Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic

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Title:
Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic
Series Title:
BMC Public Health
Physical Description:
Book
Language:
English
Creator:
Burke, Ronald L.
Vest, Kelly G.
Eick, Angelia A.
Sanchez, Jose L.
Johns, Matthew C.
Pavlin, Julie A.
Jarman, Richard G.
Mothershead, Jerry L.
Quintana, Miguel
Palys, Thomas
Cooper, Michael J.
Guan, Jian
Schnabel, David
Waitumbi, John
Wilma, Alisa
Daniels, Candelaria
Brown, Matthew L.
Tobias, Steven
Kasper, Matthew R.
Williams, Maya
Tjaden, Jeffrey A.
Oyofo, Buhari
Styles, Timothy
Blair, Patrick J.
Hawksworth, Anthony
Montgomery, Joel M.
Razuri, Hugo
Laguna-Torres, Alberto
Schoepp, Randal J.
Norwood, David A.
MacIntosh, Victor H.
Gibbons, Thomas
Gray, Gregory C.
Blazes, David L.
Russell, Kevin L.
AFHSC-GEIS Influenza Surveillance Writing Group
Publisher:
BioMed Central
Publication Date:

Notes

Abstract:
The Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supports and oversees surveillance for emerging infectious diseases, including respiratory diseases, of importance to the U.S. Department of Defense (DoD). AFHSC-GEIS accomplishes this mission by providing funding and oversight to a global network of partners for respiratory disease surveillance. This report details the system’s surveillance activities during 2009, with a focus on efforts in responding to the novel H1N1 Influenza A (A/H1N1) pandemic and contributions to global public health. Active surveillance networks established by AFHSC-GEIS partners resulted in the initial detection of novel A/H1N1 influenza in the U.S. and several other countries, and viruses isolated from these activities were used as seed strains for the 2009 pandemic influenza vaccine. Partners also provided diagnostic laboratory training and capacity building to host nations to assist with the novel A/H1N1 pandemic global response, adapted a Food and Drug Administration-approved assay for use on a ruggedized polymerase chain reaction platform for diagnosing novel A/H1N1 in remote settings, and provided estimates of seasonal vaccine effectiveness against novel A/H1N1 illness. Regular reporting of the system’s worldwide surveillance findings to the global public health community enabled leaders to make informed decisions on disease mitigation measures and controls for the 2009 A/H1N1 influenza pandemic. AFHSC-GEIS’s support of a global network contributes to DoD’s force health protection, while supporting global public health.

Record Information

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-S6
System ID:
AA00012387:00001

Full Text

PAGE 1

In response to the 2009 pandemic H1N1 influenza outbreak, the Kenya Ministry of Public Health and Sanitation (MoPHS) began implementing its influenza pandemic preparedness plans in mid May. The MoPHS consulted with o fficials from the AFHSC GEIS funded U.S. Army Medical Research Unit Kenya (USAMRU K) laboratory on preparedness, diagnostic and public outreach planning prior to implement ing the plan On June 29, 2009, the Centers for Disease Control and Prevention Kenya (CDC Kenya) and the AFHSC GEIS infl uenza program at USAMRU K jointly confirmed the first case of novel A/H1N1 in Kenya Working with the Kenya MoPHS personnel from the World Health Organization (WHO), CDC Kenya and USAMRU K developed case definitions, hospital response programs, risk commu nications messages, and laboratory testing algorithms for the pandemic. USAMRU K also assisted with the deployment of medical education training teams that traveled around the country to train 756 healthcare providers on matters relating to the pandemic H1N1 influenza outbreak. In tandem with its mandate as a regional laboratory, the Kenya National Influenza Centre (NIC), with the assistance of USAMRU K, also served as the r eference and diagnostic laboratory for pandemic influenza diagnosis for the R epublic of Seychelles and Republic of Somalia. Within three months of its introduction into Kenya, the novel A/H1N1 influenza virus had spread to many regions within the country ( Vignette Figure 1). In the first three months of the pandemic outbreak, 1 439 samples were sent to the NIC for diagnostic testing and 233 samples (16 percent ) tested positive for the novel A/H1N1 influenza. From May 1 to Oct 10, the Kenya NIC received 99 samples from suspected cases of novel A/H1N1 influenza in the Republic of Seychelles. Nearly half (46 percent ) of the specimens were positive for influenza. Among positive influenza cases, a majority (76 percent ) was novel

PAGE 2

A/H1N1. During this same period, the Kenya NIC received 10 samples from the Garowe Hospital in Somalia. Two specimens tested positive for the novel A/H1N1 virus and four tested positive for seasonal influenza A. By leveraging the previously developed capacity built in support of human influenza sentinel surveillance, USAMRU K and AFHSC GEIS supported the rapid diagnosis and response to the 2009 H1N1 influenza pandemic within the region, consistent with its global mandate and objectives.


