublicHealthServicehelped assistindisseminatingconfirmedresultsthroughweekly surveillancereportssenttomilitaryclinicians,hospital commanders,andotherpublichealthofficialswithinthe U.S.militaryandthelocalGermanpublichealthinfrastructure.ThisarrangementgreatlyaidedtheU.S. EuropeanCommand sabilitytoconductsurveillancefor novelA/H1N1withintheEuropeanmilitarycommunity andassistedGermangovernmentofficialsinmonitoring thelevelofdiseasewithintheircountry. Effortshavebeenestablishedtocollaborateonmore expansiveandcross-cuttingsurveillancesystemswithmilitarypartnersinPolandandSingapore.Theseefforts includeawidespectrumofsurveillancefromelectronic earlydetectionsystemsandroutinelaboratory-basedsentinelsurveillancetorobustpat hogendiscoveryinitiatives andfocusedpublichealthresearchendeavors.Collaboratively,theseeffortshavedevelopedsignificantlyduringthe pastyearandhavehelpedserveasamodelforother AFHSC-GEISpartnerstoengagetheirregionalforeign militarycounterparts.Thesemil-milpartnershipswith alliedcountriesallowforopencollaboration,capacity buildingandtransparentdialoguebetweenpartnercountries,andthushavethepotentialtodevelopameaningful frameworktobetterunderstanddiseasedynamicsamong militarypopulationsindifferentpartsoftheworld.To furtherfosteropportunitiesforthesemil-milpartnerships, AFHSC-GEISisworkingwiththeInternationalCongress onMilitaryMedicineandtheWHObyfacilitatingeducationalopportunitieswithregardtoIHR(2005)andcreationofaportfolioofrobustepidemiologicaltoolsand trainingthatmembercountriescanaccessasneeded[17].FuturedirectionsandchallengesSignificantprogresswasattainedinexpansionofworldwideEIDsurveillanceandresponseinitiativesinfiscal 2009throughthecapacity-buildingeffortsofthe AFHSC-GEISnetworkdescribedabove.Atthisjuncture, however,itisnecessarytoachieverealisticgoalsinterms ofmaturation,standardizationandunificationofthedivision sglobalsurveillanceefforts.ThiscanbestbeSanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page7of9

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accomplishedbypursuingthefollowingstrategicgoals: 1)adoptingobjectivemetricsofevaluation,suchastimelinessofdiseasedetectionandreportingtohigherlevels, proportionofsitessubmittingtimelyweeklyormonthly reports,proportionofinvestigatedoutbreakswithconfirmedlaboratoryresults,andproportionofconfirmed outbreakswithnationally recommendedpublichealth response[18];2)ensuringfuturestandardizationof geneticandmolecular-basedtestingplatforms(e.g.,PCRbasedassays)acrossthenetworkofpartners;3)establishingelectronicsequencedatar epositoriesformoreeffectiveinformationsharingwiththeCDC,WHOandlocal regionalhealthauthorities(especiallyforinfluenzaand otherrespiratorypathogens);4)continuingemphasison collaborativeworkwithhost-countrypartnersto empowerthemtoreachIHR(2005)capacity-building milestonesby2012;and,5)achievingstandardized reportingschemesforallAFHSC-GEISpartnersinthe areasofinfluenza,entericdiseases,febrileandvectorborneillnesses,sexuallytransmittedinfections,andantimicrobialresistancemonitoring.Inthismanner,the AFHSC-GEISnetworkwillcontinuetocontributetothe globaleffortsindiseasecontrolandpreventionthrough theDoD slaboratory-basedsurveillanceandbyenhancingharmonizationofeffortswithotherkeyUSGstakeholders,suchastheU.S.DepartmentofHealthand HumanServices,theU.S.AgencyforInternationalDevelopmentandtheU.S.DepartmentofState. Manychallengesexisttobuildingcapacityforpublic healthinresource-limitedsettings,includingachievingsustainabilityofeffortsaftersupportiswithdrawn,containing thedepartureofhighly-trained,capablescientistsafter training,andminimizingtheduplicationofeffortsamong multiplesponsoragencieswithintheUSGandwithother organizations.Datasovereigntyanddatasharingarealso keyissuesthatrequiretransparencyonthepartofboththe sponsorandrecipientinorder tooptimallyconductdisease surveillancethatsatisfiesthespiritofIHR(2005).Solutions tomanyofthesechallengesaresometimesdifficultandfrequentlyrequirecontinuousre-evaluationofbestofpractice solutionsforindividualsettings. Throughthedevelopmentofactive,mutuallysupportiverelationshipswithlocalhealthofficialsandtheestablishmentofimportantprotocol-drivenclinicaland laboratorysurveillanceprojects,AFHSC-GEISsupported scientistshavebecomerelevantstakeholderswithinhostcountrypublichealthcommunitiesandareabletocontinuetoworkinthecriticaldevelopmentofsurveillance, laboratoryandcommunicationsinfrastructurewithin partnercountries.InadditiontotheIHR(2005),the AFHSC-GEISglobalnetworkrecognizestherecently releasedNationalStrategyforCounteringBiological Threats(PPD-2)asanotherguidingframeworkforalignmentofourprogramwiththelargerUSGinitiatives[19], keepingthemaintenanceoftheU.S.military shealth (knownas ForceHealthProtection )asourunique nicheinthesettingofimprovingglobalpublichealth. Meaningfulpublichealthinitiativestakingplaceinany oneofthepartnercountrieswithintheAFHSC-GEIS globalnetworkmustaimforinc remental,albeitsustainable,developmentofcapacityonbehalfoftheirpartner hostcountriesanddosoinlinewiththespecificPPD-2 objectivesandIHR(2005)competencies.Inthismanner, smallimprovementsincapacity,improvedtestingabilities,andultimately,compliancewithreportingwilllead tobenefitsforthehealthofU.S.servicemembersandfor thehealthoftheworld.Acknowledgements #AFHSC-GEISCapacityBuildingWritingGroup : ClaraJWitt1,NishaNMoney1, JoelCGaydos1,JulieAPavlin2,RobertVGibbons2,RichardGJarman2,Mikal Stoner2,SanjayaKShrestha2,AngelaBOwens3,NaomiIioshi3,MiguelA Osuna3,SamuelKMartin4,ScottWGordon4,WallaceDBulimo4,Dr.John Waitumbi4,BerhaneAssefa4,JeffreyATjaden5,KennethCEarhart5,Matthew RKasper6,GaryTBrice6,WilliamORogers6,TadeuszKochel7,VictorAlberto Laguna-Torres7,JosefinaGarcia7,WhitneyBaker8,NathanWolfe9,Ubald Tamoufe9,CyrilleFDjoko9,JosephNFair9,JaneFrancisAkoachere10,Brian