International Health Regulations (2005) and the U.S. Department of Defense: building core capacities on a foundation of partnership and trust

A cornerstone of effective global health surveillance programs is the ability to build systems that identify, track and respond to public health threats in a timely manner. These functions are often difficult and require international cooperation given the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by both humans and animals. As part of the U.S. Armed Forces Health Surveillance Center (AFHSC), the Department of Defense’s (DoD) Globa Emerging Infections Surveillance and Response System (AFHSC-GEIS) has developed a global network of surveillance sites over the past decade that engages in a wide spectrum of support activities in collaboration with host country partners. Many of these activities are in direct support of International Health Regulations (IHR[2005]). The network also supports host country military forces around the world, which are equally affected by these threats and are often in a unique position to respond in areas of conflict or during complex emergencies. With IHR(2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.

Region-Europe (PHRC-Europe) in Landstuhl, Germany function as a regional military medical center and support surveillance for respira tory pathogens and other emerging infectious diseases (EID) within the U.S. European Command, or EUCOM. Building the core capacities at the local level as described in Annex 1 of the IHR(2005) is a primary focus and strategic goal of the AFHSC-GEIS network [5]. Support for these eff orts develops the capability for open lines of communication between IHR States Parties, but takes years of system strengthening and development. Th e interaction and communication between States Parties, as defi ned in Article 44 in the IHR(2005), allow for collaborative exchanges and system strengthening, and most importantly, build bilateral relationships on a fi rm foundation of trust at the local level. We feel these are critical components of the long-standing relationships between the AFHSC-GEIS network partners and their sponsor host countries and all move the greater global health community closer to implementation of the IHR(2005).

Laboratory-based surveillance
Beginning in 2006, the DoD's global disease surveillance network has worked to enhance the existing surveillance infrastructure to prepare for a potential infl uenza pandemic. Th e goals of these expansion eff orts include broadening the network to monitor and detect increasing numbers of avian (H5N1) infl uenza outbreaks around the world and identifying new infectious disease threats [6]. Th is expansion of capacity and function was both appropriate and fortuitous as AFHSC-GEIS network partners at NHRC and USAFSAM were the fi rst in the world to identify the novel infl uenza A/H1N1 strain in April 2009 in California and Texas [7,8]. Th is rapid detection and subsequent response during the tail end of the infl uenza season allowed the appearance of this novel strain to be identifi ed and reported as a potential public health emergency of international concern (PHEIC) by the U.S. IHR National Focal Point to the WHO. With the onset of this infl uenza A/H1N1 pandemic in April of 2009, there were signifi cant eff orts by AFHSC-GEIS network partners to assist the global health community in responding to this global threat.

Electronic surveillance
Electronic disease surveillance is also an important compo nent of a comprehensive global public health disease prevention and control strategy, and contributes significantly to capacity building and support for IHR(2005) implementation in partner countries. Using electronic methods for data collection and analysis allows for accurate and timely outbreak detection as well as providing meaningful situational awareness during, or in the aftermath of, an outbreak or pandemic. Th e AFHSC-GEIS network has supported a number of electronic disease surveillance initiatives over the past several years in partnership with several DoD overseas laboratories, host country health and defense ministries and our technical partner, the Johns Hopkins University Applied Physics Laboratory (JHU/APL) [9].
AFHSC-GEIS has relied on the extensive experience that JHU/APL acquired in the design and implementation of the Electronic Syndromic Surveillance for Early Notifi cation of Community-based Epidemics (also known as ESSENCE) system [10]. Th is electronic disease surveillance system is used worldwide at all DoD military treatment facilities, throughout the entire U.S. Veterans Health Administration system, and in at least twelve U.S. state health facilities. Tools have been created to enable data collection from the most sophisticated sources down to remote settings where data have traditionally been diffi cult, if not impossible, to collect and analyze. Th ese tools have broad-reaching applicability in any resource-limited setting, whether it is overseas or in response to a complex emergency in the United States [11]. Th e following describes some of the eff orts that have focused on adapting electronic surveillance techniques to resource-limited settings.
Two electronic surveillance eff orts were developed by partners in Southeast Asia and optimized in 2009, including a project with the Royal Th ai Army (RTA) in remote border areas as well as a pilot Short Message Service (SMS)-based project in the Philippines. Th is project was developed by the RTA with support from AFRIMS and AFHSC-GEIS, and reports diseases in both military and local civilian populations through faxing reports or through voice via military radio. Th e next generation of the system was fi elded recently, and simplifi ed data collection from 216 symptoms and categorization into 12 syndromes that are consistent with the Th ai Ministry of Health's reporting requirements. Th is updated system also added questions about poultry exposure, leptospirosis, novel A/H1N1 infection, and chickungunya virus infection. Although no major outbreaks of disease were detected by this system in 2009, it continued to provide situational awareness for the RTA and Th ai Ministry of Health [9].