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A2 VestGKellyKelly.Vest@us.army.mil
A3 EickAAngeliaAngie.Eick@us.army.mil
A4 SanchezLJoseToti.Sanchez@us.army.mil
A5 JohnsCMatthewMatthew.C.Johns@us.army.mil
A6 PavlinAJulieI2 Julie.Pavlin@afrims.org
A7 JarmanGRichardRichard.Jarman@afrims.org
A8 MothersheadLJerryI3 USNA1974@cox.net
A9 QuintanaMiguelI4 Miguel.Quintana@us.army.mil
A10 PalysThomasI5 Thomas.Palys1@us.army.mil
A11 CooperJMichaelI6 Michael.Cooper38@us.army.mil
A12 GuanJianI7 Jian.Guan@us.army.mil
A13 SchnabelDavidI8 DSchnabel@wrp-nbo.org
A14 WaitumbiJohnJWaitumbi@wrp-ksm.org
A15 WilmaAlisaI9 Alisa.R.Wilma@amedd.army.mil
A16 DanielsCandelariaTina.Daniels@us.army.mil
A17 BrownLMatthewI10 Matthew.Lee.Brown1@us.army.mil
A18 TobiasStevenI11 Steven.Tobias@yahoo.com
A19 KasperRMatthewKaspernamru2@yahoo.com
A20 WilliamsMayaWilliamsnamru2@yahoo.com
A21 TjadenAJeffreyI12 Jeffrey.Tjaden2@med.navy.mil
A22 OyofoBuhariBuhari.Oyofo@med.navy.mil
A23 StylesTimothyI13 Timothy.Styles@med.navy.mil
A24 BlairJPatrickI14 Patrick.Blair@med.navy.mil
A25 HawksworthAnthonyAnthony.Hawksworth@med.navy.mil
A26 MontgomeryMJoelI15 Joel.Montgomery@med.navy.mil
A27 RazuriHugoHugo.Razuri@med.navy.mil
A28 Laguna-TorresAlbertoAlberto.Laguna@med.navy.mil
A29 SchoeppJRandalI16 Randal.Schoepp@us.army.mil
A30 NorwoodADavidDavid.A.Norwood@us.army.mil
A31 MacIntoshHVictorI17 Victor.Macintosh@brooks.af.mil
A32 GibbonsThomasThomas.Gibbons@brooks.af.mil
A33 GrayCGregoryI18 Gcgray@phhp.ufl.edu
A34 BlazesLDavidDavid.Blazes@us.army.mil
A35 RussellLKevinKevin.Russell4@us.army.mil
A36 cnm AFHSC-GEIS Influenza Surveillance Writing GroupI19 I20 I21 I22 I23 I24
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
Center for Disaster and Humanitarian Assistance Medicine, Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
Public Health Region-South, Building 2472, Schofield Road, Fort Sam Houston, TX 78234, USA
Landstuhl Regional Medical Center, Department of Pathology and Area Laboratory Services, CMR 402, APO AE 09180, USA
Public Health Region-Europe, CMR 402, APO AE 09180, USA
Public Health Region-Pacific, Unit 45006, APO AE 96343, USA
U.S. Embassy, Attention: MRU, United Nations Avenue, Post Office Box 606, Village Market 00621 Nairobi, Kenya
Department of Defense Veterinary Food Analysis & Diagnostic Laboratory, 2472 Schofield Road, Suite 2630, Fort Sam Houston, TX 78234, USA
USAMEDDAC-Korea, Microbiology Section, Unit 15244, Box 459, APO AP 96205, USA
Naval Medical Research Unit Number 2, Kompleks Pergudangan DEPKES R.I., JI. Percetakan Negara II No. 23, Jakarta 10560, Indonesia
Naval Medical Research Unit No. 3, Extension of Ramses Street, Adjacent to Abbassia Fever Hospital, Postal Code 11517, Cairo, Egypt
U.S. Navy Environmental Preventive Medicine Unit No. 2, 1887 Powhatan Street, Norfolk, VA 23511, USA
Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106, USA
Naval Medical Research Center Detachment, Centro Medico Naval “CMST,” Av. Venezuela CDRA 36, Callao 2, Lima, Peru
U.S. Army Medical Research Institute of Infectious Diseases, Diagnostic Systems Division, 1425 Porter Street, Fort Detrick, MD 21702, USA
U.S. Air Force School of Aerospace Medicine, 2513 Kennedy Circle, Building 180, Brooks City Base, TX 78235, USA
Department of Environmental and Global Health, College of Public Health and Health Professions, University of Florida, Post Office Box 100188, Gainesville, FL 32610, USA
Walter Reed Army Institute of Research, Emerging Infectious Diseases Research Unit, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
Australian Army Malaria Institute, Gallipoli Barracks, Enoggera, QLD 4051, Australia
Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Road, Laurel, MD 20723, USA
U.S. Navy and Marine Corps Public Health Center, 620 John Paul Jones Circle, Suite 1100, Portsmouth, VA 23708, USA
Laboratory for Emerging Infectious Diseases, University of Buea, Post Office Box 63, Buea, Cameroon
Global Viral Forecasting Initiative, 1 Sutter, Suite 600, San Francisco, CA 94104, USA
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 S6
http://www.biomedcentral.com/1471-2458/11/S2/S6
xrefbib pubidlist pubid idtype pmpid 21388566doi 10.1186/1471-2458-11-S2-S6
history pub date day 4month 3year 2011
cpyrt 2011collab Burke 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.
abs
sec
st
Abstract
The Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supports and oversees surveillance for emerging infectious diseases, including respiratory diseases, of importance to the U.S. Department of Defense (DoD). AFHSC-GEIS accomplishes this mission by providing funding and oversight to a global network of partners for respiratory disease surveillance. This report details the system’s surveillance activities during 2009, with a focus on efforts in responding to the novel H1N1 Influenza A (A/H1N1) pandemic and contributions to global public health. Active surveillance networks established by AFHSC-GEIS partners resulted in the initial detection of novel A/H1N1 influenza in the U.S. and several other countries, and viruses isolated from these activities were used as seed strains for the 2009 pandemic influenza vaccine. Partners also provided diagnostic laboratory training and capacity building to host nations to assist with the novel A/H1N1 pandemic global response, adapted a Food and Drug Administration-approved assay for use on a ruggedized polymerase chain reaction platform for diagnosing novel A/H1N1 in remote settings, and provided estimates of seasonal vaccine effectiveness against novel A/H1N1 illness. Regular reporting of the system’s worldwide surveillance findings to the global public health community enabled leaders to make informed decisions on disease mitigation measures and controls for the 2009 A/H1N1 influenza pandemic. AFHSC-GEIS’s support of a global network contributes to DoD’s force health protection, while supporting global public health.
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Background
In response to the 1996 Presidential Directive (NSTC-7), the U.S. Department of Defense (DoD) established the Global Emerging Infections Surveillance and Response System (DoD-GEIS) in 1997, with the mission to monitor newly emerging and re-emerging infectious diseases (EIDs) among U.S. servicemembers and dependent populations abbrgrp
abbr bid B1 1
. Comparable to their global burden of disease, respiratory infections are responsible for 25 percent to 30 percent of both outpatient illness and hospitalizations among U.S. military personnel
B2 2
B3 3
. Influenza and adenovirus infections are among the etiologies that greatly contribute to morbidity and mortality in military members
B4 4
. During the 1918 influenza pandemic, the U.S. military experienced attack rates as high as 25 percent and case fatality rates averaging 5 percent (ranging from 1 percent to 8 percent)
B5 5
.
DoD-GEIS, a division of the Armed Forces Health Surveillance Center (AFHSC) since early 2008, centralized the coordination of DoD influenza and other respiratory disease surveillance efforts beginning in 1998. The program was expanded with 2006 congressional supplementary appropriations
B6 6
B7 7
B8 8
. Subsequent funding in 2007-2009 has maintained this effort. Today, AFHSC-GEIS provides direction, funding and oversight to a system that consists of a network of global partners, including approximately 500 sites in 70 countries (Figure figr fid F1 1).
fig Figure 1caption AFHSC-GEIS global influenza surveillance presence worldwide, as of May 2009.text
AFHSC-GEIS global influenza surveillance presence worldwide, as of May 2009.
graphic file 1471-2458-11-S2-S6-1
During the past four years (2006-2009), the AFHSC-GEIS influenza surveillance system increased support for avian and pandemic influenza preparedness to include activities in surveillance and response to newly identified strains and pandemics, such as H5N1 and the 2009 novel A/H1N1. By supporting global surveillance and directing response efforts, DoD serves as a sentinel for local epidemics and can assist in limiting disease transmission. An immediate focus of DoD is decreasing the impact of the novel A/H1N1 pandemic on the armed forces, including reducing recruit- and other training-associated illnesses and deaths, and controlling secondary viral and bacterial associated morbidity. These efforts are similar in intent to those undertaken at the time of the appearance of the new virus strain during the 1918 H1N1 pandemic when efforts were also made to reduce the impact of the virus on the military during World War I.
The AFHSC-GEIS influenza surveillance system plays a major role in the U.S. government’s (USG) contributions to the global surveillance of influenza viruses and contributes to the World Health Organization’s (WHO) Global Influenza Surveillance Network
B9 9
. Core components of the AFHSC-GEIS influenza surveillance system are a network of specialized diagnostic and reference laboratories in the continental United States, medical treatment facilities within the Military Health System, and five DoD overseas laboratories, along with their respective detachments. The system, built around networks of hub and satellite laboratories, comprises many joint ventures with host countries.
This article focuses on the 2009 activities and accomplishments of the AFHSC-GEIS laboratory-based network regarding global surveillance for respiratory diseases and responding to the novel A/H1N1 influenza pandemic. These activities are described relative to, and by means of, AFHSC-GEIS strategic goals: surveillance and response; training and capacity building; research, innovation and integration; and assessment and communication of value added.
2009 contributions
Surveillance and response
During April 2009, the first two U.S. cases of novel A/H1N1 were detected in two separate Naval Health Research Center (NHRC) surveillance projects supported by AFHSC-GEIS. In the first instance, NHRC investigators collected a specimen from a 10-year-old DoD dependent who had enrolled in a biomedical trial to test a new influenza diagnostic platform conducted at the Naval Medical Center, San Diego, Calif. Initial results by an external reference laboratory suggested an influenza A/untypable virus
B10 10
B11 11
. At the same time, a 9-year-old female from the U.S./Mexico border was sampled in a collaborative surveillance study with the Centers for Disease Control and Prevention’s (CDC) Border Infectious Disease Surveillance Project. NHRC determined infection from an influenza A/untyped virus. Further testing on the IBIS T5000 platform, which infers H and N types from multiple genomic signatures, indicated an influenza A/swine/H1 virus. Samples from both patients were shipped to the CDC for confirmation and characterization.
Shortly thereafter, the U.S. Air Force School of Aerospace Medicine (USAFSAM) detected two near simultaneous cases among military dependents in the San Antonio area. The WHO used three of the strains (A/California/7/2009, A/California/4/2009 and A/Texas/5/2009) as potential strains for the 2009 pandemic influenza vaccine. A/California/7/2009 was eventually selected as the seed strain
9
.
In addition to detecting several of the initial cases of novel A/H1N1 within the U.S., AFHSC-GEIS partner laboratories were instrumental in monitoring the global spread of the virus. The Armed Forces Research Institute of the Medical Sciences (AFRIMS) laboratory was the first to detect novel A/H1N1 virus in Nepal and Bhutan, while the Naval Medical Research Unit No. 2 (NAMRU-2) provided support for the initial confirmation on novel A/H1N1 in Cambodia and Lao People’s Democratic Republic. The U.S. Army Medical Research Unit-Kenya (USAMRU-K), another AFHSC-GEIS partner, supported initial laboratory confirmation for Kenya and the Republic of Seychelles, and the Naval Medical Research Center Detachment (NMRCD) identified the first cases in Peru and supported initial confirmation in Colombia and Ecuador. Additionally, NHRC diagnosed the first infection in Guam/Micronesia, and the Naval Medical Research Unit No. 3 (NAMRU-3) not only identified the first cases in Kuwait, but also confirmed outbreaks in Afghanistan, Bahrain, Djibouti, Egypt and Lebanon.
Results of AFHSC-GEIS-sponsored influenza surveillance sample testing were reported via host-nation collaborators to their respective ministries to ensure the ministries could make informed and timely decisions about influenza control. The AFHSC-GEIS network surveillance support of the 2009 influenza pandemic was instrumental in the timely tracking and monitoring of the virus. In recognition of AFHSC-GEIS support, the AFRIMS field laboratory in Cebu was made an official Philippine Department of Health testing laboratory, Public Health Command Region-South (PHCR-South) assisted the Guatemalan Ministry of Health Influenza laboratory in becoming a National Influenza Center (NIC), and the Peruvian Instituto Nacional de Salud (National Institute of Health) awarded a commendation medal to NMRCD for its support in the pandemic response.
In addition to the novel A/H1N1 pandemic support provided to foreign host nations, AFHSC-GEIS network partners continued to support influenza and respiratory disease surveillance among military recruits, active-duty servicemembers, and U.S. military beneficiaries. AFHSC-GEIS supported the timely surveillance and rapid diagnosis of circulating influenza and other respiratory viruses within our overseas military populations through its partners in Europe (PHCR-Europe and Landstuhl Regional Medical Center (LRMC)), Japan (PHCR-Pacific and Naval Hospital Yokosuka), and the Republic of Korea (Brian Allgood Army Community Hospital (BAACH)).
Although many network laboratories, such as LRMC and BAACH, could not confirm a novel A/H1N1 infection during the initial months of the pandemic, the facilities provided a strong presumptive diagnosis of novel A/H1N1 based on their findings of untypable influenza A infections. With AFHSC-GEIS support, BAACH became one of the first U.S. overseas laboratories capable of providing on-site diagnosis of novel A/H1N1 for U.S. military personnel and their families. Likewise, the ability of the Navy Environmental Preventive Medicine Unit No. 2, in collaboration with NAMRU-3, to stand up a novel A/H1N1 testing site in Kuwait on short notice also helped provide a timely diagnosis for deployed clinicians. In turn, this effort helped ease tensions between the U.S. military and host countries in Southwest Asia and the Middle East by allowing the rapid identification and subsequent isolation of infected individuals to reduce the likelihood of transmitting influenza virus to local civilians.
A significant challenge for AFHSC-GEIS partners in 2009 was the need to balance their novel A/H1N1 pandemic response with their ability to continue surveillance efforts for other influenza viruses and respiratory diseases (e.g., adenovirus), including potential zoonotic viruses. Over 50 percent of EIDs are zoonotic, including the H5N1 and 2009 novel A/H1N1 viruses
B12 12
. In 2009, AFRIMS and NAMRU-2 scientists, in collaboration with the University of Iowa’s Center for Emerging Infectious Diseases, further strengthened important research of the human-animal interface and epidemiology of influenza viruses by expanding established cohort-based studies and creating new ones in five countries (Cambodia, Mongolia, Nigeria, Romania and Thailand). The endeavor allowed researchers to examine risk factors and transmission patterns of influenza at the human-animal interface.
Likewise, USAMRU-K initiated similar surveillance work in Uganda and continued to conduct migratory bird surveillance to monitor and track the spread of highly pathogenic avian influenza (HPAI). NMRCD conducted similar migratory bird surveillance in Peru. In conjunction with the CDC, NAMRU-3 and NMRCD initiated population-based, influenza-like illness and severe acute respiratory illness surveillance efforts among hospital and community cohorts in Egypt and Peru, respectively (Figure F2 2).
Figure 2Naval Medical Research Center Detachment influenza surveillance activities in Peru during 2009.
Naval Medical Research Center Detachment influenza surveillance activities in Peru during 2009.
1471-2458-11-S2-S6-2
Finally, AFHSC-GEIS partners provided laboratory diagnosis for 37 of the 52 (71 percent) reported cases of human H5N1 infection worldwide in 2009
3
. NAMRU-3, serving as the WHO’s Eastern Mediterranean Regional Influenza Reference Center (EMRO), provided laboratory diagnosis for 36 of 38 (95 percent) of reported cases of human H5N1 infection in Egypt, and NAMRU-2 identified an additional case in Cambodia
B13 13
.
Training and capacity building
Although these initiatives are more fully addressed in other articles within this supplement, the strategic goal of training and capacity building was a significant focus of AFHSC-GEIS influenza funding
B14 14
B15 15
. Nearly all AFHSC-GEIS partners assisted with training and capacity building programs. While the primary objective of these programs is to develop and strengthen global surveillance capacity, the endeavors have the added benefit of improving USG civil-military and military-military relations with host nations. AFHSC-GEIS provided funding to the Center for Disaster and Humanitarian Assistance Medicine at the Uniformed Services University to conduct 14 training sessions for 36 countries. A total of 885 individuals attended the training in support of U.S. Combatant Command partnerships with priority nations.
AFHSC-GEIS funding also supported the Kenyan NIC designation in late 2009 as the WHO East Africa regional influenza laboratory through the assistance of USAMRU-K. Within three months of the novel A/H1N1 virus introduction into the region, the Kenyan NIC received and tested over 1,500 influenza samples from Kenya, Republic of Seychelles and Somalia (Additional File supplr sid S1 1). While serving as the WHO’s EMRO reference laboratory, NAMRU-3 supported the development of NICs in Afghanistan, Iraq and Jordan, and the sustainment of NICs in Egypt, Kuwait, Oman, Pakistan, Sudan and Syria. In response to the 2009 influenza pandemic, NAMRU-3 also worked closely with the WHO to train over 70 participants from 32 countries in North/West Africa, Central Asia, and the Middle East on real-time reverse transcriptase polymerase chain reaction (rRT-PCR) using the CDC H1N1 assay kits. In the Lao People’s Democratic Republic, initial cases of A/H1N1 were tested at the National Center for Laboratory and Epidemiology using equipment and supplies furnished by NAMRU-2 and AFHSC-GEIS funding. All of these efforts helped strengthen the global public health community.
suppl
Additional File 1
b AFHSC-GEIS supports pandemic H1N1 influenza outbreak response in Kenya and East Africa. Figure Laboratory-confirmed cases of novel A/H1N1 influenza in Kenya, as of Oct. 8, 2009.
name 1471-2458-11-S2-S6-S1.docx
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Research, innovation and integration
One of the primary focus areas within the strategic goal of research, innovation and integration is the development of rapidly deployable, field-expedient diagnostic platforms for influenza. Although they generally have a high specificity, point-of-care tests have a poor sensitivity for influenza, especially the 2009 novel A/H1N1 virus
B16 16
. Moreover, while these tests can distinguish between influenza A and B viruses, they are rarely able to subtype specific viruses.
During 2009, AFHSC-GEIS supported the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) and the Chemical Biological Medical Systems-Joint Program Management Office transition of the CDC H5N1 and novel H1N1 assays to the Joint Biological Agent Identification and Diagnostic System (JBAIDS). The system had been developed as a ruggedized PCR platform for field identification of priority pathogens of interest. During 2009, USAMRIID successfully optimized and tested the CDC H5N1 assays, and the data will be used in a DoD-sponsored 510K application to the Food and Drug Administration (FDA) for use on the JBAIDS in the future.
In addition, USAMRIID and NHRC successfully optimized the CDC H1N1 assay for use on the JBAIDS platform, and DoD submitted a request to the FDA to extend the current H1N1 Emergency Use Authorization for the JBAIDS H1N1 pandemic influenza assay. The FDA commissioner signed the request on Aug. 24, 2009. As a result, DoD now has the capability to provide a timely clinical diagnosis of novel A/H1N1 in U.S. servicemembers and civilians in deployed and field settings, and is well positioned to extend this capability to include H5N1 influenza diagnosis (Additional File S2 2).
Additional File 2
Deployment of the JBAIDS for diagnosis of novel A/H1N1 influenza in the deployed operations. Figure Use of the JBAIDS for diagnosis of the novel A/H1N1 influenza virus in a deployed setting.
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In addition to the CDC H5N1 assays, AFHSC-GEIS also supported FDA approval of a rapid avian H5N1 influenza test (Arbor Vita Corp., AVantage™) using NHRC clinical trial data and validation of the National Veterinary Service Laboratory assay for the AI matrix, H5N1 and H7N3 strains on the JBAIDS by the DoD Veterinary Food Analysis and Diagnostic Laboratory at Fort Sam Houston, Texas. These capabilities will help to further increase DoD’s capacity for HPAI surveillance and outbreak response in remote settings.
In 2009, AFHSC-GEIS also sought to integrate influenza full genome sequencing within DoD. To this end, the Walter Reed Army Institute of Research (WRAIR) established full-length and ultra-deep, high-throughput genome sequencing. Twenty-six viruses (two seasonal A/H1N1, two A/H3N2, and 22 novel A/H1N1) from six countries were fully sequenced and submitted to GenBank. In turn, this sequencing provided valuable information on current viral mutations to DoD and the global public health community.
Assessment and communication of value added
By utilizing data from the Defense Medical Surveillance System, AFHSC conducts assessments on influenza activity, safety of the novel A/H1N1 influenza vaccine and effectiveness of influenza vaccine. Influenza activity among all DoD beneficiaries is monitored weekly and summarized in a weekly report disseminated to service-specific public health centers, preventive medicine physicians and DoD leadership. In addition, AFHSC-GEIS generates a weekly summary of all influenza surveillance reports from DoD laboratories, service-specific public health centers, Combatant Commands and other AFHSC-GEIS partners. The weekly report is posted on the DoD Pandemic Influenza Watchboard (http://fhpr.osd.mil/aiWatchboard/). Both reports are valuable in providing DoD decision makers and global public health leaders with a timely and succinct accounting of influenza activity, severity and geographic distribution.
AFHSC has also partnered with the Military Vaccine Agency, CDC and FDA to provide weekly safety assessments of the novel A/H1N1 influenza vaccine among active component servicemembers. AFHSC provides the only data within DoD for this collaboration. As a result, the center plays a valuable role in the country’s assessment of the safety of this vaccine.
Each year, AFHSC-GEIS conducts mid-season assessments of the effectiveness of the seasonal vaccines, and during 2010, will examine the effectiveness of the novel A/H1N1 influenza vaccine. Initial estimates of seasonal vaccine effectiveness against novel A/H1N1-associated illness have been presented at scientific meetings and have been published.
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Mid-season evaluations generated in January and February 2010 aimed to provide crucial information to the Vaccine and Related Biologic Products Advisory Committee and the public health community at large.
Additionally, network partners at NHRC and USAFSAM also evaluate vaccine effectiveness among important subpopulations throughout DoD. NHRC has established a framework for evaluating influenza vaccine effectiveness among basic military trainees that has served as a valuable tool in the larger effort to monitor this important indicator. USAFSAM works diligently each season to identify and molecularly analyze viruses from cases considered potential vaccine breakthroughs (e.g., cases occurring ≥14 days after vaccination) as determined by the surveillance questionnaire data collected as part of routine sentinel surveillance. The Defense Department is well positioned to determine the overall effectiveness of both seasonal and pandemic vaccines in military populations. However, results of these evaluations may not be generalizable to the population at large, given the young, healthy and highly vaccinated nature of military populations. This function is viewed favorably and of great value to the vaccine and public health communities.
Discussion
Although many goals were accomplished during this past year, the novel A/H1N1 influenza virus pandemic of 2009 presented unique management challenges for AFHSC-GEIS and its network of partners. The first significant problem centered on “sensitivity” in terms of reporting cases to host-country health authorities, while simultaneously providing U.S. military and civilian health agencies with the reports. Although the identification of cases was important, many host-country officials perceived that reporting of cases could be detrimental to their economy or community. In tandem with the high visibility of reports, laboratory testing associated with the large increase in processing specimens presented a challenge in terms of local and regional expectation of timely results that each partner needed to address. The consolidation of testing results was found to be challenging, thus, the authors see a pressing need for standardization of reporting in the future. Other challenges occurred in terms of achieving effective ongoing strain-sequencing analysis and reporting to CDC and WHO officials. Lastly, given the high volume of testing required during a pandemic, the program must take a closer look at changing the paradigm of testing whereby only a representative portion (i.e., 10 percent to 20 percent), instead of every sample, is given priority. For example, researchers could test severe cases (e.g., SARI, hospitalized, pneumonia) to more effectively provide reliable estimates of the virus’ impact.
A primary focus of the AFHSC-GEIS influenza surveillance system in 2010 is the continued monitoring and tracking of novel A/H1N1 virus for changes in severity, antiviral resistance or transmissibility, particularly in our special populations (e.g., recruits, deployed and shipboard personnel) within the military. Sentinel-based surveillance by our partners (e.g., USAFSAM, LRMC, BAACH) will continue to remain a key component of the surveillance program, as will the population-based surveillance at eight of 10 military recruit-training centers and the Pacific Rim Surveillance at Naval Hospital Yokosuka by NHRC.
To expand DoD’s surveillance efforts within the Military Health System, AFHSC-GEIS is partnering with the Infectious Disease Clinical Research Program to establish an acute respiratory infection consortium at several large DoD medical treatment facilities. This group will examine the pandemic’s impact on the U.S. military health care population and evaluate the effectiveness of potential intervention measures, including vaccine-specific effectiveness and non-vaccine interventions, such as hand washing, febrile screening, cohorting and recruit space allocation.
Besides continued surveillance within DoD, AFHSC-GEIS partners are fostering and developing new relationships for surveillance within other military populations to expand the center’s global surveillance program and enhance its contribution to global public health. Examples of potential future collaborations include NMRCD partnerships with Bolivia and Ecuador; AFRIMS surveillance in Vietnam; NAMRU-3 development of a veterinary and human influenza surveillance network in western Africa with Burkina Faso, Cote d’Ivoire and Ghana armed forces; establishment of a central African military alliance by the Global Viral Forecasting Initiative in Cameroon; and expansion of DoD and foreign military influenza and EID surveillance efforts in East Africa (Kenya, Tanzania and Uganda) and Central America (El Salvador, Guatemala and Honduras). Further expansion of AFHSC-GEIS-sponsored partnerships with Ministries of Health will also be explored (e.g., by PHCR-South in Central America) to provide improved surveillance in regions of the world where surveillance is lacking or inadequate.
Surveillance of zoonotic influenza will become more focused in 2010. While waterfowl, especially ducks and geese, can be infected and shed many subtypes of influenza A viruses, viral presence in these species does not necessarily imply a risk to humans due to the potential for species-specific strains and especially a lack of human exposure to the waterfowl necessary for transmission
B18 18
. As a result, instead of focusing on migratory birds, AFHSC-GEIS will concentrate on those areas, such as live-bird markets, abattoirs and large breeding farms, and occupations, such as backyard agricultural workers, where individuals are more likely to be exposed to animals, thus selecting a subset that is at much higher risk of infection with, and transmission of, zoonotic influenza strains.
Finally, AFHSC-GEIS will seek to expand DoD’s capability to analyze and characterize viruses in-house. In 2009, AFHSC-GEIS funding was used to equip several laboratories with antiviral resistance testing capacity (genotypically by pyrosequencing and phenotypically by inhibition in culture). The capability will be further developed in the future. Likewise, WRAIR’s genomic sequencing capacity and throughput will also increase. Additionally, funding will be provided to expand the JBAIDS influenza capability from novel A/H1N1 and H5N1 to include pan-influenza A, pan-influenza B, H1 seasonal and H3 seasonal viruses.
Conclusions
The 1996 Presidential Directive charged the U.S. DoD with monitoring EIDs in the military population. The directive led to creation of the AFHSC-GEIS influenza surveillance system, which strives to be a valuable asset to DoD and the global public health community. Its specimen catchment area includes regions noted for their regular contribution to global strain circulation, such as Southeast Asia, as well as South America, Africa and the Middle East, where strain circulation information is limited.
During 2009, the AFHSC-GEIS influenza and respiratory disease surveillance network not only detected the first cases of novel A/H1N1 among U.S. military beneficiaries, but also detected the first laboratory-confirmed cases within the United States and many countries throughout the world
B19 19
. In addition to its EID surveillance, the network also assisted with providing a rapid global response to the 2009 influenza pandemic through training and capacity-building efforts with partner nations, developing new surveillance and diagnostic platforms, and timely reporting of surveillance results and disease trends to public health authorities such as the CDC and WHO.
This extensive network is positioned to detect the emergence of new respiratory pathogens or significant mutations in the novel A/H1N1 2009 influenza virus as they transpire. The projects and initiatives in 2010 and beyond will help to further strengthen and maintain this network, and ultimately contribute to the sustainment of force health protection and global public health.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
RLB was responsible for oversight and management of the AFHSC-GEIS Avian and Pandemic Influenza Department and drafted the manuscript. KGV, MCJ and JLS were responsible for regional oversight and management within the AFHSC-GEIS Avian and Pandemic Influenza Department. AAE was responsible for analysis of influenza trends within the U.S. DoD. JAP and RGP provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at AFRIMS. JLM was responsible for program management of the CDHAM pandemic influenza training support to U.S. Combatant Commands. MQ provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at PHCR-South. TP and MJC provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at LRMC and PHCR-Europe. JG provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at PHCR-Pacific. DS and JW provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at USAMRU-K. AW and CCD were responsible for optimizing the avian H5 panel for use on the JBAIDS platform. MLB provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at BAACH. ST, MRK and MW provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at NAMRU-2. JAT and BO provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at NAMRU-3. PJB and AH provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at NHRC. JMM, HR and AL provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at NMRCD. RJS and DAN were responsible for optimizing the H5N1 assay for use on the JBAIDS platform. VHM and TG provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at USAFSAM. TS provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at Navy Environmental and Preventive Medicine Unit-2. GCG provided oversight and conducted AFHSC-GEIS respiratory disease surveillance at the University of Iowa. DLB was responsible for oversight and management of AFHSC-GEIS operations and developed the reporting format. KLR was the director of DoD GEIS and provided oversight and direction of its surveillance activities.
bm
ack
Acknowledgements
#AFHSC-GEIS Influenza Surveillance Writing Group: Jennifer Rubensteinsup 1, Kyle Hathaway2, Robert Gibbons2, In-Kyu Yoon2, David Saunders2, Jariyanart Gaywee2, Mikal Stoner2, Ans Timmermans2, Sanjaya K Shrestha2, John Mark S Velasco2, Maria T Alera2, Darunee Tannitisupawong2, Khin Saw Myint2, Sathit Pichyangkul2, Ben Woods3, Kurt H Jerke5, Michael G Koenig5, Denis K Byarugaba8, Fred Wabwire Mangen8, Berhane Assefa8, Maya Williams11, Gary Brice11, Moustafa Mansour12, Guillermo Pimentel12, Peter Sebeny12, Maha Talaat12, Tamer Saeed12, Ben Espinosa13, Dennis Faix14, Ryan Maves15, Tadeusz Kochel15, James Smith17, Alicia Guerrero17, Gen Maupin17, Paul Sjoberg17, Mark Duffy17, Jason Garner17, Linda Canas17, Elizabeth Macias17, Robert A Kuschner19, Dennis Shanks20, Sheri Lewis21, Gosia Nowak22, Lucy M Ndip23, Nathan Wolfe24, Karen Saylors24
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.
This article has been published as part of it 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.
refgrp Presidential Decision Directive NSTC-7ClintonWJpublisher The White House1996Acute respiratory disease in the militaryGrayGCFederal Practioner19951227lpage 33Recent trends of pneumonia morbidity in U.S. Naval personnelPazzagliaGPasternackMMil Med198314886476516415517Respiratory diseases among U.S. military personnel: countering emerging threatsGrayGCCallahanJDHawksworthAWFisherCAGaydosJCEmerg Infect Dis19995337938510.3201/eid0503.990308pmcid 264076410341174Interactions between influenza and bacterial respiratory pathogens: implications for pandemic preparednessBrundageJFThe Lancet infectious diseases20066530331210.1016/S1473-3099(06)70466-2link fulltext 16631551The Department of Defense laboratory-based global influenza surveillance systemCanasLCLohmanKPavlinJAEndyTSinghDLPandeyPShresthaMPScottRMRussellKLWattsDetal Mil Med20001657 Suppl 2525610920641A commentary on the military role in global influenza surveillanceKelleyPWAm J Prev Med200937326026110.1016/j.amepre.2009.06.00319666164Department of Defense Global Laboratory-Based Influenza Surveillance: 1998-2005OwensABCanasLCRussellKLNevilleJSPavlinJAMacIntoshVHGrayGCGaydosJCAm J Prev Med200937323524110.1016/j.amepre.2009.04.02219666159Influenza and respiratory disease surveillance: the U.S. military's global laboratory-based networkSuekerJJBlazesDLJohnsMCBlairPJSjobergPATjadenJAMontgomeryJMPavlinJASchnabelDCEickAAInfluenza Other Respi Viruses20104315516110.1111/j.1750-2659.2010.00129.x20409212Swine influenza A (H1N1) infection in two children—Southern California, March-April 2009MMWR Morb Mortal Wkly Rep2009581540040219390508Update: swine influenza A (H1N1) infections—California and Texas, April 2009MMWR Morb Mortal Wkly Rep2009581643543719407739Host range and emerging and reemerging pathogenshttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16485468Influenza epidemiology and characterization of influenza viruses in patients seeking treatment for acute fever in CambodiaBlairPJWierzbaTFTouchSVonthanakSXuXGartenRJOkomo-AdhiamboMAKlimovAIKasperMRPutnamSDEpidemiol Infect138219920910.1017/S095026880999063X19698213Review: Training efforts within AFHSC/GEISOttoJBMC Public Healthinpress Review: Capacity building within AFHSC/GEISSanchezJLBMC Public HealthRapid antigen tests for diagnosis of pandemic (Swine) influenza A/H1N1VasooSStevensJSinghKClin Infect Dis20094971090109310.1086/64474319725784Seasonal influenza vaccine and protection against pandemic (H1N1) 2009-associated illness among U.S. military personnelJohnsMCEickAABlazesDLLeeSEPerdueCLLipnickRVestKGRussellKLDeFraitesRFSanchezJLPloS one55e1072210.1371/journal.pone.0010722287328420502705Avian influenza virus: of virus and bird ecologyMunsterVJFouchierRAVaccine200927456340634410.1016/j.vaccine.2009.02.08219840670Emergence of a novel swine-origin influenza A (H1N1) virus in humansDawoodFSJainSFinelliLShawMWLindstromSGartenRJGubarevaLVXuXBridgesCBUyekiTMThe New England Journal of Medicine2009360252605261510.1056/NEJMoa090381019423869