Feighner11,AnthonyHawksworth12,ChristopherAMyers12,WilliamG Courtney13,VictorAMacintosh13,ThomasGibbons13,ElizabethAMacias13, MaxGrogl14,MichaelTO Neil14,ArthurGLyons14,Huo-ShuHoung14, LeopoldoRueda14,AnitaMattero14,EdwardSekonde14,RosemarySang15, WilliamSang15,ThomasJPalys16,KurtHJerke16,MonicaMillard17,Bernard Erima17,DerrickMimbe17,DenisByarugaba18,FredWabwire-Mangen18, DannyShiau19,NatalieWells19,DavidBacon19,GeraldMisinzo20,Chesnodi Kulanga20,GeertHaverkamp20,YadonMtarimaKohi21,MatthewLBrown22, TerryAKlein22,MitchellMeyers22,RandallJSchoepp23,DavidANorwood23, MichaelJCooper24,JohnPMaza24,WilliamE.Reeves25,andJianGuan25. Theauthorswishtothankthenumerousindividualswhoperform surveillanceaspartoftheAFHSC-GEISglobalnetwork,includingall individualsintheMinistriesofHealthandMinistriesofDefenseofour partnernationswhoseeffortshavecontributedtothesuccessofthe network. Disclaimer Theopinionsstatedinthispaperarethoseoftheauthorsanddonot representtheofficialpositionoftheU.S.DepartmentofDefense,local countryMinistriesofHealth,AgricultureorDefense,orothercontributing networkpartners. Thisarticlehasbeenpublishedaspartof BMCPublicHealth Volume11 Supplement1,2011:DepartmentofDefenseGlobalEmergingInfections SurveillanceandResponseSystem(GEIS):anupdatefor2009.Thefull contentsofthesupplementareavailableonlineat http://www.biomedcentral.com/1471-2458/11?issue=S2. Authordetails1ArmedForcesHealthSurveillanceCenter,503RobertGrantAvenue,Silver Spring,MD20910,USA.2ArmedForcesResearchInstituteofMedical Sciences,315/6RajavithiRoad,Bangkok,Thailand10400.3U.S.ArmyPublic HealthCommandRegion-South,Building2472,SchofieldRoad,FortSam Houston,TX78234,USA.4U.S.ArmyMedicalResearchUnit-Kenya,U.S. Embassy,Attn:MRU,UnitedNationsAvenue,P.O.Box606,VillageMarket 00621Nairobi,Kenya.5NavalMedicalResearchUnitNumber3,Extensionof RamsesStreet,AdjacenttoAbbassiaFeverHospital,PostalCode11517, Cairo,Egypt.6NavalMedicalResearchUnitNumber2,Kompleks PergudanganDEPKESR.I.,JI.PercetakanNegaraIINo.23,Jakarta,10560, Indonesia.7NavalMedicalResearchCenterDetachment-Peru,CentroMedico Naval CMST, Av.VenezuelaCDRA36,Callao2,Lima,Peru.8Departmentof EnvironmentalandGlobalHealth,CollegeofPublicHealthandHealth Professions,UniversityofFlorida,PostOfficeBox100188,Gainesville,FL 32610,USA.9GlobalViralForecastingInitiative,OneSutterStreet,Suite600, SanFrancisco,CA94104,USA.10UniversityofBuea,DepartmentofSanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page8of9

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BiochemistryandMicrobiology,FacultyofScience,PostOfficeBox63,Buea, SouthWesternProvince,Cameroon.11JohnsHopkinsUniversityApplied PhysicsLaboratory,11100JohnsHopkinsRoad,MP2-160,Laurel,MD207236099,USA.12NavalHealthResearchCenter,140SylvesterRoad,SanDiego, CA92106,USA.13U.S.AirForceSchoolofAerospaceMedicine,PublicHealth andPreventiveMedicineDepartment,2513KennedyCircle,Building180, BrooksCity-Base,TX78235-5116,USA.14WalterReedArmyInstituteof Research,Building503,503RobertGrantAvenue,SilverSpring,MD209107500,USA.15KenyanMedicalResearchInstitute,MbagathiPostOfficeBox 54840,00200,Nairobi,Kenya.16LandstuhlRegionalMedicalCenter,CMR402, Box483,APOAE09180,USA.17MakerereUniversityWalterReedProject,Plot 42,NakaseroRoad,PostOfficeBox16524,Kampala,Uganda.18Makerere University,FacultyofVeterinaryMedicine&Medicine,PostOfficeBox16524, Kampala,Uganda.19NavyEnvironmentalandPreventiveMedicineUnit Number2,1887PowhatanStreet,Norfolk,VA23511-3394,USA.20PharmAccessFoundation,SkywayBuilding,ThirdFloor,PlotNumber149/ 32,CornerofOhioStreet/SokoineStreet,PostOfficeBox635,DaresSalaam, Tanzania.21TanzaniaPeople sDefenceForces,DefenceForcesHeadquarters MedicalServices,PostOfficeBox9203,DaresSalaam,Tanzania.22U.S.Army MedicalDepartmentActivity&65thMedicalBrigade,Korea,Unit15281,Box 769,APOAP96205-5281.23U.S.ArmyMedicalResearchInstituteofInfectious Diseases,DiagnosticSystemsDivision,1425PorterStreet,FortDetrick,MD 21702-5011,USA.24U.S.ArmyPublicHealthCommandRegion-Europe, Building3810,CMR402,Box808,APOAE09180.25U.S.ArmyPublicHealth CommandRegion-Pacific,Building715,CampZama,Japan,Unit45006,APO AP96343-5006. Competinginterests Tothebestknowledgeoftheauthors,therearenocompetinginterests. Published:4March2011 References1.WHO: InternationalHealthRegulations(2005). Geneva,Switzerland:World HealthOrganizationPress;,2nd2008. 2.UnitedStates.GovernmentAccountabilityOffice: GlobalHealth:U.S. AgenciesSupportProgramstoBuildOverseasCapacityforInfectious DiseaseSurveillance. Washington,D.C.:U.S.GovernmentAccountability Office;GAO-07-1186;2007. 3.LopezA,CaceresVM: CentralAmericaFieldEpidemiologyTraining Program(CAFETP):Apathwaytosustainablepublichealthcapacity development. Humanresourcesforhealth 2008, 6 :27. 4.WertheimHF,PuthavathanaP,NghiemNM,vanDoornHR,NguyenTV, PhamHV,SubektiD,HarunS,MalikS,RobinsonJ, etal : Laboratory capacitybuildinginAsiaforinfectiousdiseaseresearch:experiences fromtheSouthEastAsiaInfectiousDiseaseClinicalResearchNetwork (SEAICRN). PLoSMedicine 7(4) :e1000231. 5.McCoyD,KembhaviG,PatelJ,LuintelA: TheBill&MelindaGates Foundation sgrant-makingprogrammeforglobalhealth. Lancet 2009, 373(9675) :1645-1653. 6.EnglandR: TheGAVI,GlobalFund,andWorldBankjointfunding platform. Lancet 2009, 374(9701) :1595-1596. 7.KlarkowskiDB,OrozcoJD: MicroscopyqualitycontrolinMdecinsSans Frontiresprogramsinresource-limitedsettings. PLoSMedicine 7(1) : e1000206. 8.BerkelmanR,CassellG,SpecterS,HamburgM,KlugmanK: The Achilles heel ofglobaleffortstocombatinfectiousdiseases. ClinInfectDis 2006, 42(10) :1503-1504. 9.PettiCA,PolageCR,QuinnTC,RonaldAR,SandeMA: Laboratorymedicine inAfrica:Abarriertoeffectivehealthcare. ClinInfectDis 2006, 42(3) :377-382. 10.SchoubBD: SurveillanceandmanagementofinfluenzaontheAfrican continent. Expertreviewofrespiratorymedicine 4(2) :167-169. 