Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 http://www.biomedcentral.com/1471-2458/11/S2/S4 REVIEW Open Access Capacity-building efforts by the AFHSC-GEIS program Jose L Sanchez1*, Matthew C Johns1, Ronald L Burke1, Kelly G Vest1, Mark M Fukuda1,2, In-Kyu Yoon2, Chanthap Lon2, Miguel Quintana3, David C Schnabel4, Guillermo Pimentel5, Moustafa Mansour5, Steven Tobias6, Joel M Montgomery7, Gregory C Gray8, Karen Saylors9, Lucy M Ndip10, Sheri Lewis11, Patrick J Blair12, Paul A Sjoberg13, Robert A Kuschner14, Kevin L Russell1, David L Blazes1, the AFHSC-GEIS Capacity Building Writing Group14,15,16,17,18,19,20,21,22,23,24,25 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. Background resource-limitedsettings,inadditiontodetectingpoten- Capacity building, as it applies to health in this context, tialoutbreaksofdisease. can be accomplished through strengthening health Though not a new concept, capacity building has systems for delivery of medical care, pursuing medical enjoyed renewed prominence as the world endeavors to researchinitiativestoanswerimportantlocalorregional meet requirements of International Health Regulations healthquestions,orsupportingpublichealthdiseasesur- 2005(IHR(2005))[1].Article5oftheregulationsrequires veillance to prioritize which diseases are affecting rele- that all countries be able to detect, assess, notify and vant populations. Within this context, global public reportonpublichealthissuesofinternationalsignificance health capacity building can be defined as developing and control any potential public health event of interna- laboratoryinfrastructure,strengtheninghost-countrydis- tionalconcernby2012.Somecountriesarecapablenow, easesurveillanceinitiatives,transferringtechnical exper- butmostarenotandwillnotbecompliantbythedeadline tise andtrainingpersonnel. Disease surveillance isoften unlessasignificantimprovementinlocalcapacityoccurs. the first step in improving public health because it In general, for capacity building to be successful in the attempts to quantify needs and allocate scarce assets in long term, efforts must not be undertaken quickly and need to be implemented through a concerted unified effort, achievingsteady, sustainable and measurable pro- gressovertime,withtheeventualgoalbeingindependence *Correspondence:[email protected] 1ArmedForcesHealthSurveillanceCenter,503RobertGrantAvenue,Silver fromtheproviderofthecapability. Spring,MD20910,USA Fulllistofauthorinformationisavailableattheendofthearticle ©2011Sanchezetal;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited. Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 1. REPORT DATE 3. DATES COVERED 2011 2. REPORT TYPE 00-00-2011 to 00-00-2011 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Capacity-building efforts by the AFHSC-GEIS program 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION Armed Forces Health Surveillance Center, ,503 Robert Grant REPORT NUMBER Avenue,Silver Spring ,MD,20910 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited 13. SUPPLEMENTARY NOTES 14. 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. 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a. REPORT b. ABSTRACT c. THIS PAGE Public Release 9 unclassified unclassified unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page2of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 In 2007, the Government Accountability Office laboratory capacity in developing countries has been issued a report describing the global infectious disease termed the “Achilles’ heel” of global efforts to combat capacity-building efforts of U.S. government (USG) infectious diseases [8]. Thus, many AFHSC-GEIS spon- entities [2]. At the time, three USG entities were iden- sored activities in capacity building were directed at tified as providing capacity building for emerging improving existing infrastructure by renovating current infectious diseases (EID), including the U.S. Centers laboratory facilities,furnishingnew scientific equipment, for Disease Control and Prevention (CDC), the U.S. andprovisioningneworenhanceddiagnostictestingsys- Agency for International Development and the Depart- temsatoverseasU.S.DoDfacilities,aswellasU.S.-based, ment of Defense’s Global Emerging Infections Surveil- DoDinfluenzareferencelaboratories,whichserveasregio- lance and Response System (DoD-GEIS). Their efforts nalreferencelaboratories,andhost-countrylaboratories. included laboratory-based disease surveillance, devel- Efforts were coordinated with over 80 local and regio- opment and testing of diagnostics, and training such as nal Ministries of Health, Agriculture and Defense, as Field Epidemiology Training Programs, the interna- well as other government officials and institutions tional version of the famed Epidemic Intelligence Ser- worldwide in 74 countries. A total of 52 National Influ- vice [3]. Currently, many other USG agencies are enza Centers (NICs) and other country-specific influ- engaged in building disease surveillance capacity, enza and EID reference laboratories (44 civilian, eight including the U.S. Department of