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The Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supports and oversees surveillance for emerging infectious diseases, including respiratory diseases, of importance to the U.S. Department of Defense (DoD). AFHSC-GEIS accomplishes this mission by providing funding and oversight to a global network of partners for respiratory disease surveillance. This report details the system’s surveillance activities during 2009, with a focus on efforts in responding to the novel H1N1 Influenza A (A/H1N1) pandemic and contributions to global public health. Active surveillance networks established by AFHSC-GEIS partners resulted in the initial detection of novel A/H1N1 influenza in the U.S. and several other countries, and viruses isolated from these activities were used as seed strains for the 2009 pandemic influenza vaccine. Partners also provided diagnostic laboratory training and capacity building to host nations to assist with the novel A/H1N1 pandemic global response, adapted a Food and Drug Administration-approved assay for use on a ruggedized polymerase chain reaction platform for diagnosing novel A/H1N1 in remote settings, and provided estimates of seasonal vaccine effectiveness against novel A/H1N1 illness. Regular reporting of the system’s worldwide surveillance findings to the global public health community enabled leaders to make informed decisions on disease mitigation measures and controls for the 2009 A/H1N1 influenza pandemic. AFHSC-GEIS’s support of a global network contributes to DoD’s force health protection, while supporting global public health.
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REVIEW OpenAccessDepartmentofDefenseinfluenzaandother respiratorydiseasesurveillanceduringthe2009 pandemicRonaldLBurke1*,KellyGVest1,AngeliaAEick1,JoseLSanchez1,MatthewCJohns1,JulieAPavlin2, RichardGJarman2,JerryLMothershead3,MiguelQuintana4,ThomasPalys5,MichaelJCooper6,JianGuan7, DavidSchnabel8,JohnWaitumbi8,AlisaWilma9,CandelariaDaniels9,MatthewLBrown10,StevenTobias11, MatthewRKasper11,MayaWilliams11,JeffreyATjaden12,BuhariOyofo12,TimothyStyles13,PatrickJBlair14, AnthonyHawksworth14,JoelMMontgomery15,HugoRazuri15,AlbertoLaguna-Torres15,RandalJSchoepp16, DavidANorwood16,VictorHMacIntosh17,ThomasGibbons17,GregoryCGray18,DavidLBlazes1,KevinLRussell1, AFHSC-GEISInfluenzaSurveillanceWritingGroup1,2,3,5,8,11,12,13,14,15,17,19,20,21,22,23,24AbstractTheArmedForcesHealthSurveillanceCenter sDivisionofGlobalEmergingInfectionsSurveillanceandResponse System(AFHSC-GEIS)supportsandoverseessurveillanceforemerginginfectiousdiseases,includingrespiratory diseases,ofimportancetotheU.S.DepartmentofDefense(DoD).AFHSC-GEISaccomplishesthismissionby providingfundingandoversighttoaglobalnetworkofpartnersforrespiratorydiseasesurveillance.Thisreport detailsthesystem ssurveillanceactivitiesduring2009,withafocusoneffortsinrespondingtothenovelH1N1 InfluenzaA(A/H1N1)pandemicandcontributionstoglobalpublichealth.Activesurveillancenetworksestablished byAFHSC-GEISpartnersresultedintheinitialdetectionofnovelA/H1N1influenzaintheU.S.andseveralother countries,andvirusesisolatedfromtheseactivitieswereusedasseedstrainsforthe2009pandemicinfluenza vaccine.Partnersalsoprovideddiagnosticlaboratorytrainingandcapacitybuildingtohostnationstoassistwith thenovelA/H1N1pandemicglobalresponse,adaptedaFoodandDrugAdministration-approvedassayforuseon aruggedizedpolymerasechainreactionplatformfordiagnosingnovelA/H1N1inremotesettings,andprovided estimatesofseasonalvaccineeffectivenessagainstnovelA/H1N1illness.Regularreportingofthesystem s worldwidesurveillancefindingstotheglobalpublichealthcommunityenabledleaderstomakeinformed decisionsondiseasemitigationmeasuresandcontrolsforthe2009A/H1N1influenzapandemic.AFHSC-GEIS s supportofaglobalnetworkcontributestoDoD sforcehealthprotection,whilesupportingglobalpublichealth.BackgroundInresponsetothe1996PresidentialDirective(NSTC-7), theU.S.DepartmentofDefense(DoD)establishedthe GlobalEmergingInfection sSurveillanceandResponse System(DoD-GEIS)in1997,withthemissiontomonitornewlyemergingandre-emerginginfectiousdiseases (EIDs)amongU.S.servicemembersanddependent populations[1].Comparabletotheirglobalburden ofdisease,respiratoryinf ectionsareresponsiblefor 25percentto30percentofbothoutpatientillnessand hospitalizationsamongU.S.militarypersonnel[2,3]. Influenzaandadenovirusinfectionsareamongtheetiologiesthatgreatlycontributetomorbidityandmortality inmilitarymembers[4].Duringthe1918influenzapandemic,theU.S.militaryexperiencedattackratesashigh as25percentandcasefatalityratesaveraging5percent (rangingfrom1percentto8percent)[5]. DoD-GEIS,adivisionoftheArmedForcesHealthSurveillanceCenter(AFHSC)sinceearly2008,centralizedthe coordinationofDoDinfluenzaandotherrespiratorydiseasesurveillanceeffortsbeginningin1998.Theprogram wasexpandedwith2006congressionalsupplementary *Correspondence:Ronald.L.Burke@us.army.mil1ArmedForcesHealthSurveillanceCenter,503RobertGrantAvenue,Silver Spring,MD20910,USA FulllistofauthorinformationisavailableattheendofthearticleBurke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 2011Burkeetal;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited.

