Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System A Program Review Philip S. Brachman, Heather C. O’Maonaigh, and Richard N. Miller, Editors Committee to Review the Department of Defense Global Emerging Infections Surveillance and Response System Medical Follow-Up Agency INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by Contract No. DAM17-00-P-0412. 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Wulf are chairman and vice chairman, respectively, of the National Research Council. COMMITTEE TO REVIEW THE DEPARTMENT OF DEFENSE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM PHILIP S. BRACHMAN (Chair), Professor, Department of International Health, Rollins School of Public Health, Emory University, Atlanta, Georgia RUTH L. BERKELMAN, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia DONALD S. BURKE, Professor, Department of International Health and Director of the Center for Immunization Research, Johns Hopkins School of Public Health, Baltimore, Maryland KATHLEEN F. GENSHEIMER, State Epidemiologist, Bureau of Health, Maine Department of Human Services, Augusta, Maine C. JAMES HOSPEDALES, Director, Caribbean Epidemiology Center, Pan American Health Organization, World Health Organization, Port of Spain, Trinidad, West Indies ANN MARIE KIMBALL, Professor, Health Services and Epidemiology, Adjunct in Medicine, University of Washington, Seattle, Washington GUÉNAËL R. RODIER, Director, Department of Communicable Disease Surveillance and Response, World Health Organization, Geneva, Switzerland RONALD K. ST. JOHN, Executive Director, Center for Emergency Preparedness and Response, Health Canada, Ottawa, Ontario, Canada Project Staff RICHARD N. MILLER, Study Director HEATHER C. O’MAONAIGH, Program Officer PAMELA RAMEY-McCRAY, Administrative Assistant ANDREA COHEN, Financial Associate v Preface The U.S. Department of Defense (DoD) has historically defined its interest in infectious diseases almost exclusively in terms of “battle- stopper” illnesses—those resulting in acute effects that can directly affect military operations. Although this approach remains central to the U.S. military’s infectious disease doctrine, development of the DoD Global Emerging Infections Surveillance and Response System (GEIS) is part of an important transition in the way that the threat of infectious diseases— and, more specifically, the threat of emerging infectious diseases—is per- ceived and addressed by the U.S. military. Emerging infectious disease surveillance is sustained globally through a network of activities maintained through the collective efforts of numer- ous governmental and nongovernmental agencies. It is through the con- tributions of many partners that surveillance for emerging infectious diseases is possible. The DoD possesses valuable resources that can be brought to bear in this effort. It maintains an extensive, diverse array of laboratory facilities, both within the United States and overseas. These DoD laboratories can perform routine diagnostic testing, but they also possess rare, sometimes unique, diagnostic capabilities. DoD overseas laboratories are located throughout the world in areas where the potential for the emergence of infectious diseases is high. Often, laboratories oper- ate in regions where alternative laboratory resources are sparse or nonex- istent (e.g., sub-Saharan Africa). No other organization or government in the world maintains such extensive or capable laboratory facilities and staffing internationally. DoD laboratory facilities represent medical re- vii viii PREFACE search, public health, and diplomatic resources that serve U.S. military, U.S. civilian, and global interests alike. For more than a decade, formal DoD participation in emerging infec- tious disease surveillance has been encouraged by many in the U.S. public health community and within the DoD. In 1996, Presidential Decision Directive NSTC-7 (NSTC is the National Science and Technology Council of the Executive Office of the President) transformed these recommenda- tions into a mandate. Thereafter, the National Intelligence Council de- clared emerging infectious diseases to be a threat to the national security of the United States, underscoring the importance of DoD participation in disease surveillance efforts. This role is not an altogether new one, as the DoD has been conducting various infectious disease surveillance projects (e.g., for influenza) for many years. Accommodation of its expanded role has led the DoD to implement GEIS. The committee recognizes this effort as a responsive and effective step toward addressing the problem of emerging infectious diseases. We would like to thank the staff of the DoD laboratories, both domes- tic and overseas, and the staff of the GEIS Central Hub for the time and effort that they have invested in sharing with us information about the GEIS operations that they support. This review effort was very much a collegial one, and the report benefited from the openness of all those who provided us with documentation, presentations, and conversations. This study was also enriched by the insights that GEIS collaborators and asso- ciates provided regarding their views of GEIS from the outside looking in. Lists of the laboratory staff and GEIS collaborators and associates who shared their time with the committee can be found at the ends of Chapters 2 through 7 of this report. Any omissions are strictly the result of over- sight. The support provided by Institute of Medicine staff was instrumental in keeping this study moving apace. We extend our thanks to Richard Miller, Heather O’Maonaigh, and Pamela Ramey-McCray of the Institute of Medicine’s Medical Follow-Up Agency and to National Academies Travel staff, particularly Ann-Marie Walko, for their assistance. This study also benefited from the attention of Andrea Cohen, financial associate; Michael Hayes, consulting editor; and Linda Kilroy, contracting officer. Medical Follow-Up Agency staff members Phillip Bailey, Salem Fisseha, Lois Joellenbeck, and Karen Kazmerzak also helped along the way. In addition, we are grateful to GEIS Central Hub staff members, par- ticularly Joel Gaydos, Steve Gubenia, Patrick Kelley, Jennifer Rubenstein, and James Writer for their tireless assistance in preparing and compiling background documents and for helping to plan and negotiate the logistics of site visits. Likewise, we offer special thanks to Roxana Lescano, Lucy Rubio, and Trueman Sharp, Naval Medical Research Center Detachment, PREFACE ix Peru; Andrew Corwin and John Sisson, Naval Medical Research Unit 2, Indonesia; Gaye Ruble, Armed Forces Research Institute of Medical Sci- ences, Thailand; Cole Church, Naval Medical Research Unit 3, Egypt; Ronald Rosenberg, U.S. Army Medical Research Unit, Kenya; and Leslie Henry, Naval Health Research Center, San Diego, for their help in putting site visits together. This report is a testament to the hard work, patience, and resolve of many. We extend to all involved our appreciation and gratitude. Philip S. Brachman (Committee Chair) Ruth L. Berkelman Donald S. Burke Kathleen F. Gensheimer C. James Hospedales Ann Marie Kimball Guénaël R. Rodier Ronald K. St. John