11.OttoJL,BaligaP,SanchezJL,GrayGC,GriecoJ,LescanoAG, MothersheadJL,WagarEJ,BlazesDL: TrainingInitiativesWithinthe AFHSC-GlobalEmergingInfectionsSurveillanceandResponseSystem: SupportforIHR(2005). BMCPublicHealth 2010. 12.JohnsM,SanchezJ,BurkeR,VestK,PavlinJ,SchnabelD,TobiasS,TjadenJ, MontgomeryJ,FaixD, etal : Review:Agrowingglobalnetwork srolein outbreakresponse,2008-09. BMCPublicHealth 2010. 13.CDC: OutbreakofPandemicInfluenzaA(pH1N1)VirusonaPeruvian NavyShip 2009. Mmwr 2010, 59(6) 14.NoedlH,SeY,SchaecherK,SmithBL,SocheatD,FukudaMM: Evidenceof artemisinin-resistantmalariainwesternCambodia. TheNewEngland JournalofMedicine 2008, 359(24) :2619-2620. 15.LewisMD,PavlinJA,MansfieldJL,O BrienS,BoomsmaLG,ElbertY, KelleyPW: Diseaseoutbreakdetectionsystemusingsyndromicdatain thegreaterWashington,D.C.area. AmericanJournalofPreventiveMedicine 2002, 23(3) :180-186. 16.HuamanMA,Araujo-CastilloRV,SotoG,NeyraJM,QuispeJA, FernandezMF,MundacaCC,BlazesDL: Impactoftwointerventionson timelinessanddataqualityofanelectronicdiseasesurveillancesystem inaresourcelimitedsetting(Peru):Aprospectiveevaluation. BMCMed InformDecisMak 2009, 9 :16. 17.RussellKL,RubensteinJ,BurkeRL,VestKG,JohnsMC,SanchezJL,MeyerW, BlazesDL: GEISOverviewPaper. BMCPublicHealth 2010. 18.WHO: ProtocolfortheAssessmentofNationalCommunicableDisease SurveillanceandResponseSystems:GuidelinesforAssessmentTeams, WHO/CDS/CSR/ISR/2001.2. Geneva,Switzerland:WorldHealthOrganization Press;2001. 19.NationalSecurityCouncil: NationalStrategyforCounteringBiological Threats. TheWhiteHouse,Washington,D.C.;2009.doi:10.1186/1471-2458-11-S2-S4 Citethisarticleas: Sanchez etal .: Capacity-buildingeffortsbythe AFHSC-GEISprogram. BMCPublicHealth 2011 11 (Suppl2):S4. Submit your next manuscript to BioMed Central and take full advantage of: Convenient online submission Thorough peer review No space constraints or color gure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Sanchez etal BMCPublicHealth 2011, 11 (Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 Page9of9


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au ca yes id A1 snm Sanchezmi Lfnm Joseinsr iid I1 email Toti.Sanchez@us.army.mil
A2 JohnsCMatthewMatthew.C.Johns@us.army.mil
A3 BurkeLRonaldRonald.L.Burke@us.army.mil
A4 VestGKellyKelly.Vest@us.army.mil
A5 FukudaMMarkI2 Mark.M.Fukuda@us.army.mil
A6 YoonIn-KyuInKyu.Yoon@afrims.org
A7 LonChanthapChanthapl@afrims.org
A8 QuintanaMiguelI3 Miguel.Quintana@us.army.mil
A9 SchnabelCDavidI4 David.Schnabel@us.army.mil
A10 PimentelGuillermoI5 Guillermo.Pimentel@med.navy.mil
A11 MansourMoustafaMoustafa.Mansour.ctr.eg@med.navy.mil
A12 TobiasStevenI6 Steven.Tobias@yahoo.com
A13 MontgomeryMJoelI7 Joel.Montgomery@med.navy.mil
A14 GrayCGregoryI8 Gcgray@phhp.ufl.edu
A15 SaylorsKarenI9 KSaylors@gvfi.org
A16 NdipMLucyI10 Lndip@yahoo.com
A17 LewisSheriI11 Sheri.Lewis@jhuapl.edu
A18 BlairJPatrickI12 Patrick.Blair@med.navy.mil
A19 SjobergAPaulI13 Paul.Sjoberg@brooks.af.mil
A20 KuschnerARobertI14 Robert.Kuschner@us.army.mil
A21 RussellLKevinKevin.Russell4@us.army.mil
A22 BlazesLDavidDavid.Blazes@us.army.mil
A23 cnm the AFHSC-GEIS Capacity Building Writing GroupI15 I16 I17 I18 I19 I20 I21 I22 I23 I24 I25
insg
ins Armed Forces Health Surveillance Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
Armed Forces Research Institute of Medical Sciences, 315/6 Rajavithi Road, Bangkok, Thailand 10400
U.S. Army Public Health Command Region-South, Building 2472, Schofield Road, Fort Sam Houston, TX 78234, USA
U.S. Army Medical Research Unit-Kenya, U.S. Embassy, Attn: MRU, United Nations Avenue, P.O. Box 606, Village Market 00621 Nairobi, Kenya
Naval Medical Research Unit Number 3, Extension of Ramses Street, Adjacent to Abbassia Fever Hospital, Postal Code 11517, Cairo, Egypt
Naval Medical Research Unit Number 2, Kompleks Pergudangan DEPKES R.I., JI. Percetakan Negara II No. 23, Jakarta, 10560, Indonesia
Naval Medical Research Center Detachment-Peru, Centro Medico Naval “CMST,” Av. Venezuela CDRA 36, Callao 2, Lima, Peru
Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Post Office Box 100188, Gainesville, FL 32610, USA
Global Viral Forecasting Initiative, One Sutter Street, Suite 600, San Francisco, CA 94104, USA
University of Buea, Department of Biochemistry and Microbiology, Faculty of Science, Post Office Box 63, Buea, South Western Province, Cameroon
Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Road, MP2-160, Laurel, MD 20723-6099, USA
Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106, USA
U.S. Air Force School of Aerospace Medicine, Public Health and Preventive Medicine Department, 2513 Kennedy Circle, Building 180, Brooks City-Base, TX 78235-5116, USA
Walter Reed Army Institute of Research, Building 503, 503 Robert Grant Avenue, Silver Spring, MD 20910-7500, USA
Kenyan Medical Research Institute, Mbagathi Post Office Box 54840, 00200, Nairobi, Kenya
Landstuhl Regional Medical Center, CMR 402, Box 483, APO AE 09180, USA
Makerere University Walter Reed Project, Plot 42, Nakasero Road, Post Office Box 16524, Kampala, Uganda
Makerere University, Faculty of Veterinary Medicine & Medicine, Post Office Box 16524, Kampala, Uganda
Navy Environmental and Preventive Medicine Unit Number 2, 1887 Powhatan Street, Norfolk, VA 23511-3394, USA
PharmAccess Foundation, Skyway Building, Third Floor, Plot Number 149/32, Corner of Ohio Street/Sokoine Street, Post Office Box 635, Dar es Salaam, Tanzania
Tanzania People’s Defence Forces, Defence Forces Headquarters Medical Services, Post Office Box 9203, Dar es Salaam, Tanzania
U.S. Army Medical Department Activity & 65th Medical Brigade, Korea, Unit 15281, Box 769, APO AP 96205-5281
