UNCLASSIFIED

Global Health Surveillance at the Armed Forces Health Surveillance Center

(AFHSC)Central Asia Regional Health Security Conference

17-19 April 2012, Garmisch-Partenkirchen, Germany

COL Robert J. Lipnick, MS, MSS, ScDChief, Division of Communications, Standards and Training

Robert.Lipnick@us.army.mil

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Global EIDs: Selected Examples

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US Military Around the Globe

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AFHSC Mission and Vision

• Vision: To be the central epidemiological resource and a global health surveillance proponent for the U.S. Armed Forces

• Mission: Provide timely, relevant, actionable, and comprehensive health surveillance information in order to promote, maintain, and enhance the health of military, military-associated populations

– Acquire, analyze/interpret, disseminate information, and recommend evidence-based policy

– Develop, refine, and improve standardized surveillance methods– Serve as focal point for sharing health surveillance products, expertise

and information– Coordinate a global program of militarily relevant infectious disease

surveillance

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Armed ForcesHealth Surveillance

Center

PHC(P) POPM

NMCPHCBUMED

USAFSAMAFMOA

MTFs

Public Health

Centers

CDC

State Depts

County Metro Depts

Dashed line indicates direct contact under appropriate circumstances

DoD

AFHSC Relationships

Similar in nature to CDC and State and local health departments

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AFHSC Overview

• Division of Epidemiology and Analysis– Utilizes the Defense Medical Surveillance System (DMSS)– Periodic reporting of DoD health statistics and surveillance– Customized analysis and reports for military leadership

• Division of Communications, Standards and Training– Coordinating web-presence, publications and public affairs– Develop and document surveillance standards– Organize and execute training exercises and conferences

• Division of GEIS Operations– Funding of infectious disease and surveillance research– Coordination among overseas laboratories and other partners in the global

surveillance network– Response to outbreak alerts and emergency notifications

• Data Management and Technical Support– Design, operation and management of the DMSS– Operation of the DoD Serum Repository

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Defense Medical Surveillance System (DMSS)

Pre-Induction

Post-Discharge

MEPS12.4 million persons27.4 million records

In-Patient Hospitalizations2.6 million records

Ambulatory Data234 million records

Health Risk Assessments575,000 records

Immunizations100 million records

Casualty Data50,339 AD Deaths

Pre / Post-DeploymentSurveys9,435,580 surveys

Reportable Diseases291,000 records

Deployments5.1 million records

Serum Specimens(DoD Serum Repository)54.2 million specimens

Personnel Data9.5 million persons114.4 million records

All counts current as of December 2011

Longitudinal Database

Chemistry19.2 million records

Microbiology1.8 million records

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DoD Serum Repository (DoDSR)

• World’s largest serum repository• Unrivaled potential for sero-epi studies• 54M serial serum specimens from 9.5M individuals• Linked to demographic, military, and medical

information via the DMSS

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• Adenovirus among military and Coast Guard recruits• Risk of HIV sero-conversion in US soldiers • Susceptibility of measles and rubella among US Army

recruits• Leishmaniasis serology in Gulf War veterans• Persistence of antibody to Japanese encephalitis vaccine• Sero-prevalence of hepatitis A, B and C in recruit

applicants• Hantavirus in military personnel from four corners area • Serologic evaluation for mycoplasm in Gulf War veterans• PSA levels and PSA velocity and the risk of prostate

cancer• Prevalence of West Nile Virus in NY military applicants

Serologic Studies

Examples Using the DoDSR

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AFHSC Periodic Reports in One Year