State, the Defense military) were supported in 46 countries (Table 1). The Threat Reduction Agency and the U.S. National Insti- efforts included support to laboratories in eight regions tutes of Health [4]. In addition, numerous state, non- of the world. Sub-Saharan (east, central and west) Africa state and non-governmental organizations, such as the were the regions with the most major laboratory capa- Bill and Melinda Gates Foundation, the World Bank city-building efforts (in 14 countries), consistent with and Médecins sans Frontières, contribute substantially the identified needs of this region relative to the world, to capacity-building efforts around the world [5-7]. especially as it relates to influenza [9,10]. Among all With the establishment of the Armed Forces Health infrastructure and capacity-building projects (Table 2), Surveillance Center (AFHSC) in late 2008, the DoD- the majority supported primarily human health entities GEIS program was transitioned to a division and (in 67 countries); however, projects also supported ani- renamed “AFHSC-GEIS”; however, its mission of work- mal health entities for zoonotic diseases in eight coun- ing to promote and facilitate national and international tries. Training efforts are mentioned, but are presented preparedness for EID was maintained. Strengthening of in detail elsewhere in this supplement [11]. U.S. military and host-country disease surveillance and OneofthemostnotableAFHSC-GEISaccomplishments public health laboratory capacity represents a critical infiscal2009wastheestablishmentoftwonewbiosafety step for contributing to compliance with the IHR (2005) level-3 (BSL-3) laboratory suites within DoD reference detection, reporting and response requirements. During laboratories. The Armed Forces Research Institute of 2009, capacity-building efforts were undertaken in a Medical Sciences(AFRIMS) in Bangkok, Thailand, com- variety of formats, including enhancement of diagnostic pletedthefirstlaboratory,which the UnitedStates certi- capabilities, expansion of surveillance for militarily rele- fied and commissioned on July 8, 2009. The suite was vant infectious and tropical diseases, and deployment of officially inaugurated September 16, 2009 and began electronic surveillance platforms. These efforts were immediatelysupportingworkinavianandpandemicinflu- coordinated with local host-country health officials and enzamonitoring,includingcultureandmolecularsequen- geographic Combatant Commands to ensure they cing capability (Figure 1). This BSL-3 laboratory addressed country and regional medical priorities as constitutesthefirstDoD-certifiedlaboratoryofitskindin well as to ensure better surveillance and response to dis- the region and provides the World Health Organization ease outbreaks and EID threats to U.S. forces abroad. (WHO), Thailand and other countries in Southeast Asia These efforts focused on influenza and other respiratory withamuch-neededhigh-containmentcapabilitytocon- diseases, malaria, dengue and other vector-borne ill- duct research and assist with outbreaks involving select nesses, acute diarrheal diseases, antimalarial and antimi- humanandanimalbacterialandviralstrains. crobial resistance, sexually transmitted diseases, and The Naval Health Research Center (NHRC) opened a bacterial wound infections. second BSL-3(agriculture-enhanced) laboratory suite in late 2009. The facility allows work with zoonotic influ- Accomplishments enzastrainssubmittedbyAFHSC-GEISpartnersaround Laboratory infrastructure development the world, includingdevelopment of new virusneutrali- Capacity-building initiatives continued to represent a zationtestingcapabilitiesagainstH5N1andotherhighly majorcomponentofAFHSC-GEIScontributionstoworld- pathogenic avian influenza strains. Additionally, two wideEIDsurveillanceandresponseactivities.Inadequate BSL-2laboratorieswerealsoestablishedattheCameroon Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page3of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 Table 12009Major LaboratoryCapacity-Building Initiatives by Geographic Region GeographicRegion MajorLaboratoryCapacityBuildingInitiative CountriesSupported SoutheastAsia NIC&militaryinfluenzalabequipment,reagent&trainingsupport;EID Bhutan,Cambodia,LaoPeople’sDemocratic laboratorydiagnostics&diseasesurveillancesystems Republic,Nepal,Singapore,Thailand FarEast NIC&militaryinfluenzalabequipment&reagentsupport;EIDlab Japan,Korea,Philippines proficiency&equipmentsupport East&CentralAfrica NIC&VHFlabequipment,reagent&trainingsupport;EIDlaboratory Cameroon,Kenya,Tanzania,Uganda diagnostics WestAfrica NIC&MoHinfluenzalabequipment,reagent&trainingsupport;VHFlab Benin,BurkinaFaso,Coted’Ivoire,Ghana, diagnostics&militaryEIDlabdiagnostictestingcapacity Liberia,Mali,Niger,Nigeria,SierraLeone,Togo NorthAfrica,Middle NIClabequipment,reagent&trainingsupport Afghanistan,Egypt,Iraq,Jordan,Kuwait,Oman, East&SouthwestAsia Pakistan,Sudan,Syria CentralAsia EID&influenzalabequipment,reagent&trainingsupport Azerbaijan,Georgia,Mongolia Europe Military&academicinfluenzalabequipment,reagent&trainingsupport