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appropriations[6-8].Subsequentfundingin2007-2009 hasmaintainedthiseffort.Today,AFHSC-GEISprovides direction,fundingandoversighttoasystemthatconsists ofanetworkofglobalpartners,includingapproximately 500sitesin70countries(Figure1). Duringthepastfouryears(2006-2009),theAFHSCGEISinfluenzasurveillancesystemincreasedsupportfor avianandpandemicinfluenzapreparednesstoinclude activitiesinsurveillanceandresponsetonewlyidentified strainsandpandemics,suchasH5N1andthe2009 novelA/H1N1.Bysupportingglobalsurveillanceand directingresponseefforts,DoDservesasasentinelfor localepidemicsandcanassistinlimitingdiseasetransmission.AnimmediatefocusofDoDisdecreasingthe impactofthenovelA/H1N1pandemiconthearmed forces,includingreducingrecruit-andothertrainingassociatedillnessesanddeat hs,andcontrollingsecondaryviralandbacterialassociatedmorbidity.These effortsaresimilarinintenttothoseundertakenatthe timeoftheappearanceofthenewvirusstrainduring the1918H1N1pandemicwheneffortswerealsomade toreducetheimpactofthevirusonthemilitaryduring WorldWarI. TheAFHSC-GEISinfluenzasurveillancesystemplays amajorroleintheU.S.government s(USG)contributionstotheglobalsurveillanceofinfluenzavirusesand contributestotheWorldHealthOrganization s(WHO) GlobalInfluenzaSurveillanceNetwork[9].CorecomponentsoftheAFHSC-GEISinfluenzasurveillancesystem areanetworkofspecializeddiagnosticandreference laboratoriesinthecontinentalUnitedStates,medical treatmentfacilitieswithintheMilitaryHealthSystem, andfiveDoDoverseaslaboratories,alongwiththeir respectivedetachments.Thesystem,builtaroundnetworksofhubandsatellitelaboratories,comprisesmany jointventureswithhostcountries. Thisarticlefocusesonthe2009activitiesandaccomplishmentsoftheAFHSC-GEI Slaboratory-basednetworkregardingglobalsurveillanceforrespiratory diseasesandrespondingtothenovelA/H1N1influenza pandemic.Theseactivitiesaredescribedrelativeto,and bymeansof,AFHSC-GEISstrategicgoals:surveillance Figure1 AFHSC-GEISglobalinfluenzasurveillancepresenceworldwide,asofMay2009. Burke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page2of8