Report Name Period Versions Recipients per year

Weekly MedEvacs report for DMDC Weekly 1 7 52

DMSS Counts Monthly 1 1 12

MHS Dashboard Measures Monthly 6 5 72

Special Surveillance: Amputations, DVT, Leish, ARDs Monthly 1 1 12

MSMR Special Surveillance MVA Monthly 1 1 12

MSMR Deployment Health Monthly 1 1 12

EUCOM RMES Monthly Report Monthly 1 1 12

Disease and Injury Distribution by service: Quarterly 2 4 8

PreDeployment Health Assessment (DD2795) Summary Monthly 2 50 24

PostDeployment Health Assessment (DD2796) Summary Monthly 2 50 24

PostDeployment Health Reassessment (DD2900) Monthly 2 50 24

Civilian PreDeployment Health Assessment (DD2795) Quarterly 1 2 4

Civilian PostDeployment Health Assessment (DD2796) Quarterly 1 2 4

DOD Eye Injury Quarterly 1 1 4

DOD Hearing Injury Quarterly 1 1 4

Civilian PostDeployment Health Reassessment (DD2900) Quarterly 1 2 4

Deployment Health Compliance Report Quarterly 4 50 16

Deployment Health Civilian Compliance Report Quarterly 1 2 4

Deployment Health Report Quarterly 1 2 4

Army DD2900 Delinquency Report Semi-annual 1 3 2

DOD Annual Eye Injury Annual 1 1 1

DOD Annual Hearing Injury Annual 1 1 1

USCG PHA, PDHA PDHR Annual 3 1 3

Smallpox Vaccine Adverse Events – Cardiac Monthly 1 1 12

Reportable Events Vaccine Adverse Events (VAERS) Monthly 1 1 12

Totals for one year versions 81 reports 757

Report Name Period Versions Recipients per year

DOD Communicable Disease Weekly 1 42 52

JTF Communicable Disease Weekly 1 27 52

Influenza Surveillance Weekly* 1 108 +Web 32

Malaria YTD Korea Monthly 1 1 12

Monthly Malaria Case Finding Report Monthly 1 5 12

Meningococcal Report Line Listing Monthly 1 1 12

AFPMB report for arthropod borne hemorrhagic fever Annual 1 Web 1

AFPMB report for mosquito borne encephalitis Annual 1 Web 1

AFPMB report for dengue/hemorrhagic fever Annual 1 Web 1

AFPMB report for Lyme disease Annual 1 Web 1

AFPMB report for West Nile fever Annual 1 Web 1

AFPMB report for Leishmaniasis Annual 1 Web 1

Annual HIV Update Annual 1 Web 1

Injury Installation Reports Monthly 1 Web 12

Lost Duty Application Monthly 1 Web 12

Force Health Protection Council Metrics Monthly 1 1 12

Reserve Lost Duty Metrics Monthly 2 4 24

Ill, Injured and Wounded Report Monthly 1 1 12

TRADOC Injury Report Monthly 2 7 24

TMDS D&I Report Quarterly 1 1 4

USASOC Special Reportable Events Semi-Annual 1 1 3

Army Annual Injury Report Annual 1 1 1

USCG Burden of Disease Annual 1 1 1

TRADOC Heat Injury Report Yearly 1 1 1

TRADOC Cold Injury Report Yearly 1 1 1

HA PTSD Monthly Monthly 2 5 24

DCoE TBI diagnoses for DTM Monthly 1 1 12

TBI Positive Screenings Line Listing Monthly 1 1 12

USASOC Mental Health and TBI Monthly Report Monthly 1 1 12

HA Mental Health Report Quarterly 1 5 12

USASOC Mental Health and TBI Quarterly Report Quarterly 1 1 12

HA TBI Quarterly 2 5 8

DoD Consolidated TBI Healthcare Encounter Report Quarterly 4 1 16

AFSOC Mental Health and TBI Quarterly Report Quarterly 1 1 12

AFSOC Mental Health and TBI Annual Report Yearly 1 1 12

*=seasonal

Disease Reports Special ReportsInjury Reports Deployment

Mental Health/ PTSD/TBI Vaccine Reports

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Medical Surveillance Monthly Report (MSMR)

– the MMWR of the military health system– Over 150 issues since April 1995

• First full-color issue—August 2011– 1,067 subscribers to the print edition

• 175 new requests per year• 500 email subscribers

– 21% of 2011 articles were outside submissions– Archives accessible online– Average MSMR issue viewed 1,483 times

during its first 60 days online– Indexed in MEDLINE since Jan 2011

• Searchable using PubMed

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Medical Surveillance Monthly Report (MSMR)

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Training

COMBATANT COMMAND ENGAGEMENTS

Trilateral Civilian-Military Forum on Outbreak Response and Bioterrorism

Investigation (USEUCOM)Chisinau, Moldova; October 2010

Emerging Infectious Diseases Conference (USCENTCOM)Amman, Jordan; October 2010

Malaria Symposium (USAFRICOM)Stuttgart, Germany; April 2011

Countering Biological Threats Conference (USEUCOM)Tbilisi, Georgia; May 2011

Command Post Exercise (USSOUTHCOM)Belmopan, Belize; May 2011

One Health Surgeon’s Conference (USNORTHCOM)Colorado Springs, CO; June 2011

Infectious Disease Border Issues Conference (USCENTCOM)Amman, Jordan; June 2011

Infectious Diseases and Disaster Response Conference (USCENTCOM)Abu Dhabi, UAE; July 2011

International Disease Surveillance Conference (USPACOM)Kurumba, Maldives; September 2011

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Vision and Mission• Vision: Be a scientifically credible and recognized

worldwide surveillance system for emerging infections, fully integrating a global network of laboratory capabilities with a comprehensive DoD health surveillance system.

• Mission: Successfully develop, implement, support, and evaluate an integrated global emerging infections surveillance and response system that supports the AFHSC and contributes to force health protection in US Forces, the Military Health System, and the global public health community.