Poland,Romania Central&South NIC&MoHinfluenzalabequipment,reagent&trainingsupport; Colombia,Ecuador,ElSalvador,Guatemala, America leishmaniamilitaryreferencelabequipment,reagent&trainingsupport Honduras,Nicaragua,Panama,Paraguay,Peru Acronyms:NIC,nationalinfluenzacenter;EID,emerginginfectiousdiseases;VHF,viralhemorrhagicfever;MoH,MinistryofHealth. Army Military Health Research Center, supported by Efforts were also undertaken to improve laboratory GlobalViralForecastingInitiativeinYaoundéandatthe capability for global influenza surveillance and diagnosis, University of Buea (Figure 2). Both facilities will greatly especially regarding the novel A/H1N1 influenza pan- improve the ability to conduct influenza and EID diag- demic. To this end, AFRIMS established viral/bacterial nosticwork,aswellaspotentiallyadvancedpathogendis- pathogen culture and molecular diagnostic capability in coveryworkinhard-to-reachlocationsinAfrica. their Nepal detachment to support the National Public Table 22009Capacity-Building Initiatives by Major Regional AFHSC-GEIS Supported Partners andType Partner TypeofInfrastructure/CapacityBuilding* Centers/ Field Countries* (seetext) Hospitals Sites AFRIMS Influenza&malaria/MDRlabs(KH,PH);enteric&influenzalabupgrade(NP,TH);bloodculture 22 51 5 (NP);influenzatesting(BT);influenzaantiviralresistance(TH) NAMRU-2 Malaria,FVBI,enteric,bloodculture&AMRtesting(KH);influenza&AFItesting(ID,KH,SG); 4 73 4 surveillancedatamanagement(LA) NAMRU-3 Influenza,bloodculture&AMRtesting(EG,JO);InfluenzaPCR/culture&antiviralresistancetesting 37 42 34 (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) NMRCD- InfluenzaPCR/culture&antiviralresistancetestingsupport(10countries);AFI&viralculture& 23 102 11 Peru serologytesting(PE,BO,EC,PY);LeishmaniaPCR,MDR,urine/vaginalPCR-STIs,RickettsialPCR& culture(PE);entericculture,PCR&AMRtesting(PE,EC,PY);Alertaelectronicdiseasesurveillance system(PE,PA,EC) USAMRU- Malaria/MDR,microscopy&PCR,rotavirus,cholera&otherADDtesting,arboviral/VHFPCR& 7 69 5 Kenya culture,AFIs,bloodculture&serologytesting,STIsculture(KE);influenzaPCR,culture&genotyping (KE,UG,CM);influenza,AFI,FVBI,cholera&otherADDs(KE,TZ,NG) PHCR-South InfluenzaPCR,culture&indirectimmunofluorescenceassay(US,HN,SV,NI,GT,PA);malaria, 4 7 6 Leishmania,&denguePCRtesting(HN) UnivIowa Respiratory&otherzoonoticrespiratoryEIDtesting&epidemiology(US,TH,KH,NG,RO,MN) 6 ~30 6 CEID JHU/APL Influenzamilitarytreatmentfacilities(PIPM)modeling(US);SMStext&ESSENCEDesktopedition 1 ~125 3 system(PH);OpensourceInteractiveVoiceRecognitionsoftwaresurveillance(PE);OpenESSENCE websitesoftwaresurveillance(US,PE);SMStext(PH) Acronyms:MDR,multidrugresistance;FVBI,febrile&vector-borneillnesses;AMR,antimicrobialresistance;AFI,acutefebrileillnesses(suchasdengue, leptospirosisandzoonoticinfections);PCR,polymerasechainreaction;ADD,acutediarrhealdiseases(suchastraveler’sdiarrhea,campylobacter,shigellosis, salmonellosis);STIs,sexuallytransmittedinfections,includingNeisseriagonorrhea;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). Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page4of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 Figure1AFRIMSBSL-3LaboratoryCommissioning.OnSeptember16,2009(fromlefttoright),MajorGeneralKrisadaDuangurai,director generalofAFRIMS;U.S.AmbassadorEricJohn,togetherwithColonelJamesBoles,commanderofAFRIMS,officiatedtheribbon-cutting ceremonyfortheAFRIMSBSL-3laboratory.Thisfacilitysignificantlycontributestothecountry’scapacitytoconductresearchandinvestigate outbreakscausedbyagents,suchasavianinfluenza,chikungunyavirusandotherendemicdiseasesthroughoutSoutheastAsia. Figure2InfluenzaSurveillanceCapacity-BuildingInitiativewithGlobalViralForecastingInitiativeandUniversityofBuea,Cameroon. Twobiosafetylevel-2laboratorieswererenovatedattheCameroonArmyMilitaryHealthResearchCenterinYaoundéandattheUniversityof Buea,incooperationwiththeCameroongovernmentandmilitary.Theselaboratorieshavethecapacitytoisolateandcharacterizehumanand animalinfluenzaviruses,aswellasotherEIDpathogensofunknownorigin. Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page5of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 Health Laboratory and also established real-time reverse AFRIMS [14] and at the U.S. Naval Medical Research transcriptase polymerase chain reaction (rRT-PCR) diag- Unit No. 2 (NAMRU-2) or the search for genetic muta- nostic capacity for influenza at a main tertiary-care hos- tions within influenza viruses that may indicate resis- pital of the Department of Health within the Visayas tance to antiviral medications. region of the Philippines. Developing influenza diagnostic capabilities at other Training NICs was also supported by the U.S. Naval Medical It is important to recognize that capacity building not Research Unit No. 3 (NAMRU-3) in Afghanistan, Iraq only involves renovating laboratories and providing diag- and Jordan; by the U.S. Naval Medical Research Center nostic equipment and supplies, but most important, Detachment in Peru (NMRCD-Peru) in the countries of building human capacity. Through training