U.S. Army Medical Research Institute of Infectious Diseases, Diagnostic Systems Division, 1425 Porter Street, Fort Detrick, MD 21702-5011, USA
U.S. Army Public Health Command Region-Europe, Building 3810, CMR 402, Box 808, APO AE 09180
U.S. Army Public Health Command Region-Pacific, Building 715, Camp Zama, Japan, Unit 45006, APO AP 96343-5006
source BMC Public Health
supplement Department of Defense Global Emerging Infections Surveillance and Response System (GEIS): an update for 2009editor David L Blazesnote Reviewsurl http://www.biomedcentral.com/content/pdf/1471-2458-11-S2-info.pdfissn 1471-2458
pubdate 2011
volume 11
issue Suppl 2
fpage S4
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history pub date day 4month 3year 2011
cpyrt 2011collab Sanchez et al; licensee BioMed Central Ltd.This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.
bdy
Background
Capacity building, as it applies to health in this context, can be accomplished through strengthening health systems for delivery of medical care, pursuing medical research initiatives to answer important local or regional health questions, or supporting public health disease surveillance to prioritize which diseases are affecting relevant populations. Within this context, global public health capacity building can be defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. Disease surveillance is often the first step in improving public health because it attempts to quantify needs and allocate scarce assets in resource-limited settings, in addition to detecting potential outbreaks of disease.
Though not a new concept, capacity building has enjoyed renewed prominence as the world endeavors to meet requirements of International Health Regulations 2005 (IHR (2005)) abbrgrp
abbr bid B1 1
. Article 5 of the regulations requires that all countries be able to detect, assess, notify and report on public health issues of international significance and control any potential public health event of international concern by 2012. Some countries are capable now, but most are not and will not be compliant by the deadline unless a significant improvement in local capacity occurs. In general, for capacity building to be successful in the long term, efforts must not be undertaken quickly and need to be implemented through a concerted unified effort, achieving steady, sustainable and measurable progress over time, with the eventual goal being independence from the provider of the capability.
In 2007, the Government Accountability Office issued a report describing the global infectious disease capacity-building efforts of U.S. government (USG) entities
B2 2
. At the time, three USG entities were identified as providing capacity building for emerging infectious diseases (EID), including the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Agency for International Development and the Department of Defense’s Global Emerging Infections Surveillance and Response System (DoD-GEIS). Their efforts included laboratory-based disease surveillance, development and testing of diagnostics, and training such as Field Epidemiology Training Programs, the international version of the famed Epidemic Intelligence Service
B3 3
. Currently, many other USG agencies are engaged in building disease surveillance capacity, including the U.S. Department of State, the Defense Threat Reduction Agency and the U.S. National Institutes of Health
B4 4
. In addition, numerous state, non-state and non-governmental organizations, such as the Bill and Melinda Gates Foundation, the World Bank and Médecins sans Frontières, contribute substantially to capacity-building efforts around the world
B5 5
B6 6
B7 7
.
With the establishment of the Armed Forces Health Surveillance Center (AFHSC) in late 2008, the DoD-GEIS program was transitioned to a division and renamed “AFHSC-GEIS”; however, its mission of working to promote and facilitate national and international preparedness for EID was maintained. Strengthening of U.S. military and host-country disease surveillance and public health laboratory capacity represents a critical step for contributing to compliance with the IHR (2005) detection, reporting and response requirements. During 2009, capacity-building efforts were undertaken in a variety of formats, including enhancement of diagnostic capabilities, expansion of surveillance for militarily relevant infectious and tropical diseases, and deployment of electronic surveillance platforms. These efforts were coordinated with local host-country health officials and geographic Combatant Commands to ensure they addressed country and regional medical priorities as well as to ensure better surveillance and response to disease outbreaks and EID threats to U.S. forces abroad. These efforts focused on influenza and other respiratory diseases, malaria, dengue and other vector-borne illnesses, acute diarrheal diseases, antimalarial and antimicrobial resistance, sexually transmitted diseases, and bacterial wound infections.
Accomplishments
Laboratory infrastructure development
Capacity-building initiatives continued to represent a major component of AFHSC-GEIS contributions to worldwide EID surveillance and response activities. Inadequate laboratory capacity in developing countries has been termed the “Achilles’ heel” of global efforts to combat infectious diseases
B8 8
. Thus, many AFHSC-GEIS sponsored activities in capacity building were directed at improving existing infrastructure by renovating current laboratory facilities, furnishing new scientific equipment, and provisioning new or enhanced diagnostic testing systems at overseas U.S. DoD facilities, as well as U.S.-based, DoD influenza reference laboratories, which serve as regional reference laboratories, and host-country laboratories.
