Emerging Infectious Diseases InTheatre: Risks and Mitigation Can current surveillance efforts and th

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Emerging Infectious Diseases In-Theatre Risks
and MitigationCan current surveillance efforts
and their results be better coordinated?
Washington DC05 June 2009
Armed Forces Health Surveillance Center Kevin
L. Russell, MD, MTMH CAPT, Medical Corps, US
Navy Director, DoD-GEIS Deputy Director,
AFHSC kevin.russll4_at_us.army.mil
www.afhsc.mil
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Can current surveillance efforts and their
results be better coordinated?
Yes
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AFHSC Initial Operating Structure
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AFHSC
ELECTRONIC DATABASES SEROSURVEYS GEIS-PARTNE
RS
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DMSS Structure Functional Relationships
(Active and Reserve Components)
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Theater Health Surveillance Data Sources and
Flow Patterns

• JCS DNBI data (weekly)
• CENTCOM SSC (daily)
• DMDC CTS Deployment Roster
• TriService Reportable Medical Events
• Occupational/Environmental Exposure Reports
• Post-Deployment Health Assessments
• Casualty Reports (subset of AFIP Mortality
  Surveillance)
• Wounded
• KIA
• RTD

AHLTA-T
SAMS
JMeWS (classified) TMDS (unclassified)

• Customers
• SecDef
• CENTCOM
• SGs
• Field units

AFHSC
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Disease Non-battle Injury (DNBI)Weekly JCS
Requirement

• Dermatologic
• GI, infections
• Gynecologic
• Ophthalmologic
• Psychiatric
• Combat stress
• Respiratory
• Intimate diseases
• Fever, gt24 hours
• Neurologic (new)
• All other, med/surg

• Injuries, heat/cold
• Injuries, sports/recreation
• Injuries, motor vehicle
• Injuries, work/training
• Injuries, other

• Problems
• Data 10-14 days old when analyze
• This wont detect WMD attacks
• Solution?Special Surveillance

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Electronic Databases Areas for Improvement

• Bridge critical data gaps
• Denominator data accuracy
• Declassification of location data after
  reasonable period of time
• Environmental exposure data, link with location
  data
• In-theater hospitalization and surgery data
• Final disposition, e.g. return to theater,
  terminated deployment
• Continued improvement in the capture of theater
  medical encounters
• Fully automate data collection and analysis
• Validate and refine syndromic categories
• Disconnect in the categories for DOD DNBI versus
  EPINATO reports
• Integrate diverse data streams
• Lab results
• Personnel data
• Geospatial data
• Monitor cohorts, e.g. - unusual exposures, risk
  groups
• Validate and refine threshold determination and
  risk assessment methodologies
• Evaluate new technologies (biomarkers,
  microarrays) and analytical approaches

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AFHSC
ELECTRONIC DATABASES SEROSURVEYS GEIS-PARTNE
RS
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Studies
AFHSC DoD Serum Repository (DoDSR)
External

• Q-Fever
• WRAIR/USAFSAM Among OIF symptomatic deployers
  approx 10 seroconversion
• Ft. Leonard Wood Sandfly fever among Army OIF
  deployers
• Leishmaniasis
• USUHS/NAMRU-3 Antibodies to sandflies
  serogate for exposure? Pre/post seroconversion
• H. pylori
• NNMC Seroconverson among OIF deployers
  Pre/post seroconversion
• Historic Desert Storm publication with 4.5
  seroconversion (Taylor DN et al, CID 1997)
• HIV-1
• WRAIR Seroconversion among OIF/OEF deployers
  Pre/post seroconversion

Internal

• Hepatitis E in Afghanistan
• AFRIMS Did testing with WRAIR methodology
  Pre/post serum from 1500 deployers for HEV
  antibody
• Very low seroconversion (0.13)
• Respiratory Infections in Afghanistan
• NHRC Did testing
• Pre/post serum from 1000 deployers for 7
  respiratory pathogens
• 30.1 seroconverted to something highest
  15.6 to Influenza A, H3

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AFHSC
ELECTRONIC DATABASES SEROSURVEYS AFHSC/GEIS
PARTNERS
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EIDs in Theatre GEIS Partners
AFHSC/GEIS

• Leptospirosis
• BAMC Acute Febrile US Service Members Evaluated
  at the Ibn Sina CSH (Bagdad)
• No diagnosis of leptospirosis in tests of sera
  from 18 febrile patients
• Leishmaniasis
• NAMRU-3 Identification of Leishmania Parasites,
  Hosts, and Vectors in Afghanistan and Libya
• Over 1000 sandfly vector samples from Afghanistan
  thus far
• Historic publications demonstrating risk in many
  areas
• Multi-drug Resistance
• BAMC Continued development of a multiply-drug
  resistant (MDR) bacteria molecular epidemiology
  referral laboratory.
• WRAMC/WRAIR Environmental sampling of patient
  care areas performed immediately before a new
  trauma/surgical suite opened at a combat support
  hospital in Iraq
• MDRO did not populate until patients admitted
• Acinetobacter
• LRMC Conducting a retrospective study of
  strains isolated from LRMC patients dating from
  April 2003 to present day
• Rep-PCR clusters into 10 genotypes
• Genotypes correlate with resistance pattern

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Acinetobacter isolates from FOB-Delta
AFHSC/GEIS
New Combat Surgical/Trauma Suite

• High risk organism isolation over time during
  construction of medical facility
• MDR Gram negatives not isolated prior to patient
  introduction into facility but high risk
  pathogens present

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EIDs in Theatre GEIS Partners
AFHSC/GEIS

• NMCPHC HL7 Electronic Data Monitoring
• Multi-drug Resistance Comparison of
  antibiograms for infections of deployed and
  non-deployed personnel
• Acinetobacter Methods for characterization of
  antimicrobial resistance using electronic
  databases
• Enterics
• NAMRU-3 Diarrhea Surveillance and Disease
  Spectrum in Africa and Middle East
• Djibouti 2 cases Shigella
• Stool samples from Afghanistan, Iran, Iraq,
  Jordan, Morocco, Sudan and Syria being analyzed
• Establish Vibrio cholerae and rotavirus reference
  center in six countries (including Iraq)
• 788 samples from 8 countries to be analyzed
• Antimalaria Drug Resistance
• NAMRU-3 Baseline anti-malarial resistance in
  and genotypes of Plasmodium falciparum in
  Afghanistan and Djibouti
• Horn of Africa as well
• 2009 H1N1
• NEPMU-2 and USAFSAM
• NAMRU-3
• CENTCOM LRMC and CHPPM-EUR

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NEPMU-2 and USAFSAM
Laboratory Results07-09
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CHPPM-EUR/Landstuhl Regional Medical
Center CENTCOM Surveillance Findings 07-09
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NAMRU-3
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Emerging Infectious Diseases In-Theatre Risks
and Mitigation
Risks

• Acinetobacter
• Q-Fever
• Influenza
• P falciparum Afghanistan Kotwal RS et al
  JAMA 2005
• Norovirus all forces multiple publications
  (deploymentsDesert Storm, ships, etc)
• Prob leishmaniasis

Mitigations

• Additional leveraging of existing capabilities
• More robust laboratory testing
• Evaluation of existing mitigation procedures
• Vaccines