public health Colombia, Ecuador, Paraguay and Venezuela; and in and laboratory personnel, the physical infrastructure Kenya, by the U.S. Army Medical Research Unit-Kenya. could be properly leveraged for optimal support of IHR Finally, in conjunction with the CDC’s Central America (2005) compliance. During 2009, AFHSC-GEIS sup- and Panama center, the U.S. Army Public Health Com- ported 18 partner organizations that conducted 123 mand Region-South (PHCR-South) provided laboratory training initiatives in 40 countries involving at least technical assistance, reagents and supplies to the Minis- 3,130 people, including many host-country personnel, in tries of Health (MoHs) in El Salvador, Guatemala, Hon- direct support of assisting with compliance with IHR duras, Nicaragua and Panama, resulting in the (2005). Significant expansion of training activities was certification of the Guatemalan NIC and the testing of attained in the areas of pandemic preparedness, out- over 5,000 specimens for novel A/H1N1. break investigation and response, EID surveillance, and In collaboration with the Peruvian Navy, NMRCD- pathogen diagnostic techniques. Peru has built a robust shipboard disease surveillance By engaging local health and other government offi- infrastructure with detection capability modeled very cials and civilian institutions in training endeavors, the closely on the NHRC shipboard surveillance system. U.S. military’s role as a key stakeholder in global public The early detection aspect of this system involves health has improved; and many opportunities for EID- equipping participating ships with real-time PCR diag- related surveillance, research and capacity-building nostic capability for emerging infectious diseases, such initiatives have been leveraged to provide a platform for as influenza or adenovirus. Short-term storage of sam- public health training, described elsewhere in this sup- ples allows for more in-depth, follow-up testing at the plement [11]. laboratory in Lima or at other collaborating regional laboratories. Since 2007, this system has successfully Electronic surveillance initiatives identified and responded to numerous outbreaks of Electronic disease surveillance, another important com- respiratory, gastrointestinal and sexually transmitted ponent of a comprehensive global public health disease infections among active-duty Peruvian personnel preventionandcontrolstrategy,contributessignificantly aboard ships [12]. More recently, this capability was to capacitybuildingandsupportforIHR(2005)compli- instrumental in identifying and responding to a large ance in partner countries. Using electronic methods for outbreak of novel A/H1N1 on board a large deck ship data collectionandanalysishasthepotential toimprove in the Pacific [13]. theaccuracyandtimelinessofoutbreakdetection,aswell This investment in laboratory infrastructure develop- as to provide situational awareness during, or in the ment has directly impacted the number of outbreak aftermath of, an outbreak or pandemic. The AFHSC- investigations that the AFHSC-GEIS network has been GEIS network has supported numerous initiatives in able to support. The capacity-building efforts contribu- electronic disease surveillance during the past several ted to outbreak responses in 76 instances in 53 coun- years, in partnership with several DoD overseas labora- tries, representing every major populated region of the tories, host-country Ministries of Health and Defense world, including support for the confirmation of the andourtechnicalpartner, theJohnsHopkinsUniversity first cases of novel A/H1N1 in 14 countries (United AppliedPhysicsLaboratory(JHU/APL). States, Bhutan, Cambodia, Colombia, Djibouti, Ecuador, AFHSC-GEIS has relied on the extensive experience Egypt, Kenya, Kuwait, Lao People’s Democratic Republic that JHU/APL acquired in the design and implementa- (PDR), Lebanon, Nepal, Peru and the Republic of the tion of the Electronic Syndromic Surveillance for Early Seychelles) [12]. The laboratory infrastructure allows for Notification of Community-based Epidemics (ESSENCE) acute response capability and the ability to monitor system [15]. This electronic disease surveillance system, ongoing epidemics or shifting EID patterns, such as the used worldwide at all DoD military treatment facilities identification and continued monitoring of artemisinin- (MTFs), the U.S. Veterans Health Administration system resistant malaria in Southeast Asia by partners from and at least 12 states in the United States, served as a Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page6of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 model for a toolkit approach to deploying electronic age, gender and symptoms. The message is transferred surveillance within the AFHSC-GEIS network. Tools into a Microsoft Access© database, cleaned, and starting have been created to enable data collection from the July 2010, reviewed in the ESSENCE Desktop Edition most sophisticated data sources to remote settings application to identify statistically significant increases in where