Efforts were coordinated with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government officials and institutions worldwide in 74 countries. A total of 52 National Influenza Centers (NICs) and other country-specific influenza and EID reference laboratories (44 civilian, eight military) were supported in 46 countries (Table tblr tid T1 1). The efforts included support to laboratories in eight regions of the world. Sub-Saharan (east, central and west) Africa were the regions with the most major laboratory capacity-building efforts (in 14 countries), consistent with the identified needs of this region relative to the world, especially as it relates to influenza
B9 9
B10 10
. Among all infrastructure and capacity-building projects (Table T2 2), the majority supported primarily human health entities (in 67 countries); however, projects also supported animal health entities for zoonotic diseases in eight countries. Training efforts are mentioned, but are presented in detail elsewhere in this supplement
B11 11
.
tbl Table 1caption 2009 Major Laboratory Capacity-Building Initiatives by Geographic Regiontblbdy cols 3
r
c left
b Geographic Region
Major Laboratory Capacity Building Initiative
center
Countries Supported
cspan
hr
Southeast Asia
NIC & military influenza lab equipment, reagent & training support; EID laboratory diagnostics & disease surveillance systems
Bhutan, Cambodia, Lao People’s Democratic Republic, Nepal, Singapore, Thailand
Far East
NIC & military influenza lab equipment & reagent support; EID lab proficiency & equipment support
Japan, Korea, Philippines
East & Central Africa
NIC & VHF lab equipment, reagent & training support; EID laboratory diagnostics
Cameroon, Kenya, Tanzania, Uganda
West Africa
NIC & MoH influenza lab equipment, reagent & training support; VHF lab diagnostics & military EID lab diagnostic testing capacity
Benin, Burkina Faso, Cote d’Ivoire, Ghana, Liberia, Mali, Niger, Nigeria, Sierra Leone, Togo
North Africa, Middle East & Southwest Asia
NIC lab equipment, reagent & training support
Afghanistan, Egypt, Iraq, Jordan, Kuwait, Oman, Pakistan, Sudan, Syria
Central Asia
EID & influenza lab equipment, reagent & training support
Azerbaijan, Georgia, Mongolia
Europe
Military & academic influenza lab equipment, reagent & training support
Poland, Romania
Central & South America
NIC & MoH influenza lab equipment, reagent & training support; leishmania military reference lab equipment, reagent & training support
Colombia, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Peru
tblfn
Acronyms: NIC, national influenza center; EID, emerging infectious diseases; VHF, viral hemorrhagic fever; MoH, Ministry of Health.
Table 22009 Capacity-Building Initiatives by Major Regional AFHSC-GEIS Supported Partners and Type5
Partner (see text)
Type of Infrastructure/Capacity Building*
Centers/Hospitals
Field Sites
Countries*
AFRIMS
Influenza & malaria/MDR labs (KH, PH); enteric & influenza lab upgrade (NP, TH); blood culture (NP); influenza testing (BT); influenza antiviral resistance (TH)
22
51
5
NAMRU-2
Malaria, FVBI, enteric, blood culture & AMR testing (KH); influenza & AFI testing (ID, KH, SG); surveillance data management (LA)
4
73
4
NAMRU-3
Influenza, blood culture & AMR testing (EG, JO); Influenza PCR/culture & antiviral resistance testing (32 countries); Joint Biological Agent Identification & Detection System (5 deployed US military sites-CENTCOM**); zoonotic disease & entomology (EG, DJ); AFI, blood/cerebrospinal spinal fluid culture & serology testing (AZ, GE); Leishmania PCR & culture (EG, LR); rotavirus testing (6 countries); cholera & other ADD testing (7 countries); FVBI testing (EG, DJ, AZ, GE)
37
42
34
NMRCD-Peru
Influenza PCR/culture & antiviral resistance testing support (10 countries); AFI & viral culture & serology testing (PE, BO, EC, PY); Leishmania PCR, MDR, urine/vaginal PCR-STIs, Rickettsial PCR & culture (PE); enteric culture, PCR & AMR testing (PE, EC, PY); Alerta electronic disease surveillance system (PE, PA, EC)
23
102
11
USAMRU-Kenya
Malaria/MDR, microscopy & PCR, rotavirus, cholera & other ADD testing, arboviral/VHF PCR & culture, AFIs, blood culture & serology testing, STIs culture (KE); influenza PCR, culture &genotyping (KE, UG, CM); influenza, AFI, FVBI, cholera & other ADDs (KE, TZ, NG)
7
69
5
PHCR-South
Influenza PCR, culture & indirect immunofluorescence assay (US, HN, SV, NI, GT, PA); malaria, Leishmania, & dengue PCR testing (HN)
4
7
6
Univ Iowa CEID
Respiratory & other zoonotic respiratory EID testing & epidemiology (US, TH, KH, NG, RO, MN)
6
~30
6
JHU/APL
Influenza military treatment facilities (PIPM) modeling (US); SMS text & ESSENCE Desktop edition system (PH); Open source Interactive Voice Recognition software surveillance (PE); OpenESSENCE website software surveillance (US, PE); SMS text (PH)
1
~125
3
Acronyms: MDR, multidrug resistance; FVBI, febrile & vector-borne illnesses; AMR, antimicrobial resistance; AFI, acute febrile illnesses (such as dengue, leptospirosis and zoonotic infections); PCR, polymerase chain reaction; ADD, acute diarrheal diseases (such as traveler’s diarrhea, campylobacter, shigellosis, salmonellosis); STIs, sexually transmitted infections, including it Neisseria gonorrhea; EID, emerging infectious diseases; PIPM, Pandemic Influenza Prevention Modeling; SMS, Short Message Service; ESSENCE, Electronic Syndromic Surveillance for Early Notification of Community-based Epidemics.
* Country names are displayed in parenthesis using the International Organization for Standardization (ISO 3166) two-character code (URL: http://www.commondatahub.com/live/geography/country/iso_3166_country_codes?gclid=CPSnst2e5KQCFQqP5god3xzd8A); Countries column represents the number where activities have been implemented; U.S. military deployment sites (such as Iraq, Afghanistan) or U.S. Department of State embassies do not contribute to separate country counts, since they represent overseas locations where U.S. forces and/or civilians are deployed or stationed.
** CENTCOM, U.S. Central Command (forward U.S. troop deployment sites).
One of the most notable AFHSC-GEIS accomplishments in fiscal 2009 was the establishment of two new biosafety level-3 (BSL-3) laboratory suites within DoD reference laboratories. The Armed Forces Research Institute of Medical Sciences (AFRIMS) in Bangkok, Thailand, completed the first laboratory, which the United States certified and commissioned on July 8, 2009. The suite was officially inaugurated September 16, 2009 and began immediately supporting work in avian and pandemic influenza monitoring, including culture and molecular sequencing capability (Figure figr fid F1 1). This BSL-3 laboratory constitutes the first DoD-certified laboratory of its kind in the region and provides the World Health Organization (WHO), Thailand and other countries in Southeast Asia with a much-needed high-containment capability to conduct research and assist with outbreaks involving select human and animal bacterial and viral strains.
fig Figure 1AFRIMS BSL-3 Laboratory Commissioningtext
AFRIMS BSL-3 Laboratory Commissioning. On September 16, 2009 (from left to right), Major General Krisada Duangurai, director general of AFRIMS; U.S. Ambassador Eric John, together with Colonel James Boles, commander of AFRIMS, officiated the ribbon-cutting ceremony for the AFRIMS BSL-3 laboratory. This facility significantly contributes to the country’s capacity to conduct research and investigate outbreaks caused by agents, such as avian influenza, chikungunya virus and other endemic diseases throughout Southeast Asia.
graphic file 1471-2458-11-S2-S4-1
The Naval Health Research Center (NHRC) opened a second BSL-3 (agriculture-enhanced) laboratory suite in late 2009. The facility allows work with zoonotic influenza strains submitted by AFHSC-GEIS partners around the world, including development of new virus neutralization testing capabilities against H5N1 and other highly pathogenic avian influenza strains. Additionally, two BSL-2 laboratories were also established at the Cameroon Army Military Health Research Center, supported by Global Viral Forecasting Initiative in Yaoundé and at the University of Buea (Figure F2 2). Both facilities will greatly improve the ability to conduct influenza and EID diagnostic work, as well as potentially advanced pathogen discovery work in hard-to-reach locations in Africa.