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andresponse;trainingandcapacitybuilding;research, innovationandintegration;andassessmentandcommunicationofvalueadded.2009contributionsSurveillanceandresponseDuringApril2009,thefirsttwoU.S.casesofnovel A/H1N1weredetectedintwoseparateNavalHealth ResearchCenter(NHRC)su rveillanceprojectssupportedbyAFHSC-GEIS.Inthefirstinstance,NHRC investigatorscollectedas pecimenfroma10-year-old DoDdependentwhohadenrolledinabiomedicaltrial totestanewinfluenzadiagnosticplatformconductedat theNavalMedicalCenter,SanDiego,Calif.Initial resultsbyanexternalreferencelaboratorysuggestedan influenzaA/untypablevirus[10,11].Atthesametime,a 9-year-oldfemalefromtheU .S./Mexicoborderwas sampledinacollaborativesurveillancestudywiththe CentersforDiseaseControlandPrevention s(CDC) BorderInfectiousDiseaseSurveillanceProject.NHRC determinedinfectionfromaninfluenzaA/untypedvirus. FurthertestingontheIBIST5000platform,whichinfers HandNtypesfrommultiplege nomicsignatures,indicatedaninfluenzaA/swine /H1virus.Samplesfrom bothpatientswereshippedtotheCDCforconfirmation andcharacterization. Shortlythereafter,theU.S.AirForceSchoolofAerospaceMedicine(USAFSAM)detectedtwonearsimultaneouscasesamongmilitarydependentsintheSan Antonioarea.TheWHOusedthreeofthestrains(A/ California/7/2009,A/California/4/2009andA/Texas/5/ 2009)aspotentialstrainsforthe2009pandemicinfluenzavaccine.A/California/7/2009waseventually selectedastheseedstrain[9]. Inadditiontodetectingseveraloftheinitialcasesof novelA/H1N1withintheU.S.,AFHSC-GEISpartner laboratorieswereinstrumentalinmonitoringtheglobal spreadofthevirus.TheArmedForcesResearchInstitute oftheMedicalSciences(A FRIMS)laboratorywasthe firsttodetectnovelA/H1N1virusinNepalandBhutan, whiletheNavalMedicalResearchUnitNo.2(NAMRU-2) providedsupportfortheinitialconfirmationonnovel A/H1N1inCambodiaandLaoPeople sDemocratic Republic.TheU.S.ArmyMedicalResearchUnit-Kenya (USAMRU-K),anotherAFHSC-GEISpartner,supported initiallaboratoryconfirmationforKenyaandtheRepublic ofSeychelles,andtheNavalMedicalResearchCenter Detachment(NMRCD)identif iedthefirstcasesinPeru andsupportedinitialconfirmationinColombiaandEcuador.Additionally,NHRCdiagnosedthefirstinfectionin Guam/Micronesia,andtheNavalMedicalResearchUnit No.3(NAMRU-3)notonlyidentifiedthefirstcases inKuwait,butalsoconfirme doutbreaksinAfghanistan, Bahrain,Djibouti,EgyptandLebanon. ResultsofAFHSC-GEIS-sponsoredinfluenzasurveillancesampletestingwerereportedviahost-nationcollaboratorstotheirrespectiveministriestoensurethe ministriescouldmakeinfor medandtimelydecisions aboutinfluenzacontrol.TheAFHSC-GEISnetworksurveillancesupportofthe2009influenzapandemicwas instrumentalinthetimelytrackingandmonitoringof thevirus.InrecognitionofAFHSC-GEISsupport,the AFRIMSfieldlaboratoryinCebuwasmadeanofficial PhilippineDepartmentofHealthtestinglaboratory, PublicHealthCommandRegion-South(PHCR-South) assistedtheGuatemalanMinistryofHealthInfluenza laboratoryinbecomingaNationalInfluenzaCenter (NIC),andthePeruvianInstitutoNacionaldeSalud (NationalInstituteofHealth)awardedacommendation medaltoNMRCDforitssupportinthepandemic response. InadditiontothenovelA/H1N1pandemicsupport providedtoforeignhostnations,AFHSC-GEISnetwork partnerscontinuedtosupportinfluenzaandrespiratory diseasesurveillanceamongmilitaryrecruits,active-duty servicemembers,andU.S.militarybeneficiaries.AFHSCGEISsupportedthetimelysurveillanceandrapiddiagnosisofcirculatinginfluenzaandotherrespiratory viruseswithinouroverseasmilitarypopulationsthrough itspartnersinEurope(PHCR-EuropeandLandstuhl RegionalMedicalCenter(LRMC)),Japan(PHCR-Pacific andNavalHospitalYokosuka),andtheRepublicof Korea(BrianAllgoodArmyCommunityHospital (BAACH)). Althoughmanynetworklaboratories,suchasLRMC andBAACH,couldnotconfirmanovelA/H1N1infectionduringtheinitialmonthsofthepandemic,thefacilitiesprovidedastrongpresumptivediagnosisofnovel A/H1N1basedontheirfindin gsofuntypableinfluenza Ainfections.WithAFHSC-GEISsupport,BAACH becameoneofthefirstU.S.overseaslaboratoriescapableofprovidingon-sitediagnosisofnovelA/H1N1for U.S.militarypersonnelandtheirfamilies.Likewise,the abilityoftheNavyEnvironmentalPreventiveMedicine UnitNo.2,incollaborationwithNAMRU-3,tostand upanovelA/H1N1testingsiteinKuwaitonshort noticealsohelpedprovideatimelydiagnosisfor deployedclinicians.Inturn,thisefforthelpedeasetensionsbetweentheU.S.militaryandhostcountriesin SouthwestAsiaandtheMiddleEastbyallowingthe rapididentificationandsubsequentisolationofinfected individualstoreducethelikelihoodoftransmitting influenzavirustolocalcivilians. AsignificantchallengeforAFHSC-GEISpartnersin 2009wastheneedtobalancetheirnovelA/H1N1pandemicresponsewiththeirabilitytocontinuesurveillanceeffortsforotherinfluenzavirusesandrespiratory diseases(e.g.,adenovirus), includingpotentialzoonoticBurke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page3of8