data have traditionally been difficult, if not reported fever cases. impossible, to collect. These tools have far-reaching Meanwhile, NAMRU-2 continued to support the opti- applicability in any resource-limited setting, whether mization of the Early Warning Outbreak Recognition overseas or after a disaster in the United States. The fol- System (EWORS) at 11 reference and provincial hospi- lowing describes some of the efforts that have focused tals in the Lao PDR allowing local MoH officials to on adapting electronic or syndromic surveillance techni- monitor the impact and burden of tropical and infec- ques to resource-limited settings. tious diseases in the country in real time. The CDC cur- Two electronic surveillance efforts were developed at rently funds most of the operating budget for EWORS AFRIMSinSoutheastAsiaandoptimizedin2009,includ- in Lao PDR. The system, jointly developed by the Indo- ing aproject withthe RoyalThaiArmy (RTA)in remote nesian MoH and NAMRU-2 with AFHSC-GEIS funding, border areas, as well as a pilot short message service is also being used in Indonesia as the national reporting (SMS)-based project in the Philippines, part of a joint system.EWORShasadditionallybeenusedinCambodia, effort with JHU/APL and the Cebu City Health Office Peru and Vietnam, although it is no longer in use in (CHO). The Thai Unit-Based Surveillance (UBS) project these countries because local health authorities favored commencedin2001andoriginallycoveredareasalongthe othersurveillancesystems. Thai-CambodiaborderwheretheThaiMoHdidnothave In South America, NMRCD-Peru supported major diseasesurveillancecapabilities.Theproject,developedby effortsinelectronicdiseasesurveillance,includingconti- the RTA with support from AFRIMS and AFHSC-GEIS, nuation and optimization of Alerta, a public-private reportsdiseasesinbothmilitaryandlocalcivilianpopula- initiativethathasrevolutionizedsurveillanceforthePer- tions by faxing reports or by voice via military radio. In uvian military during the past seven years. The Alerta 2009, the Thai-Myanmar border area was added and an system has seen recent expansion to all branches of the additional497personnel weretrained.Version2.0ofthe Peruvianmilitary,aswellasadoptionbytheMoHofone UBS simplified data collection from 216 symptoms and othercountryintheregion—Panama.Thissystemidenti- categorizationinto12syndromesthatareconsistentwith fied17 outbreaksduring2009,including influenza, den- the Thai MoH’s reporting requirements. This updated gue,mumps,malaria,hepatitisAandrespiratorydisease. system added questions about poultry exposure, leptos- Finally, in collaboration with the JHU/APL group, pirosis, novel A/H1N1infectionand chickungunya virus NMRCD-Peru worked to develop an electronic syndro- infection. Although no major outbreaks of disease were mic surveillance system based on open-source software detected by this system in 2009, it continued to provide foruseinresource-limitedenvironments.Asaresult,the situationalawarenessfortheRTAandThaiMoH. systemcanbesustainedwithoutcontinuedmajorinvest- Dengue fever poses a significant health threat in the mentsorsoftwarelicensingfees.Thiseffortinvolvedthe Philippines. Current hospital-based surveillance is highly development of interactive voice response reporting, as valid, but poorly suited for rapid identification of dengue wellasbuildingaweb-basedinfrastructureand database ”hot spots” because of delays associated with laboratory on an open-source version of the ESSENCE system confirmation. To capture this important data for the (OpenESSENCE) in use in the United States. Addition- purposes of surveillance, a more rapid, but less specific ally, NMRCD-Peru supported the systematic evaluation surveillance method was implemented and compared to of these electronic surveillance systems and research on the standard sentinel surveillance system. This pilot waystoimprovereportingviaelectronicsystems[16]. study implements and evaluates a simple dengue surveil- These electronic surveillance initiatives constitute a lance protocol using SMS text messages to send daily, vibrant portfolio that capitalizes on the expertise of the person-based dengue surveillance data from local Baran- JHU/APLgroupandnumerousAFHSC-GEISpartnersat gay Health Centers (BHCs) to the city health office overseaslaboratoriesandwithinhost-countryMinistries (CHO) in Cebu City. The pilot activity was originally ofHealthandDefense.Manyofthelessonslearned,chal- established in five clinics as of March 2009, but was lenges, successes and failures have been shared within soon instituted in all BHCs in the city. Beginning July 1, thisnetworkofcollaborators,andaharmonizedstrategy 2009, all BHCs have been identifying all patients report- is emerging to develop and deploy an electronic disease ing to clinic with fever. Each day, BHC personnel send surveillance system that is modular and responsive to this information to the CHO, creating a text message various needs found in developing settings. This for each patient with fever. The SMS message contains approachshouldassistmanycountriesincomplyingwith the date and clinic name, as well as the patient’s name, IHR(2005)bythe2012deadline. Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page7of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 Provision of technical expertise/reference and foreign military counterparts continued to be an laboratory support area of high interest and priority for AFHSC-GEIS. The In addition to supporting laboratory infrastructure network currently supports active military partnerships development and new surveillance initiatives, AFHSC- in 14 countries. These partnerships resulted in a num- GEIS provided technical expertise in support of capa- ber of collaborative response activities that supported city-building efforts. In 2009, one of the largest such foreign military partners, multinational peacekeepers efforts was the network’s global response to the novel and observers in joint exercises and missions. A/H1N1 influenza pandemic. For example, NAMRU-3 The late spring and summer outbreaks of novel provided training on laboratory techniques for 73 scien- A/H1N1 in military treatment facilities throughout tists and technical personnel from 32 countries in wes- Europe resulted in collaboration between Landstuhl tern and northern Africa, the Middle East, and central Regional Medical Center and PHCR-Europe and the Asia, as well as equipment and reagent support to estab- German Military Reference Laboratory. The long-stand- lished NICs in Egypt, Kuwait, Oman, Pakistan, Sudan ing relationship between the U.S. European Command and Syria. Support for further viral characterization by and the German Army’s Public Health Service helped genetic sequencing and antiviral resistance testing was assist in disseminating confirmed results through weekly also performed at NAMRU-3, with reference testing surveillance reports sent to military clinicians, hospital support by the CDC in Atlanta. This virology diagnos- commanders, and other public health officials within the tic-testing capacity building of national reference labora- U.S. military and the local German public health infra- tories constituted an essential step in establishing the structure. This arrangement greatly aided the U.S. capability for H5N1 and novel A/H1N1 detection and European Command’s ability to conduct surveillance for rapid response, and resulted in a better understanding novel A/H1N1 within the European military community of the epidemiologic patterns of respiratory viruses cir- and assisted German government officials in monitoring culating in the region. It also represented the first step the level of disease within their country. toward NIC accreditation and collaboration with the Efforts have been established to collaborate on more WHO Global Influenza Surveillance Network in support expansiveandcross-cuttingsurveillancesystemswithmili- of influenza vaccine development. By linking countries tary partners in Poland and Singapore. These efforts in regional and sub-regional networks and by fostering include a wide spectrum of surveillance from electronic participation in WHO missions to assess laboratory test- earlydetectionsystemsandroutinelaboratory-basedsenti- ing capacity needs, NAMRU-3 played a direct role in nel surveillance to robust pathogen discovery initiatives promoting IHR (2005) compliance. andfocusedpublichealthresearchendeavors.Collabora- Working closely with U.S. Central Command andU.S. tively,theseeffortshavedevelopedsignificantlyduringthe AfricaCommand,NAMRU-3andtheU.S.NavyEnviron- past year and have helped serve as a model for other mental andPreventive Medicine Unit No. 2(NEPMU-2) AFHSC-GEIS partners to engage their regional foreign provided focused laboratory assessment, training, emer- military counterparts. These mil-mil partnerships with gencysuppliesandqualityassurancesupporttofivemili- allied countries allow for open collaboration, capacity tary,far-forwarddeployed,influenzatestinglaboratoriesin buildingandtransparentdialoguebetweenpartnercoun- Southwest Asia and assisted with the deployment of the tries,andthushavethepotentialtodevelopameaningful JointBiologicalAgentIdentificationandDetectionSystem frameworktobetterunderstanddiseasedynamicsamong (JBAIDS) platform for confirmation of novel A/H1N1 military populations in different parts of the world. To casesin-theater.Thiscapabilitysubsequentlyprovedcriti- furtherfosteropportunitiesforthesemil-milpartnerships, cal when Expeditionary Medical Forces in Kuwait and AFHSC-GEISisworkingwiththeInternationalCongress Djibouti were able to identify and respond to novel onMilitaryMedicineandtheWHObyfacilitatingeduca- A/H1N1andseasonalinfluenzaoutbreaks,respectively. tional opportunities withregardto IHR (2005) and crea- Network expertise and competence were important in tion of a portfolio of robust epidemiological tools and supporting global influenza testing efforts. For instance, trainingthatmembercountriescanaccessasneeded[17]. the AFRIMS-supported laboratory in the Philippines was designated by the Philippine NIC as the only other Future directions and challenges facility authorized to conduct novel A/H1N1 testing, in Significant progress wasattained in expansion ofworld- support of central and southern regions of the country wide EID surveillance and response initiatives in fiscal (specifically, Mindanao and Visayas). 