Figure 2Influenza Surveillance Capacity-Building Initiative with Global Viral Forecasting Initiative and University of Buea, Cameroon
Influenza Surveillance Capacity-Building Initiative with Global Viral Forecasting Initiative and University of Buea, Cameroon. Two biosafety level-2 laboratories were renovated at the Cameroon Army Military Health Research Center in Yaoundé and at the University of Buea, in cooperation with the Cameroon government and military. These laboratories have the capacity to isolate and characterize human and animal influenza viruses, as well as other EID pathogens of unknown origin.
1471-2458-11-S2-S4-2
Efforts were also undertaken to improve laboratory capability for global influenza surveillance and diagnosis, especially regarding the novel A/H1N1 influenza pandemic. To this end, AFRIMS established viral/bacterial pathogen culture and molecular diagnostic capability in their Nepal detachment to support the National Public Health Laboratory and also established real-time reverse transcriptase polymerase chain reaction (rRT-PCR) diagnostic capacity for influenza at a main tertiary-care hospital of the Department of Health within the Visayas region of the Philippines.
Developing influenza diagnostic capabilities at other NICs was also supported by the U.S. Naval Medical Research Unit No. 3 (NAMRU-3) in Afghanistan, Iraq and Jordan; by the U.S. Naval Medical Research Center Detachment in Peru (NMRCD-Peru) in the countries of Colombia, Ecuador, Paraguay and Venezuela; and in Kenya, by the U.S. Army Medical Research Unit-Kenya. Finally, in conjunction with the CDC’s Central America and Panama center, the U.S. Army Public Health Command Region-South (PHCR-South) provided laboratory technical assistance, reagents and supplies to the Ministries of Health (MoHs) in El Salvador, Guatemala, Honduras, Nicaragua and Panama, resulting in the certification of the Guatemalan NIC and the testing of over 5,000 specimens for novel A/H1N1.
In collaboration with the Peruvian Navy, NMRCD-Peru has built a robust shipboard disease surveillance infrastructure with detection capability modeled very closely on the NHRC shipboard surveillance system. The early detection aspect of this system involves equipping participating ships with real-time PCR diagnostic capability for emerging infectious diseases, such as influenza or adenovirus. Short-term storage of samples allows for more in-depth, follow-up testing at the laboratory in Lima or at other collaborating regional laboratories. Since 2007, this system has successfully identified and responded to numerous outbreaks of respiratory, gastrointestinal and sexually transmitted infections among active-duty Peruvian personnel aboard ships
B12 12
. More recently, this capability was instrumental in identifying and responding to a large outbreak of novel A/H1N1 on board a large deck ship in the Pacific
B13 13
.
This investment in laboratory infrastructure development has directly impacted the number of outbreak investigations that the AFHSC-GEIS network has been able to support. The capacity-building efforts contributed to outbreak responses in 76 instances in 53 countries, representing every major populated region of the world, including support for the confirmation of the first cases of novel A/H1N1 in 14 countries (United States, Bhutan, Cambodia, Colombia, Djibouti, Ecuador, Egypt, Kenya, Kuwait, Lao People’s Democratic Republic (PDR), Lebanon, Nepal, Peru and the Republic of the Seychelles)
12
. The laboratory infrastructure allows for acute response capability and the ability to monitor ongoing epidemics or shifting EID patterns, such as the identification and continued monitoring of artemisinin-resistant malaria in Southeast Asia by partners from AFRIMS
B14 14
and at the U.S. Naval Medical Research Unit No. 2 (NAMRU-2) or the search for genetic mutations within influenza viruses that may indicate resistance to antiviral medications.
Training
It is important to recognize that capacity building not only involves renovating laboratories and providing diagnostic equipment and supplies, but most important, building human capacity. Through training public health and laboratory personnel, the physical infrastructure could be properly leveraged for optimal support of IHR (2005) compliance. During 2009, AFHSC-GEIS supported 18 partner organizations that conducted 123 training initiatives in 40 countries involving at least 3,130 people, including many host-country personnel, in direct support of assisting with compliance with IHR (2005). Significant expansion of training activities was attained in the areas of pandemic preparedness, outbreak investigation and response, EID surveillance, and pathogen diagnostic techniques.
By engaging local health and other government officials and civilian institutions in training endeavors, the U.S. military’s role as a key stakeholder in global public health has improved; and many opportunities for EID-related surveillance, research and capacity-building initiatives have been leveraged to provide a platform for public health training, described elsewhere in this supplement
11
.
Electronic surveillance initiatives
Electronic disease surveillance, another important component of a comprehensive global public health disease prevention and control strategy, contributes significantly to capacity building and support for IHR (2005) compliance in partner countries. Using electronic methods for data collection and analysis has the potential to improve the accuracy and timeliness of outbreak detection, as well as to provide situational awareness during, or in the aftermath of, an outbreak or pandemic. The AFHSC-GEIS network has supported numerous initiatives in electronic disease surveillance during the past several years, in partnership with several DoD overseas laboratories, host-country Ministries of Health and Defense and our technical partner, the Johns Hopkins University Applied Physics Laboratory (JHU/APL).
AFHSC-GEIS has relied on the extensive experience that JHU/APL acquired in the design and implementation of the Electronic Syndromic Surveillance for Early Notification of Community-based Epidemics (ESSENCE) system
B15 15
. This electronic disease surveillance system, used worldwide at all DoD military treatment facilities (MTFs), the U.S. Veterans Health Administration system and at least 12 states in the United States, served as a model for a toolkit approach to deploying electronic surveillance within the AFHSC-GEIS network. Tools have been created to enable data collection from the most sophisticated data sources to remote settings where data have traditionally been difficult, if not impossible, to collect. These tools have far-reaching applicability in any resource-limited setting, whether overseas or after a disaster in the United States. The following describes some of the efforts that have focused on adapting electronic or syndromic surveillance techniques to resource-limited settings.