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viruses.Over50percentofEIDsarezoonotic,including theH5N1and2009novelA/H1N1viruses[12].In 2009,AFRIMSandNAMRU-2scientists,incollaborationwiththeUniversityofIowa sCenterforEmerging InfectiousDiseases,furth erstrengthenedimportant researchofthehuman-anima linterfaceandepidemiologyofinfluenzavirusesbyexpandingestablished cohort-basedstudiesandcreatingnewonesinfive countries(Cambodia,Mongo lia,Nigeria,Romaniaand Thailand).Theendeavorallowedresearcherstoexamine riskfactorsandtransmissionpatternsofinfluenzaatthe human-animalinterface. Likewise,USAMRU-Kinitiatedsimilarsurveillance workinUgandaandcontinuedtoconductmigratory birdsurveillancetomonitorandtrackthespreadof highlypathogenicavianinfluenza(HPAI).NMRCDconductedsimilarmigratorybi rdsurveillanceinPeru.In conjunctionwiththeCDC,NAMRU-3andNMRCD initiatedpopulation-based,influenza-likeillnessand severeacuterespiratoryillnesssurveillanceefforts amonghospitalandcommunitycohortsinEgyptand Peru,respectively(Figure2). Finally,AFHSC-GEISpartnersprovidedlaboratory diagnosisfor37ofthe52(71percent)reportedcases ofhumanH5N1infectionworldwidein2009[3]. NAMRU-3,servingastheWHO sEasternMediterraneanRegionalInfluenzaReferenceCenter(EMRO), providedlaboratorydiagnosisfor36of38(95percent) ofreportedcasesofhumanH5N1infectionin Egypt,andNAMRU-2identi fiedanadditionalcasein Cambodia[13].TrainingandcapacitybuildingAlthoughtheseinitiativesaremorefullyaddressedin otherarticleswithinthissupplement,thestrategicgoal oftrainingandcapacitybuildingwasasignificantfocus ofAFHSC-GEISinfluenzafunding[14,15].Nearlyall AFHSC-GEISpartnersassistedwithtrainingandcapacitybuildingprograms.Whiletheprimaryobjectiveof theseprogramsistodevelopandstrengthenglobalsurveillancecapacity,theendeavorshavetheaddedbenefit ofimprovingUSGcivil-militaryandmilitary-military relationswithhostnations.AFHSC-GEISprovided fundingtotheCenterforDisasterandHumanitarian AssistanceMedicineattheUniformedServicesUniversitytoconduct14trainingsessionsfor36countries. Atotalof885individualsattendedthetraininginsupportofU.S.CombatantCommandpartnershipswith prioritynations. AFHSC-GEISfundingalsosupportedtheKenyan NICdesignationinlate2009astheWHOEastAfrica regionalinfluenzalaboratorythroughtheassistance ofUSAMRU-K.Withinthreemonthsofthenovel A/H1N1virusintroductionintotheregion,theKenyan NICreceivedandtestedover1,500influenzasamples fromKenya,RepublicofSeychellesandSomalia(AdditionalFile1).WhileservingastheWHO sEMROreferencelaboratory,NAMRU-3supportedthedevelopment ofNICsinAfghanistan,IraqandJordan,andthesustainmentofNICsinEgypt,Kuwait,Oman,Pakistan, SudanandSyria.Inresponsetothe2009influenzapandemic,NAMRU-3alsoworkedcloselywiththeWHO totrainover70participantsfrom32countriesin North/WestAfrica,CentralAsia,andtheMiddleEast onreal-timereversetranscriptasepolymerasechain reaction(rRT-PCR)usingtheCDCH1N1assaykits. IntheLaoPeople sDemocraticRepublic,initialcasesof A/H1N1weretestedattheNationalCenterforLaboratoryandEpidemiologyusingequipmentandsupplies furnishedbyNAMRU-2andAFHSC-GEISfunding.All oftheseeffortshelpedstrengthentheglobalpublic healthcommunity.Research,innovationandintegrationOneoftheprimaryfocusareaswithinthestrategicgoal ofresearch,innovationandintegrationisthedevelopmentofrapidlydeployable,field-expedientdiagnostic platformsforinfluenza.Althoughtheygenerallyhavea highspecificity,point-of-caretestshaveapoorsensitivityforinfluenza,especiallythe2009novelA/H1N1 virus[16].Moreover,whilet hesetestscandistinguish betweeninfluenzaAandBviruses,theyarerarelyable tosubtypespecificviruses. During2009,AFHSC-GEISsupportedtheU.S.Army MedicalResearchInstituteofInfectiousDiseases (USAMRIID)andtheChemicalBiologicalMedicalSystems-JointProgramManagementOfficetransitionof theCDCH5N1andnovelH1N1assaystotheJointBiologicalAgentIdentificationandDiagnosticSystem (JBAIDS).ThesystemhadbeendevelopedasaruggedizedPCRplatformforfieldidentificationofpriority pathogensofinterest.During2009,USAMRIIDsuccessfullyoptimizedandtestedtheCDCH5N1assays,and thedatawillbeusedinaDoD-sponsored510KapplicationtotheFoodandDrugAdministration(FDA)for useontheJBAIDSinthefuture. Inaddition,USAMRIIDandNHRCsuccessfully optimizedtheCDCH1N1assayforuseonthe JBAIDSplatform,andDoDsubmittedarequesttothe FDAtoextendthecurrentH1N1EmergencyUse AuthorizationfortheJBAIDSH1N1pandemicinfluenzaassay.TheFDAcommissionersignedtherequest onAug.24,2009.Asaresult,DoDnowhasthecapabilitytoprovideatimelyclinicaldiagnosisofnovel A/H1N1inU.S.servicemembersandciviliansin deployedandfieldsettings,andiswellpositionedto extendthiscapabilitytoinc ludeH5N1influenzadiagnosis(AdditionalFile2).Burke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page4of8

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InadditiontotheCDCH5N1assays,AFHSC-GEIS alsosupportedFDAapprovalofarapidavianH5N1 influenzatest(ArborVitaCorp.,AVantage )using NHRCclinicaltrialdataand validationoftheNational VeterinaryServiceLaboratoryassayfortheAImatrix, H5N1andH7N3strainsontheJBAIDSbytheDoD VeterinaryFoodAnalysisandDiagnosticLaboratoryat FortSamHouston,Texas.Thesecapabilitieswillhelpto furtherincreaseDoD scapacityforHPAIsurveillance andoutbreakresponseinremotesettings. In2009,AFHSC-GEISalsosoughttointegrateinfluenzafullgenomesequencingwithinDoD.Tothisend, theWalterReedArmyInstit uteofResearch(WRAIR) establishedfull-lengthandultra-deep,high-throughput genomesequencing.Twentysixviruses(twoseasonal A/H1N1,twoA/H3N2,and22novelA/H1N1)fromsix Legend Human influenza cohort Zoonotic influenza cohort Avian influenza surveillance in wild birds Avian influenza in wet markets Avian influenza survey in wet markets Swine influenza survey Tropical dry fores t Amazonia Andean mountain forest Dry Andean forest Dry Peruvian forest Figure2 NavalMedicalResearchCenterDetachmentinfluenzasurveillanceactivitiesinPeruduring2009. Burke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page5of8

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countrieswerefullysequencedandsubmittedtoGenBank.Inturn,thissequencingprovidedvaluableinformationoncurrentviralmutationstoDoDandthe globalpublichealthcommunity.AssessmentandcommunicationofvalueaddedByutilizingdatafromtheDefenseMedicalSurveillance System,AFHSCconductsassessmentsoninfluenzaactivity,safetyofthenovelA/H1N1influenzavaccineand effectivenessofinfluenzavaccine.Influenzaactivityamong allDoDbeneficiariesismonitoredweeklyandsummarized inaweeklyreportdisseminatedtoservice-specificpublic healthcenters,preventivemedicinephysiciansandDoD leadership.Inaddition,AFHSC-GEISgeneratesaweekly summaryofallinfluenzasurveillancereportsfromDoD laboratories,service-specificpublichealthcenters,CombatantCommandsandotherAFHSC-GEISpartners.The weeklyreportispostedontheDoDPandemicInfluenza Watchboard(http://fhpr.osd.mil/aiWatchboard/).Both reportsarevaluableinprovidingDoDdecisionmakers andglobalpublichealthleaderswithatimelyandsuccinct accountingofinfluenzaactivity,severityandgeographic distribution. AFHSChasalsopartneredwiththeMilitaryVaccine Agency,CDCandFDAtoprovideweeklysafetyassessmentsofthenovelA/H1N1influenzavaccineamong activecomponentservicemembers.AFHSCprovidesthe onlydatawithinDoDforthiscollaboration.Asaresult, thecenterplaysavaluableroleinthecountry sassessmentofthesafetyofthisvaccine. Eachyear,AFHSC-GEISconductsmid-seasonassessmentsoftheeffectivenessoftheseasonalvaccines,and during2010,willexaminetheeffectivenessofthenovel A/H1N1influenzavaccine.Initialestimatesofseasonal vaccineeffectivenessagainstnovelA/H1N1-associated illnesshavebeenpresentedatscientificmeetingsand havebeenpublished.[17]Mid-seasonevaluationsgeneratedinJanuaryandFebruary2010aimedtoprovide crucialinformationtotheVaccineandRelatedBiologic ProductsAdvisoryCommitteeandthepublichealth communityatlarge. Additionally,networkpartnersatNHRCandUSAFSAMalsoevaluatevaccineeffectivenessamongimportantsubpopulationsthroughoutDoD.NHRChas establishedaframeworkforevaluatinginfluenzavaccine effectivenessamongbasi cmilitarytraineesthathas servedasavaluabletoolinthelargerefforttomonitor thisimportantindicator.USAFSAMworksdiligently eachseasontoidentifyandmolecularlyanalyzeviruses fromcasesconsideredpotentialvaccinebreakthroughs (e.g.,casesoccurring 14daysaftervaccination)as determinedbythesurveillancequestionnairedatacollectedaspartofroutinesentinelsurveillance.The DefenseDepartmentiswellpositionedtodeterminethe overalleffectivenessofbothseasonalandpandemicvaccinesinmilitarypopulations.However,resultsofthese evaluationsmaynotbegeneralizabletothepopulation atlarge,giventheyoung,healthyandhighlyvaccinated natureofmilitaryp opulations.Thisfunctionisviewed favorablyandofgreatvaluetothevaccineandpublic healthcommunities.DiscussionAlthoughmanygoalswereaccomplishedduringthis pastyear,thenovelA/H1N1influenzaviruspandemic of2009presenteduniquemanagementchallengesfor AFHSC-GEISanditsnetworkofpartners.Thefirstsignificantproblemcenteredon sensitivity intermsof reportingcasestohost-countryhealthauthorities,while simultaneouslyprovidingU.S.militaryandcivilian healthagencieswiththereports.Althoughtheidentificationofcaseswasimportant,manyhost-countryofficialsperceivedthatrep ortingofcasescouldbe detrimentaltotheireconomyorcommunity.Intandem withthehighvisibilityofr eports,laboratorytesting associatedwiththelargein creaseinprocessingspecimenspresentedachallengeintermsoflocalandregionalexpectationoftimelyresultsthateachpartner neededtoaddress.Theconso lidationoftestingresults wasfoundtobechallenging,thus,theauthorsseea pressingneedforstandardizationofreportinginthe future.Otherchallengesoccurredintermsofachieving effectiveongoingstrain-sequencinganalysisandreportingtoCDCandWHOofficials.Lastly,giventhehigh volumeoftestingrequiredduringapandemic,theprogrammusttakeacloserlookatchangingtheparadigm oftestingwherebyonlyarepresentativeportion(i.e., 10percentto20percent),insteadofeverysample,is givenpriority.Forexample,researcherscouldtestsevere cases(e.g.,SARI,hospitalized,pneumonia)tomore effectivelyprovidereliableestimatesofthevirus impact. AprimaryfocusoftheAFHSC-GEISinfluenzasurveillancesystemin2010isthecontinuedmonitoringand trackingofnovelA/H1N1virusforchangesinseverity, antiviralresistanceortransmissibility,particularlyinour specialpopulations(e.g.,recruits,deployedandshipboardpersonnel)withinthemilitary.Sentinel-basedsurveillancebyourpartners(e.g.,USAFSAM,LRMC, BAACH)willcontinuetoremainakeycomponentof thesurveillanceprogram,aswillthepopulation-based surveillanceateightof10militaryrecruit-trainingcentersandthePacificRimSurveillanceatNavalHospital YokosukabyNHRC. ToexpandDoD ssurveillanceeffortswithintheMilitaryHealthSystem,AFHSC-GEISispartneringwiththe InfectiousDiseaseClinical ResearchProgramtoestablishanacuterespiratoryinfectionconsortiumatseveral largeDoDmedicaltreatmentfacilities.ThisgroupwillBurke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page6of8