2009 through the capacity-building efforts of the AFHSC-GEISnetworkdescribedabove.Atthisjuncture, Military-to-military (mil-mil) partnerships however,itisnecessarytoachieverealisticgoalsinterms Growing collaborative military-military partnerships and ofmaturation,standardizationandunificationofthedivi- surveillance exchanges among global network partners sion’s global surveillance efforts. This can best be Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page8of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 accomplished by pursuing the following strategic goals: keeping the maintenance of the U.S. military’s health 1)adoptingobjectivemetricsofevaluation,suchastime- (known as “Force Health Protection”) as our unique linessofdiseasedetectionandreportingtohigherlevels, niche in the setting of improving global public health. proportionofsites submittingtimely weekly ormonthly Meaningful public health initiatives taking place in any reports, proportion of investigated outbreaks with con- one of the partner countries within the AFHSC-GEIS firmed laboratory results, and proportion of confirmed globalnetworkmustaimforincremental,albeitsustain- outbreaks with nationally recommended public health able, development of capacity on behalf of their partner response [18]; 2) ensuring future standardization of host countries and do so in line withthe specific PPD-2 geneticandmolecular-basedtestingplatforms(e.g.,PCR- objectivesandIHR(2005)competencies.Inthismanner, basedassays)acrossthenetworkofpartners;3)establish- small improvements in capacity, improved testing abil- ing electronic sequence datarepositoriesformore effec- ities,andultimately,compliance withreportingwilllead tive informationsharing with the CDC, WHO and local tobenefitsforthehealthofU.S.servicemembersandfor regional health authorities (especially for influenza and thehealthoftheworld. otherrespiratorypathogens);4)continuingemphasison collaborative work with host-country partners to empower them to reach IHR (2005) capacity-building Acknowledgements #AFHSC-GEISCapacityBuildingWritingGroup:ClaraJWitt1,NishaNMoney1, milestones by 2012; and, 5) achieving standardized JoelCGaydos1,JulieAPavlin2,RobertVGibbons2,RichardGJarman2,Mikal reporting schemes for all AFHSC-GEIS partners in the Stoner2,SanjayaKShrestha2,AngelaBOwens3,NaomiIioshi3,MiguelA areas of influenza, enteric diseases, febrile and vector- Osuna3,SamuelKMartin4,ScottWGordon4,WallaceDBulimo4,Dr.John Waitumbi4,BerhaneAssefa4,JeffreyATjaden5,KennethCEarhart5,Matthew borneillnesses,sexuallytransmittedinfections,andanti- RKasper6,GaryTBrice6,WilliamORogers6,TadeuszKochel7,VictorAlberto microbial resistance monitoring. In this manner, the Laguna-Torres7,JosefinaGarcia7,WhitneyBaker8,NathanWolfe9,Ubald AFHSC-GEISnetworkwillcontinuetocontributetothe Tamoufe9,CyrilleFDjoko9,JosephNFair9,JaneFrancisAkoachere10,Brian Feighner11,AnthonyHawksworth12,ChristopherAMyers12,WilliamG global efforts in disease control and prevention through Courtney13,VictorAMacintosh13,ThomasGibbons13,ElizabethAMacias13, the DoD’s laboratory-based surveillance and by enhan- MaxGrogl14,MichaelTO’Neil14,ArthurGLyons14,Huo-ShuHoung14, cing harmonizationofeffortswithotherkeyUSGstake- LeopoldoRueda14,AnitaMattero14,EdwardSekonde14,RosemarySang15, WilliamSang15,ThomasJPalys16,KurtHJerke16,MonicaMillard17,Bernard holders, such as the U.S. Department of Health and Erima17,DerrickMimbe17,DenisByarugaba18,FredWabwire-Mangen18, HumanServices,theU.S.AgencyforInternationalDevel- DannyShiau19,NatalieWells19,DavidBacon19,GeraldMisinzo20,Chesnodi opmentandtheU.S.DepartmentofState. Kulanga20,GeertHaverkamp20,YadonMtarimaKohi21,MatthewLBrown22, TerryAKlein22,MitchellMeyers22,RandallJSchoepp23,DavidANorwood23, Many challenges exist to building capacity for public MichaelJCooper24,JohnPMaza24,WilliamE.Reeves25,andJianGuan25. healthinresource-limitedsettings,includingachievingsus- Theauthorswishtothankthenumerousindividualswhoperform tainabilityofeffortsaftersupportiswithdrawn,containing surveillanceaspartoftheAFHSC-GEISglobalnetwork,includingall individualsintheMinistriesofHealthandMinistriesofDefenseofour the departure of highly-trained, capable scientists after partnernationswhoseeffortshavecontributedtothesuccessofthe training,andminimizingtheduplicationofeffortsamong network. multiplesponsoragencieswithintheUSGandwithother Disclaimer Theopinionsstatedinthispaperarethoseoftheauthorsanddonot organizations. Data sovereignty and data sharing are also representtheofficialpositionoftheU.S.DepartmentofDefense,local keyissuesthatrequiretransparencyonthepartofboththe countryMinistriesofHealth,AgricultureorDefense,orothercontributing sponsorandrecipientinordertooptimallyconductdisease networkpartners. ThisarticlehasbeenpublishedaspartofBMCPublicHealthVolume11 surveillancethatsatisfiesthespiritofIHR(2005).Solutions