Two electronic surveillance efforts were developed at AFRIMS in Southeast Asia and optimized in 2009, including a project with the Royal Thai Army (RTA) in remote border areas, as well as a pilot short message service (SMS)-based project in the Philippines, part of a joint effort with JHU/APL and the Cebu City Health Office (CHO). The Thai Unit-Based Surveillance (UBS) project commenced in 2001 and originally covered areas along the Thai-Cambodia border where the Thai MoH did not have disease surveillance capabilities. The project, developed by the RTA with support from AFRIMS and AFHSC-GEIS, reports diseases in both military and local civilian populations by faxing reports or by voice via military radio. In 2009, the Thai-Myanmar border area was added and an additional 497 personnel were trained. Version 2.0 of the UBS simplified data collection from 216 symptoms and categorization into 12 syndromes that are consistent with the Thai MoH’s reporting requirements. This updated system added questions about poultry exposure, leptospirosis, novel A/H1N1 infection and chickungunya virus infection. Although no major outbreaks of disease were detected by this system in 2009, it continued to provide situational awareness for the RTA and Thai MoH.
Dengue fever poses a significant health threat in the Philippines. Current hospital-based surveillance is highly valid, but poorly suited for rapid identification of dengue ”hot spots” because of delays associated with laboratory confirmation. To capture this important data for the purposes of surveillance, a more rapid, but less specific surveillance method was implemented and compared to the standard sentinel surveillance system. This pilot study implements and evaluates a simple dengue surveillance protocol using SMS text messages to send daily, person-based dengue surveillance data from local Barangay Health Centers (BHCs) to the city health office (CHO) in Cebu City. The pilot activity was originally established in five clinics as of March 2009, but was soon instituted in all BHCs in the city. Beginning July 1, 2009, all BHCs have been identifying all patients reporting to clinic with fever. Each day, BHC personnel send this information to the CHO, creating a text message for each patient with fever. The SMS message contains the date and clinic name, as well as the patient’s name, age, gender and symptoms. The message is transferred into a Microsoft Access© database, cleaned, and starting July 2010, reviewed in the ESSENCE Desktop Edition application to identify statistically significant increases in reported fever cases.
Meanwhile, NAMRU-2 continued to support the optimization of the Early Warning Outbreak Recognition System (EWORS) at 11 reference and provincial hospitals in the Lao PDR allowing local MoH officials to monitor the impact and burden of tropical and infectious diseases in the country in real time. The CDC currently funds most of the operating budget for EWORS in Lao PDR. The system, jointly developed by the Indonesian MoH and NAMRU-2 with AFHSC-GEIS funding, is also being used in Indonesia as the national reporting system. EWORS has additionally been used in Cambodia, Peru and Vietnam, although it is no longer in use in these countries because local health authorities favored other surveillance systems.
In South America, NMRCD-Peru supported major efforts in electronic disease surveillance, including continuation and optimization of Alerta, a public-private initiative that has revolutionized surveillance for the Peruvian military during the past seven years. The Alerta system has seen recent expansion to all branches of the Peruvian military, as well as adoption by the MoH of one other country in the region—Panama. This system identified 17 outbreaks during 2009, including influenza, dengue, mumps, malaria, hepatitis A and respiratory disease.
Finally, in collaboration with the JHU/APL group, NMRCD-Peru worked to develop an electronic syndromic surveillance system based on open-source software for use in resource-limited environments. As a result, the system can be sustained without continued major investments or software licensing fees. This effort involved the development of interactive voice response reporting, as well as building a web-based infrastructure and database on an open-source version of the ESSENCE system (OpenESSENCE) in use in the United States. Additionally, NMRCD-Peru supported the systematic evaluation of these electronic surveillance systems and research on ways to improve reporting via electronic systems
B16 16
.
These electronic surveillance initiatives constitute a vibrant portfolio that capitalizes on the expertise of the JHU/APL group and numerous AFHSC-GEIS partners at overseas laboratories and within host-country Ministries of Health and Defense. Many of the lessons learned, challenges, successes and failures have been shared within this network of collaborators, and a harmonized strategy is emerging to develop and deploy an electronic disease surveillance system that is modular and responsive to various needs found in developing settings. This approach should assist many countries in complying with IHR (2005) by the 2012 deadline.
Provision of technical expertise/reference laboratory support
In addition to supporting laboratory infrastructure development and new surveillance initiatives, AFHSC-GEIS provided technical expertise in support of capacity-building efforts. In 2009, one of the largest such efforts was the network’s global response to the novel A/H1N1 influenza pandemic. For example, NAMRU-3 provided training on laboratory techniques for 73 scientists and technical personnel from 32 countries in western and northern Africa, the Middle East, and central Asia, as well as equipment and reagent support to established NICs in Egypt, Kuwait, Oman, Pakistan, Sudan and Syria. Support for further viral characterization by genetic sequencing and antiviral resistance testing was also performed at NAMRU-3, with reference testing support by the CDC in Atlanta. This virology diagnostic-testing capacity building of national reference laboratories constituted an essential step in establishing the capability for H5N1 and novel A/H1N1 detection and rapid response, and resulted in a better understanding of the epidemiologic patterns of respiratory viruses circulating in the region. It also represented the first step toward NIC accreditation and collaboration with the WHO Global Influenza Surveillance Network in support of influenza vaccine development. By linking countries in regional and sub-regional networks and by fostering participation in WHO missions to assess laboratory testing capacity needs, NAMRU-3 played a direct role in promoting IHR (2005) compliance.
Working closely with U.S. Central Command and U.S. Africa Command, NAMRU-3 and the U.S. Navy Environmental and Preventive Medicine Unit No. 2 (NEPMU-2) provided focused laboratory assessment, training, emergency supplies and quality assurance support to five military, far-forward deployed, influenza testing laboratories in Southwest Asia and assisted with the deployment of the Joint Biological Agent Identification and Detection System (JBAIDS) platform for confirmation of novel A/H1N1 cases in-theater. This capability subsequently proved critical when Expeditionary Medical Forces in Kuwait and Djibouti were able to identify and respond to novel A/H1N1 and seasonal influenza outbreaks, respectively.
Network expertise and competence were important in supporting global influenza testing efforts. For instance, the AFRIMS-supported laboratory in the Philippines was designated by the Philippine NIC as the only other facility authorized to conduct novel A/H1N1 testing, in support of central and southern regions of the country (specifically, Mindanao and Visayas).
Military-to-military (mil-mil) partnerships
Growing collaborative military-military partnerships and surveillance exchanges among global network partners and foreign military counterparts continued to be an area of high interest and priority for AFHSC-GEIS. The network currently supports active military partnerships in 14 countries. These partnerships resulted in a number of collaborative response activities that supported foreign military partners, multinational peacekeepers and observers in joint exercises and missions.
The late spring and summer outbreaks of novel A/H1N1 in military treatment facilities throughout Europe resulted in collaboration between Landstuhl Regional Medical Center and PHCR-Europe and the German Military Reference Laboratory. The long-standing relationship between the U.S. European Command and the German Army’s Public Health Service helped assist in disseminating confirmed results through weekly surveillance reports sent to military clinicians, hospital commanders, and other public health officials within the U.S. military and the local German public health infrastructure. This arrangement greatly aided the U.S. European Command’s ability to conduct surveillance for novel A/H1N1 within the European military community and assisted German government officials in monitoring the level of disease within their country.