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examinethepandemic simpactontheU.S.military healthcarepopulationandevaluatetheeffectivenessof potentialinterventionmeasures,includingvaccine-specificeffectivenessandnon-vaccineinterventions,suchas handwashing,febrilescreening,cohortingandrecruit spaceallocation. Besidescontinuedsurvei llancewithinDoD,AFHSCGEISpartnersarefosteringanddevelopingnew relationshipsforsurveillancewithinothermilitarypopulationstoexpandthecenter sglobalsurveillanceprogramandenhanceitscontributiontoglobalpublic health.Examplesofpotentialfuturecollaborations includeNMRCDpartnershipswithBoliviaandEcuador; AFRIMSsurveillanceinVi etnam;NAMRU-3developmentofaveterinaryandhuma ninfluenzasurveillance networkinwesternAfricawithBurkinaFaso,Cote d IvoireandGhanaarmedforces;establishmentofa centralAfricanmilitaryalliancebytheGlobalViral ForecastingInitiativeinCameroon;andexpansionof DoDandforeignmilitaryinfluenzaandEIDsurveillance effortsinEastAfrica(Kenya,TanzaniaandUganda)and CentralAmerica(ElSalvador,GuatemalaandHonduras).FurtherexpansionofAFHSC-GEIS-sponsored partnershipswithMinistriesofHealthwillalsobe explored(e.g.,byPHCR-SouthinCentralAmerica)to provideimprovedsurveillanceinregionsoftheworld wheresurveillanceislackingorinadequate. Surveillanceofzoonotic influenzawillbecomemore focusedin2010.Whilewaterf owl,especiallyducksand geese,canbeinfectedandshedmanysubtypesofinfluenzaAviruses,viralpresenceinthesespeciesdoesnot necessarilyimplyarisktohu mansduetothepotential forspecies-specificstrainsandespeciallyalackof humanexposuretothewaterfowlnecessaryfortransmission[18].Asaresult,insteadoffocusingonmigratorybirds,AFHSC-GEISwillconcentrateonthose areas,suchaslive-birdmark ets,abattoirsandlarge breedingfarms,andoccupations,suchasbackyardagriculturalworkers,whereindividualsaremorelikelytobe exposedtoanimals,thusselectingasubsetthatisat muchhigherriskofinfectionwith,andtransmissionof, zoonoticinfluenzastrains. Finally,AFHSC-GEISwillseektoexpandDoD scapabilitytoanalyzeandcharacterizevirusesin-house.In 2009,AFHSC-GEISfundingwasusedtoequipseveral laboratorieswithantiviralre sistancetestingcapacity (genotypicallybypyrosequencingandphenotypicallyby inhibitioninculture).Thecapabilitywillbefurther developedinthefuture.Likewise,WRAIR sgenomic sequencingcapacityandthroughputwillalsoincrease. Additionally,fundingwillbeprovidedtoexpandthe JBAIDSinfluenzacapabilityfromnovelA/H1N1and H5N1toincludepan-influenzaA,pan-influenzaB,H1 seasonalandH3seasonalviruses.ConclusionsThe1996PresidentialDirectivechargedtheU.S.DoDwith monitoringEIDsinthemilitarypopulation.Thedirective ledtocreationoftheAFHSC-GEISinfluenzasurveillance system,whichstrivestobeavaluableassettoDoDandthe globalpublichealthcommunity.Itsspecimencatchment areaincludesregionsnotedfortheirregularcontribution toglobalstraincirculation,suchasSoutheastAsia,aswell asSouthAmerica,AfricaandtheMiddleEast,wherestrain circulationinformationislimited. During2009,theAFHSC-GEISinfluenzaandrespiratorydiseasesurveillancenetworknotonlydetectedthe firstcasesofnovelA/H1N1amongU.S.militarybeneficiaries,butalsodetectedthefirstlaboratory-confirmed caseswithintheUnitedStatesandmanycountries throughouttheworld[19].InadditiontoitsEIDsurveillance,thenetworkalsoassistedwithprovidinga rapidglobalresponsetothe 2009influenzapandemic throughtrainingandcapacity-buildingeffortswithpartnernations,developingnewsurveillanceanddiagnostic platforms,andtimelyreportingofsurveillanceresults anddiseasetrendstopublichealthauthoritiessuchas theCDCandWHO. Thisextensivenetworkispositionedtodetectthe emergenceofnewrespiratorypathogensorsignificant mutationsinthenovelA/H1N12009influenzavirusas theytranspire.Theprojectsandinitiativesin2010and beyondwillhelptofurtherstrengthenandmaintain thisnetwork,andultimatelycontributetothesustainmentofforcehealthprotectionandglobalpublic health.AdditionalFile1:AFHSC-GEISsupportspandemicH1N1influenza outbreakresponseinKenyaandEastAfrica.Figure-LaboratoryconfirmedcasesofnovelA/H1N1influenzainKenya,asofOct.8, 2009. AdditionalFile2:DeploymentoftheJBAIDSfordiagnosisofnovel A/H1N1influenzainthedeployedoperations.Figure-Useofthe JBAIDSfordiagnosisofthenovelA/H1N1influenzavirusina deployedsetting. Acknowledgements #AFHSC-GEISInfluenzaSurveillanceWritingGroup :JenniferRubenstein1, KyleHathaway2,RobertGibbons2,In-KyuYoon2,DavidSaunders2,Jariyanart Gaywee2,MikalStoner2,AnsTimmermans2,SanjayaKShrestha2,JohnMarkS Velasco2,MariaTAlera2,DaruneeTannitisupawong2,KhinSawMyint2,Sathit Pichyangkul2,BenWoods3,KurtHJerke5,MichaelGKoenig5,DenisK Byarugaba8,FredWabwireMangen8,BerhaneAssefa8,MayaWilliams11,Gary Brice11,MoustafaMansour12,GuillermoPimentel12,PeterSebeny12,Maha Talaat12,TamerSaeed12,BenEspinosa13,DennisFaix14,RyanMaves15, TadeuszKochel15,JamesSmith17,AliciaGuerrero17,GenMaupin17,Paul Sjoberg17,MarkDuffy17,JasonGarner17,LindaCanas17,ElizabethMacias17, RobertAKuschner19,DennisShanks20,SheriLewis21,GosiaNowak22,LucyM Ndip23,NathanWolfe24,KarenSaylors24. Theauthorswishtothankthenumerousindividualswhoperform surveillanceaspartoftheAFHSC-GEISglobalnetwork,includingall individualsintheMinistriesofHealthandMinistriesofDefenseofour partnernationswhoseeffortshavecontributedtothesuccessofthe network.Burke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page7of8