Supplement1,2011:DepartmentofDefenseGlobalEmergingInfections tomanyofthesechallengesaresometimesdifficultandfre- SurveillanceandResponseSystem(GEIS):anupdatefor2009.Thefull quentlyrequirecontinuousre-evaluationofbestofpractice contentsofthesupplementareavailableonlineat http://www.biomedcentral.com/1471-2458/11?issue=S2. solutionsforindividualsettings. Through the development of active, mutually suppor- Authordetails tiverelationshipswithlocalhealthofficialsandtheestab- 1ArmedForcesHealthSurveillanceCenter,503RobertGrantAvenue,Silver Spring,MD20910,USA.2ArmedForcesResearchInstituteofMedical lishment of important protocol-driven clinical and Sciences,315/6RajavithiRoad,Bangkok,Thailand10400.3U.S.ArmyPublic laboratorysurveillanceprojects,AFHSC-GEISsupported HealthCommandRegion-South,Building2472,SchofieldRoad,FortSam scientistshavebecomerelevantstakeholderswithinhost- Houston,TX78234,USA.4U.S.ArmyMedicalResearchUnit-Kenya,U.S. Embassy,Attn:MRU,UnitedNationsAvenue,P.O.Box606,VillageMarket country public health communities and are able to con- 00621Nairobi,Kenya.5NavalMedicalResearchUnitNumber3,Extensionof tinuetoworkinthecriticaldevelopmentofsurveillance, RamsesStreet,AdjacenttoAbbassiaFeverHospital,PostalCode11517, laboratory and communications infrastructure within Cairo,Egypt.6NavalMedicalResearchUnitNumber2,Kompleks PergudanganDEPKESR.I.,JI.PercetakanNegaraIINo.23,Jakarta,10560, partner countries. In addition to the IHR (2005), the Indonesia.7NavalMedicalResearchCenterDetachment-Peru,CentroMedico AFHSC-GEIS global network recognizes the recently Naval“CMST,”Av.VenezuelaCDRA36,Callao2,Lima,Peru.8Departmentof released National Strategy for Countering Biological EnvironmentalandGlobalHealth,CollegeofPublicHealthandHealth Professions,UniversityofFlorida,PostOfficeBox100188,Gainesville,FL Threats(PPD-2)asanotherguidingframeworkforalign- 32610,USA.9GlobalViralForecastingInitiative,OneSutterStreet,Suite600, mentofourprogramwiththelargerUSGinitiatives[19], SanFrancisco,CA94104,USA.10UniversityofBuea,Departmentof Sanchezetal.BMCPublicHealth2011,11(Suppl2):S4 Page9of9 http://www.biomedcentral.com/1471-2458/11/S2/S4 BiochemistryandMicrobiology,FacultyofScience,PostOfficeBox63,Buea, 13. CDC:OutbreakofPandemicInfluenzaA(pH1N1)VirusonaPeruvian SouthWesternProvince,Cameroon.11JohnsHopkinsUniversityApplied NavyShip—2009.Mmwr2010,59(6). PhysicsLaboratory,11100JohnsHopkinsRoad,MP2-160,Laurel,MD20723- 14. NoedlH,SeY,SchaecherK,SmithBL,SocheatD,FukudaMM:Evidenceof 6099,USA.12NavalHealthResearchCenter,140SylvesterRoad,SanDiego, artemisinin-resistantmalariainwesternCambodia.TheNewEngland CA92106,USA.13U.S.AirForceSchoolofAerospaceMedicine,PublicHealth JournalofMedicine2008,359(24):2619-2620. andPreventiveMedicineDepartment,2513KennedyCircle,Building180, 15. LewisMD,PavlinJA,MansfieldJL,O’BrienS,BoomsmaLG,ElbertY, BrooksCity-Base,TX78235-5116,USA.14WalterReedArmyInstituteof KelleyPW:Diseaseoutbreakdetectionsystemusingsyndromicdatain Research,Building503,503RobertGrantAvenue,SilverSpring,MD20910- thegreaterWashington,D.C.area.AmericanJournalofPreventiveMedicine 7500,USA.15KenyanMedicalResearchInstitute,MbagathiPostOfficeBox 2002,23(3):180-186. 54840,00200,Nairobi,Kenya.16LandstuhlRegionalMedicalCenter,CMR402, 16. HuamanMA,Araujo-CastilloRV,SotoG,NeyraJM,QuispeJA, Box483,APOAE09180,USA.17MakerereUniversityWalterReedProject,Plot FernandezMF,MundacaCC,BlazesDL:Impactoftwointerventionson 42,NakaseroRoad,PostOfficeBox16524,Kampala,Uganda.18Makerere timelinessanddataqualityofanelectronicdiseasesurveillancesystem University,FacultyofVeterinaryMedicine&Medicine,PostOfficeBox16524, inaresourcelimitedsetting(Peru):Aprospectiveevaluation.BMCMed Kampala,Uganda.19NavyEnvironmentalandPreventiveMedicineUnit InformDecisMak2009,9:16. Number2,1887PowhatanStreet,Norfolk,VA23511-3394,USA. 17. RussellKL,RubensteinJ,BurkeRL,VestKG,JohnsMC,SanchezJL,MeyerW, 20PharmAccessFoundation,SkywayBuilding,ThirdFloor,PlotNumber149/ BlazesDL:GEISOverviewPaper.BMCPublicHealth2010. 32,CornerofOhioStreet/SokoineStreet,PostOfficeBox635,DaresSalaam, 18. WHO:ProtocolfortheAssessmentofNationalCommunicableDisease Tanzania.21TanzaniaPeople’sDefenceForces,DefenceForcesHeadquarters SurveillanceandResponseSystems:GuidelinesforAssessmentTeams, MedicalServices,PostOfficeBox9203,DaresSalaam,Tanzania.22U.S.Army WHO/CDS/CSR/ISR/2001.2.Geneva,Switzerland:WorldHealthOrganization MedicalDepartmentActivity&65thMedicalBrigade,Korea,Unit15281,Box Press;2001. 769,APOAP96205-5281.23U.S.ArmyMedicalResearchInstituteofInfectious 19. NationalSecurityCouncil:NationalStrategyforCounteringBiological Diseases,DiagnosticSystemsDivision,1425PorterStreet,FortDetrick,MD Threats.TheWhiteHouse,Washington,D.C.;2009. 21702-5011,USA.24U.S.ArmyPublicHealthCommandRegion-Europe, Building3810,CMR402,Box808,APOAE09180.25U.S.ArmyPublicHealth doi:10.1186/1471-2458-11-S2-S4 CommandRegion-Pacific,Building715,CampZama,Japan,Unit45006,APO Citethisarticleas:Sanchezetal.:Capacity-buildingeffortsbythe AP96343-5006. AFHSC-GEISprogram.BMCPublicHealth201111(Suppl2):S4. 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