“Partnering in the Fight against Emerging Infections”

Div of GEIS Operations

15

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Global Emerging Infectious Surveillance

and Response System – Network PartnersFHP Research, Biosurveillance, Capacity Building

OCONUS LaboratoriesParticipating Countries

NAMRU-6

LRMC

NAMRU-3

USAMRU-G (prop)

AFRIMS NAMRU-2 HI

NAMRU-2 PP

USAFSAM WRAIRNMRC

NHRC

USAMRU-K

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Division of AFHSC-GEIS

Strategic Goals and Priority Pillars

AR

D

GI

Feb

rile

Dis

DR

O

ST

I

Assessment and Communication of Value AddedResearch, Innovation and Integration

Surveillance and ResponseTraining and Capacity Building

RI

GI

AR

ST

I

FV

BI

Force Health Protection

RI = Respiratory Infection

GI = Gastrointestinal Infection

FVBI = Febrile and Vector-borne Infection

AR = Antimicrobial Resistance

STI = Sexually Transmitted Infection

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GEIS Supported Surveillance Programs

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FY12 PACOM Activities Summary by Country

Cambodia• Malaria• FVBI• Capacity Building• Respiratory• Gastrointestinal• E. coli

Australia• Malaria

Indonesia• FVBI

Vietnam• FVBI• Malaria• Respiratory• Capacity Building

Singapore• Capacity Building• Respiratory• FVBI

Sri Lanka• Malaria

Japan• Respiratory• Malaria• FVBI• Hantavirus

Republic of Korea• Influenza • Malaria• FVBI• Hantavirus• Rickettsia

Nepal• Antimicrobial Resistance• Gastrointestinal• Salmonella• E. coli• FVBI• Capacity Building• Respiratory

Thailand• Antimicrobial Resistance• Capacity Building• Respiratory• Malaria•Gastrointestinal• Salmonella• E. coli• STI• FVBI• Leptospirosis• Arbovirus

The Philippines• Capacity Building• FVBI• Respiratory• Malaria

Bhutan• Gastrointestinal• Respiratory

Myanmar• Malaria

Laos• Capacity Building• Respiratory

Solomon Islands• Malaria

Vanuatu• Malaria

Guam• Respiratory• Malaria

Samoa• Malaria

19

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GEIS AFRICOM FOOTPRINTFY12

Cameroon•Capacity Building•Respiratory•STI

Gabon•Malaria•Enterics

Kenya•Capacity Building•FVBI•Enterics•Malaria•Respiratory•STI•ARO

Djibouti•FVBI•Respiratory•STI•Malaria•Enterics

Tanzania•Respiratory•Capacity Building•Malaria•FVBI

Uganda•Malaria•Respiratory•ARO

Sudan•FVBI•Capacity Building

Nigeria•Respiratory•Malaria

Burkina Faso, Mali, Mauritania, Morocco & Libya•Capacity Building –Respiratory (NICs)

Ghana•Capacity Building•Malaria•STI•Respiratory•FVBI•ARO•Enterics

Cote d’Ivoire & Togo•Respiratory•Capacity Building

Liberia•FVBI•Malaria•Enterics

Sierra Leone•FVBI•Capacity Building

20

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EUCOM Activities by Country

Germany•Respiratory•Multi-drug resistant pathogens

Georgia•Respiratory•Febrile illness•Sexually transmitted infections

United Kingdom•Respiratory

Italy•Respiratory

Greece•Respiratory

Belgium•Respiratory

Spain•Respiratory

Ukraine• Febrile illness

Poland•Respiratory

Bulgaria• Febrile illness

Portugal•Respiratory

Turkey•Respiratory

Kosovo•Respiratory

21

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CENTCOM Activities by Country

Egypt• Crimean Congo

Hemorrhagic Fever•Capacity building•Respiratory•Enteropathogens

Afghanistan•Capacity building

Oman•Respiratory

Yemen•Chikungunya •Dengue•Respiratory

Jordan•Hospital acquired infections•Respiratory

Qatar•Respiratory

Iraq•Respiratory

22

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Respiratory Infections

Sexually Transmitted Infections

Febrile / Vector Borne(VBI) / Malaria

Febrile / VBI / Neurological

Gastrointestinal Infections

Antimicrobial Resistance

Laboratory capacity building

NAMRU-3, Egypt

Ghana Detachment

Afghanistan Satellite Lab

Active Duty Site

NAMRU-3 Activities in CENTCOM EUCOM AFRICOM

23

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Outbreak Investigation (FY11)

• Over 50 Outbreaks in 15 countries– Influenza, cholera, dengue, malaria and others

• Multiple populations– 16 at US installations (CONUS & OCONUS)– 18 in partnership with foreign civilian entities– 3 in collaboration with foreign military partners– 8 in animal populations

• Field support, epidemiological consultation, laboratory diagnostics

UNCLASSIFIED

AFHSC’s Website

http://www.afhsc.mil

UNCLASSIFIED

Questions?

COL Robert J. Lipnick, MS, MSS, ScDChief, Division of Communications, Standards & Training

Robert.Lipnick@us.army.mil