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Disclaimer Theopinionsstatedinthispaperarethoseoftheauthorsanddonot representtheofficialpositionoftheU.S.DepartmentofDefense. Thisarticlehasbeenpublishedaspartof BMCPublicHealth Volume11 Supplement1,2011:DepartmentofDefenseGlobalEmergingInfections SurveillanceandResponseSystem(GEIS):anupdatefor2009.The fullcontentsofthesupplementareavailableonlineat http://www.biomedcentral.com/1471-2458/11?issue=S2. Authordetails1ArmedForcesHealthSurveillanceCenter,503RobertGrantAvenue,Silver Spring,MD20910,USA.2ArmedForcesResearchInstituteofMedical Sciences,315/6RajavithiRoad,Bangkok,Thailand10400.3CenterforDisaster andHumanitarianAssistanceMedicine,UniformedServicesUniversityofthe HealthSciences,F.EdwardHbertSchoolofMedicine,4301JonesBridge Road,Bethesda,MD20814,USA.4PublicHealthRegion-South,Building2472, SchofieldRoad,FortSamHouston,TX78234,USA.5LandstuhlRegional MedicalCenter,DepartmentofPathologyandAreaLaboratoryServices,CMR 402,APOAE09180,USA.6PublicHealthRegion-Europe,CMR402,APOAE 09180,USA.7PublicHealthRegion-Pacific,Unit45006,APOAE96343,USA.8U.S.Embassy,Attention:MRU,UnitedNationsAvenue,PostOfficeBox606, VillageMarket00621Nairobi,Kenya.9DepartmentofDefenseVeterinary FoodAnalysis&DiagnosticLaboratory,2472SchofieldRoad,Suite2630,Fort SamHouston,TX78234,USA.10USAMEDDAC-Korea,MicrobiologySection, Unit15244,Box459,APOAP96205,USA.11NavalMedicalResearchUnit Number2,KompleksPergudanganDEPKESR.I.,JI.PercetakanNegaraIINo. 23,Jakarta10560,Indonesia.12NavalMedicalResearchUnitNo.3,Extension ofRamsesStreet,AdjacenttoAbbassiaFeverHospital,PostalCode11517, Cairo,Egypt.13U.S.NavyEnvironmentalPreventiveMedicineUnitNo.2,1887 PowhatanStreet,Norfolk,VA23511,USA.14NavalHealthResearchCenter, 140SylvesterRoad,SanDiego,CA92106,USA.15NavalMedicalResearch CenterDetachment,CentroMedicoNaval CMST, Av.VenezuelaCDRA36, Callao2,Lima,Peru.16U.S.ArmyMedicalResearchInstituteofInfectious Diseases,DiagnosticSystemsDivision,1425PorterStreet,FortDetrick,MD 21702,USA.17U.S.AirForceSchoolofAerospaceMedicine,2513Kennedy Circle,Building180,BrooksCityBase,TX78235,USA.18Departmentof EnvironmentalandGlobalHealth,CollegeofPublicHealthandHealth Professions,UniversityofFlorida,PostOfficeBox100188,Gainesville,FL 32610,USA.19WalterReedArmyInstituteofResearch,EmergingInfectious DiseasesResearchUnit,503RobertGrantAvenue,SilverSpring,MD20910, USA.20AustralianArmyMalariaInstitute,GallipoliBarracks,Enoggera,QLD 4051,Australia.21JohnsHopkinsUniversityAppliedPhysicsLaboratory,11100 JohnsHopkinsRoad,Laurel,MD20723,USA.22U.S.NavyandMarineCorps PublicHealthCenter,620JohnPaulJonesCircle,Suite1100,Portsmouth,VA 23708,USA.23LaboratoryforEmergingInfectiousDiseases,Universityof Buea,PostOfficeBox63,Buea,Cameroon.24GlobalViralForecasting Initiative,1Sutter,Suite600,SanFrancisco,CA94104,USA. Authors contributions RLBwasresponsibleforoversightandmanagementoftheAFHSC-GEIS AvianandPandemicInfluenzaDepartmentanddraftedthemanuscript.KGV, MCJandJLSwereresponsibleforregionaloversightandmanagement withintheAFHSC-GEISAvianandPandemicInfluenzaDepartment.AAEwas responsibleforanalysisofinfluenzatrendswithintheU.S.DoD.JAPandRGP providedoversightandconductedAFHSC-GEISrespiratorydisease surveillanceatAFRIMS.JLMwasresponsibleforprogrammanagementof theCDHAMpandemicinfluenzatrainingsupporttoU.S.Combatant Commands.MQprovidedoversightandconductedAFHSC-GEISrespiratory diseasesurveillanceatPHCR-South.TPandMJCprovidedoversightand conductedAFHSC-GEISrespiratorydiseasesurveillanceatLRMCandPHCREurope.JGprovidedoversightandconductedAFHSC-GEISrespiratory diseasesurveillanceatPHCR-Pacific.DSandJWprovidedoversightand conductedAFHSC-GEISrespiratorydiseasesurveillanceatUSAMRU-K.AW andCCDwereresponsibleforoptimizingtheavianH5panelforuseonthe JBAIDSplatform.MLBprovidedoversightandconductedAFHSC-GEIS respiratorydiseasesurveillanceatBAACH.ST,MRKandMWprovided oversightandconductedAFHSC-GEISrespiratorydiseasesurveillanceat NAMRU-2.JATandBOprovidedoversightandconductedAFHSC-GEIS respiratorydiseasesurveillanceatNAMRU-3.PJBandAHprovidedoversight andconductedAFHSC-GEISrespiratorydiseasesurveillanceatNHRC.JMM, HRandALprovidedoversightandconductedAFHSC-GEISrespiratory diseasesurveillanceatNMRCD.RJSandDANwereresponsiblefor optimizingtheH5N1assayforuseontheJBAIDSplatform.VHMandTG providedoversightandconductedAFHSC-GEISrespiratorydisease surveillanceatUSAFSAM.TSprovidedoversightandconductedAFHSC-GEIS respiratorydiseasesurveillanceatNavyEnvironmentalandPreventive MedicineUnit-2.GCGprovidedoversightandconductedAFHSC-GEIS respiratorydiseasesurveillanceattheUniversityofIowa.DLBwas responsibleforoversightandmanagementofAFHSC-GEISoperationsand developedthereportingformat.KLRwasthedirectorofDoDGEISand providedoversightanddirectionofitssurveillanceactivities. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Published:4March2011 References1.ClintonWJ: PresidentialDecisionDirectiveNSTC-7. TheWhiteHouse;1996. 2.GrayGC: Acuterespiratorydiseaseinthemilitary. FederalPractioner 1995, 12 :27-33. 3.PazzagliaG,PasternackM: RecenttrendsofpneumoniamorbidityinU.S. Navalpersonnel. MilMed 1983, 148(8) :647-651. 4.GrayGC,CallahanJD,HawksworthAW,FisherCA,GaydosJC: Respiratory diseasesamongU.S.militarypersonnel:counteringemergingthreats. EmergInfectDis 1999, 5(3) :379-385. 5.BrundageJF: Interactionsbetweeninfluenzaandbacterialrespiratory pathogens:implicationsforpandemicpreparedness. TheLancetinfectious diseases 2006, 6(5) :303-312. 6.CanasLC,LohmanK,PavlinJA,EndyT,SinghDL,PandeyP,ShresthaMP, ScottRM,RussellKL,WattsD, etal : TheDepartmentofDefense laboratory-basedglobalinfluenzasurveillancesystem. MilMed 2000, 165(7Suppl2):52-56. 7.KelleyPW: Acommentaryonthemilitaryroleinglobalinfluenza surveillance. AmJPrevMed 2009, 37(3) :260-261. 8.OwensAB,CanasLC,RussellKL,NevilleJS,PavlinJA,MacIntoshVH, GrayGC,GaydosJC: DepartmentofDefenseGlobalLaboratory-Based InfluenzaSurveillance:1998-2005. AmJPrevMed 2009, 37(3) :235-241. 9.SuekerJJ,BlazesDL,JohnsMC,BlairPJ,SjobergPA,TjadenJA, MontgomeryJM,PavlinJA,SchnabelDC,EickAA, etal : Influenzaand respiratorydiseasesurveillance:theU.S.military sgloballaboratorybasednetwork. InfluenzaOtherRespiViruses 2010, 4(3) :155-161. 10. SwineinfluenzaA(H1N1)infectionintwochildren SouthernCalifornia, March-April2009. MMWRMorbMortalWklyRep 2009, 58(15) :400-402. 11. Update:swineinfluenzaA(H1N1)infections CaliforniaandTexas,April 2009. MMWRMorbMortalWklyRep 2009, 58(16) :435-437. 12. Hostrangeandemergingandreemergingpathogens. [http://www.ncbi. nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16485468]. 13.BlairPJ,WierzbaTF,TouchS,VonthanakS,XuX,GartenRJ,OkomoAdhiamboMA,KlimovAI,KasperMR,PutnamSD: Influenzaepidemiology andcharacterizationofinfluenzavirusesinpatientsseekingtreatment foracutefeverinCambodia. EpidemiolInfect 138(2) :199-209. 14.OttoJ: Review:TrainingeffortswithinAFHSC/GEIS. BMCPublicHealth 15.SanchezJL: Review:CapacitybuildingwithinAFHSC/GEIS. BMCPublicHealth. 16.VasooS,StevensJ,SinghK: Rapidantigentestsfordiagnosisof pandemic(Swine)influenzaA/H1N1. ClinInfectDis 2009, 49(7) :1090-1093. 17.JohnsMC,EickAA,BlazesDL,LeeSE,PerdueCL,LipnickR,VestKG, RussellKL,DeFraitesRF,SanchezJL: Seasonalinfluenzavaccineand protectionagainstpandemic(H1N1)2009-associatedillnessamongU.S. militarypersonnel. PloSone 5(5) :e10722. 18.MunsterVJ,FouchierRA: Avianinfluenzavirus:ofvirusandbirdecology. Vaccine 2009, 27(45) :6340-6344. 19.DawoodFS,JainS,FinelliL,ShawMW,LindstromS,GartenRJ, GubarevaLV,XuX,BridgesCB,UyekiTM: EmergenceofanovelswineorigininfluenzaA(H1N1)virusinhumans. TheNewEnglandJournalof Medicine 2009, 360(25) :2605-2615.doi:10.1186/1471-2458-11-S2-S6 Citethisarticleas: Burke etal .: DepartmentofDefenseinfluenzaand otherrespiratorydiseasesurveillanceduringthe2009pandemic. BMC PublicHealth 2011 11 (Suppl2):S6.Burke etal BMCPublicHealth 2011, 11 (Suppl2):S6 http://www.biomedcentral.com/1471-2458/11/S2/S6 Page8of8

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In response to the 2009 pandemic H1N1 influenza outbreak, the Kenya Ministry of Public Health and Sanitation (MoPHS) began implementing its influenza pandemic preparedness plans in mid May. The MoPHS consulted with o fficials from the AFHSC GEIS funded U.S. Army Medical Research Unit Kenya (USAMRU K) laboratory on preparedness, diagnostic and public outreach planning prior to implement ing the plan On June 29, 2009, the Centers for Disease Control and Prevention Kenya (CDC Kenya) and the AFHSC GEIS infl uenza program at USAMRU K jointly confirmed the first case of novel A/H1N1 in Kenya Working with the Kenya MoPHS personnel from the World Health Organization (WHO), CDC Kenya and USAMRU K developed case definitions, hospital response programs, risk commu nications messages, and laboratory testing algorithms for the pandemic. USAMRU K also assisted with the deployment of medical education training teams that traveled around the country to train 756 healthcare providers on matters relating to the pandemic H1N1 influenza outbreak. In tandem with its mandate as a regional laboratory, the Kenya National Influenza Centre (NIC), with the assistance of USAMRU K, also served as the r eference and diagnostic laboratory for pandemic influenza diagnosis for the R epublic of Seychelles and Republic of Somalia. Within three months of its introduction into Kenya, the novel A/H1N1 influenza virus had spread to many regions within the country ( Vignette Figure 1). In the first three months of the pandemic outbreak, 1 439 samples were sent to the NIC for diagnostic testing and 233 samples (16 percent ) tested positive for the novel A/H1N1 influenza. From May 1 to Oct 10, the Kenya NIC received 99 samples from suspected cases of novel A/H1N1 influenza in the Republic of Seychelles. Nearly half (46 percent ) of the specimens were positive for influenza. Among positive influenza cases, a majority (76 percent ) was novel

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A/H1N1. During this same period, the Kenya NIC received 10 samples from the Garowe Hospital in Somalia. Two specimens tested positive for the novel A/H1N1 virus and four tested positive for seasonal influenza A. By leveraging the previously developed capacity built in support of human influenza sentinel surveillance, USAMRU K and AFHSC GEIS supported the rapid diagnosis and response to the 2009 H1N1 influenza pandemic within the region, consistent with its global mandate and objectives.

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1 The battle against the A/H1N1 influenza virus has taken a turn for the better with the introduction of the Joint Biological Agent Identification and Diagnostic System (JBAIDS) in field laboratories within the U.S. Central Command region. With the support of the A rmed F orces H ealth S urveillance C enter G lobal E merging I nfections and Surveillance and Respon se System (AFHSC GEIS) Navy Medical Research Unit No. 3 (NAMRU 3) and Chemical Biological Medical Systems Joint Program Management Office (CBMS JPMO) provide d training and capability for real time diagnosis of novel A/H1N1diagnostic in the deployed settin g. T o confirm influenza cases JBAIDS was employed as a stand in for the Applied Bio systems ( ABI) 7500 FAST r eal t ime polymerase chain reaction (PCR) s ystem a more sensitive instrument that is not yet readily available in combat zones The extension of the Food and Drug Administration Emergency Use Authorization in August 2009 to include use of the Centers for Disease Control and Prevention H1N1 real time PCR diagnostic kit, allowed NAMRU 3 researchers to be certified and serve as regional JBAIDS trainers for real time detection of the pandemic H1N1influenza virus of 2009 On short notice, NAMRU 3 was able to deploy a team of four personnel to train and certify 15 laboratory medical personnel on the JBAIDS platform at five install ations in Central Command. Following completi o n of training and certification on JBAIDS, combat field clinics now possess the means to clinically diagnose novel A/H1N1 influenza in patients presenting with influenza like illnesses. Because of its versatil ity and portability JBAIDS promises to offer a significant advantage in the combat zone. Continued collaborations among AFHSC GEIS NAMRU 3 and C B M S JPMO will ensure that JBAIDS usage thrives on and off the battlefield.

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1 The battle against the A/H1N1 influenza virus has taken a turn for the better with the introduction of the Joint Biological Agent Identification and Diagnostic System (JBAIDS) in field laboratories within the U.S. Central Command region. With the support of the A rmed F orces H ealth S urveillance C enter G lobal E merging I nfections and Surveillance and Respon se System (AFHSC GEIS) Navy Medical Research Unit No. 3 (NAMRU 3) and Chemical Biological Medical Systems Joint Program Management Office (CBMS JPMO) provide d training and capability for real time diagnosis of novel A/H1N1diagnostic in the deployed settin g. T o confirm influenza cases JBAIDS was employed as a stand in for the Applied Bio systems ( ABI) 7500 FAST r eal t ime polymerase chain reaction (PCR) s ystem a more sensitive instrument that is not yet readily available in combat zones The extension of the Food and Drug Administration Emergency Use Authorization in August 2009 to include use of the Centers for Disease Control and Prevention H1N1 real time PCR diagnostic kit, allowed NAMRU 3 researchers to be certified and serve as regional JBAIDS trainers for real time detection of the pandemic H1N1influenza virus of 2009 On short notice, NAMRU 3 was able to deploy a team of four personnel to train and certify 15 laboratory medical personnel on the JBAIDS platform at five install ations in Central Command. Following completi o n of training and certification on JBAIDS, combat field clinics now possess the means to clinically diagnose novel A/H1N1 influenza in patients presenting with influenza like illnesses. Because of its versatil ity and portability JBAIDS promises to offer a significant advantage in the combat zone. Continued collaborations among AFHSC GEIS NAMRU 3 and C B M S JPMO will ensure that JBAIDS usage thrives on and off the battlefield.

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