Efforts have been established to collaborate on more expansive and cross-cutting surveillance systems with military partners in Poland and Singapore. These efforts include a wide spectrum of surveillance from electronic early detection systems and routine laboratory-based sentinel surveillance to robust pathogen discovery initiatives and focused public health research endeavors. Collaboratively, these efforts have developed significantly during the past year and have helped serve as a model for other AFHSC-GEIS partners to engage their regional foreign military counterparts. These mil-mil partnerships with allied countries allow for open collaboration, capacity building and transparent dialogue between partner countries, and thus have the potential to develop a meaningful framework to better understand disease dynamics among military populations in different parts of the world. To further foster opportunities for these mil-mil partnerships, AFHSC-GEIS is working with the International Congress on Military Medicine and the WHO by facilitating educational opportunities with regard to IHR (2005) and creation of a portfolio of robust epidemiological tools and training that member countries can access as needed
B17 17
.
Future directions and challenges
Significant progress was attained in expansion of worldwide EID surveillance and response initiatives in fiscal 2009 through the capacity-building efforts of the AFHSC-GEIS network described above. At this juncture, however, it is necessary to achieve realistic goals in terms of maturation, standardization and unification of the division’s global surveillance efforts. This can best be accomplished by pursuing the following strategic goals: 1) adopting objective metrics of evaluation, such as timeliness of disease detection and reporting to higher levels, proportion of sites submitting timely weekly or monthly reports, proportion of investigated outbreaks with confirmed laboratory results, and proportion of confirmed outbreaks with nationally recommended public health response
B18 18
; 2) ensuring future standardization of genetic and molecular-based testing platforms (e.g., PCR-based assays) across the network of partners; 3) establishing electronic sequence data repositories for more effective information sharing with the CDC, WHO and local regional health authorities (especially for influenza and other respiratory pathogens); 4) continuing emphasis on collaborative work with host-country partners to empower them to reach IHR (2005) capacity-building milestones by 2012; and, 5) achieving standardized reporting schemes for all AFHSC-GEIS partners in the areas of influenza, enteric diseases, febrile and vector-borne illnesses, sexually transmitted infections, and antimicrobial resistance monitoring. In this manner, the AFHSC-GEIS network will continue to contribute to the global efforts in disease control and prevention through the DoD’s laboratory-based surveillance and by enhancing harmonization of efforts with other key USG stakeholders, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.
Many challenges exist to building capacity for public health in resource-limited settings, including achieving sustainability of efforts after support is withdrawn, containing the departure of highly-trained, capable scientists after training, and minimizing the duplication of efforts among multiple sponsor agencies within the USG and with other organizations. Data sovereignty and data sharing are also key issues that require transparency on the part of both the sponsor and recipient in order to optimally conduct disease surveillance that satisfies the spirit of IHR (2005). Solutions to many of these challenges are sometimes difficult and frequently require continuous re-evaluation of best of practice solutions for individual settings.
Through the development of active, mutually supportive relationships with local health officials and the establishment of important protocol-driven clinical and laboratory surveillance projects, AFHSC-GEIS supported scientists have become relevant stakeholders within host-country public health communities and are able to continue to work in the critical development of surveillance, laboratory and communications infrastructure within partner countries. In addition to the IHR (2005), the AFHSC-GEIS global network recognizes the recently released National Strategy for Countering Biological Threats (PPD-2) as another guiding framework for alignment of our program with the larger USG initiatives
B19 19
, keeping the maintenance of the U.S. military’s health (known as “Force Health Protection”) as our unique niche in the setting of improving global public health. Meaningful public health initiatives taking place in any one of the partner countries within the AFHSC-GEIS global network must aim for incremental, albeit sustainable, development of capacity on behalf of their partner host countries and do so in line with the specific PPD-2 objectives and IHR (2005) competencies. In this manner, small improvements in capacity, improved testing abilities, and ultimately, compliance with reporting will lead to benefits for the health of U.S. servicemembers and for the health of the world.
Competing interests
To the best knowledge of the authors, there are no competing interests.
bm
ack
Acknowledgements
#AFHSC-GEIS Capacity Building Writing Group: Clara J Wittsup 1, Nisha N Money1, Joel C Gaydos1, Julie A Pavlin2, Robert V Gibbons2, Richard G Jarman2, Mikal Stoner2, Sanjaya K Shrestha2, Angela B Owens3, Naomi Iioshi3, Miguel A Osuna3, Samuel K Martin4, Scott W Gordon4, Wallace D Bulimo4, Dr. John Waitumbi4, Berhane Assefa4, Jeffrey A Tjaden5, Kenneth C Earhart5, Matthew R Kasper6, Gary T Brice6, William O Rogers6, Tadeusz Kochel7, Victor Alberto Laguna-Torres7, Josefina Garcia7, Whitney Baker8, Nathan Wolfe9, Ubald Tamoufe9, Cyrille F Djoko9, Joseph N Fair9, Jane Francis Akoachere10, Brian Feighner11, Anthony Hawksworth12, Christopher A Myers12, William G Courtney13, Victor A Macintosh13, Thomas Gibbons13, Elizabeth A Macias13, Max Grogl14, Michael T O’Neil14, Arthur G Lyons14, Huo-Shu Houng14, Leopoldo Rueda14, Anita Mattero14, Edward Sekonde14, Rosemary Sang15, William Sang15, Thomas J Palys16, Kurt H Jerke16, Monica Millard17, Bernard Erima17, Derrick Mimbe17, Denis Byarugaba18, Fred Wabwire-Mangen18, Danny Shiau19, Natalie Wells19, David Bacon19, Gerald Misinzo20, Chesnodi Kulanga20, Geert Haverkamp20, Yadon Mtarima Kohi21, Matthew L Brown22, Terry A Klein22, Mitchell Meyers22, Randall J Schoepp23, David A Norwood23, Michael J Cooper24, John P Maza24, William E. Reeves25, and Jian Guan25.
The authors wish to thank the numerous individuals who perform surveillance as part of the AFHSC-GEIS global network, including all individuals in the Ministries of Health and Ministries of Defense of our partner nations whose efforts have contributed to the success of the network.
Disclaimer
The opinions stated in this paper are those of the authors and do not represent the official position of the U.S. Department of Defense, local country Ministries of Health, Agriculture or Defense, or other contributing network partners.
This article has been published as part of BMC Public Health Volume 11 Supplement 1, 2011: Department of Defense Global Emerging Infections Surveillance and Response System (GEIS): an update for 2009. The full contents of the supplement are available online at http://www.biomedcentral.com/1471-2458/11?issue=S2.
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Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.
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BMC Public Health. 2011 Mar 04;11(Suppl 2):S4
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