Infrastructure development
Capacity building initiatives continue to be a major focus area for the AFHSC-GEIS contributions to worldwide EID surveillance and response activities. Surveillance, response, laboratory capacity and human resource develop ment are listed as four of the main core capacities within the IHR(2005). With regards to laboratory capacity, it has been suggested in developing countries this function may be the "Achilles' Heel" of global eff orts to combat infectious diseases [12]. As a result of this, many of the AFHSC-GEIS sponsored activities in capacity building have been directed at improving the existing infrastructure through renovation of existing laboratory facilities, furnishing of new scientifi c equipment, and provision of new or enhanced diagnostic testing systems for overseas host country laboratories. In 2009 alone, eff orts were coordinated with over 80 local and regional health, agriculture and defense ministries, as well as other governmental offi cials and institutions in 74 countries worldwide. During the same time period, a total of 52 National Infl uenza Centers (NICs) and other country-specifi c infl uenza and other EID reference laboratories (44 civilian, 8 military) were supported in 46 countries [9]. Partner countries in all major regions of the world were supported but special emphasis was placed on capacity building eff orts in Sub-Saharan (East, Central and West) Africa, with activities taking place in fourteen diff erent countries in-line with stated global health priorities and areas of enhanced focus for such eff orts [13,14].
Th is past year, AFHSC-GEIS established two new biosafety level 3 (BSL-3) laboratory suites within DoD partner countries. Th e fi rst suite was established by the AFRIMS in Bangkok, Th ailand and was U.S.-certifi ed and commissioned on July 8, 2009. Th e suite was offi cially inaugurated in September of 2009 and began immediately supporting work in avian and pandemic infl uenza monitoring, including culture and molecular sequencing capability. Th is BSL-3 laboratory constitutes the fi rst certifi ed laboratory of its kind in the region and provides the host country and other countries in Southeast Asia with a much-needed high containment capability to conduct research and assist with outbreaks involving select human and animal bacterial and viral strains. A second BSL-3 laboratory suite was opened in late 2009 in San Diego, California by partners at NHRC, allowing work with zoonotic infl uenza strains submitted by AFHSC-GEIS partners throughout the world, to include development of new virus testing capabilities against H5N1 and other highly pathogenic avian infl uenza strains. Additionally, two BSL-2 laboratories were established in Cameroon, including the Cameroon Army Military Health Research Center in Yaoundé and at the University of Buea in Western Cameroon ( Figure 2). Both laboratories will help to improve the ability to conduct infl uenza and EID diagnostic work in the country [5].
Developing and deploying infl uenza diagnostic capabili ties through other NICs were also supported by the NAMRU-3 in Afghanistan, Jordan, and Iraq; by the U.S. NMRCD-Peru in Venezuela, Colombia, Paraguay, and Ecuador; and, in Kenya by the USAMRU-Kenya. Finally, in collaboration with the CDC's Central America and Panama Center, the U.S. Army Public Health Command Region-South (PHCR-South) provided laboratory technical assistance, reagents and supplies to the health ministries in El Salvador, Guatemala, Honduras, Nicaragua, and Panama, resulting in the certifi cation of the Guatemalan NIC and in the testing of over 5,000 specimens for novel A/H1N1 [5].

Outbreak support
Rapid identifi cation of outbreaks and support of timely response eff orts are key components of complying with IHR(2005), and are core focus areas of the AFHSC-GEIS network [5,15]. Th ese eff orts are provided in response to host country requests for assistance with new or ongoing outbreaks and consists of a wide range of functional support. Th ese support eff orts include fi eld team support, epidemiology or consultative support and/or laboratory diagnostic support. Th ese collaborative exchanges strengthen relationships, build and maintain trust and are a critical component of the long-standing relationships built between the network partners and their sponsor host countries. Several of the partnerships between the U.S. and host country militaries (mil-mil partnerships) that have developed over many years have served to empower the host country military's role in supporting outbreak response activities within their own countries and ultimately support the guiding principles of surveillance and response core capacities within the IHR(2005) [16].
Over the past full year of surveillance (September 2008-October 2009), the AFHSC-GEIS network responded to 76 outbreaks in 53 countries, several in direct support of the IHR(2005). Th e most common events investigated were infl uenza (47), cholera (4), dengue fever (4) and hepatitis (3). Human disease was detected in all but one of these outbreaks and specifi c causative agents were identifi ed in 92%, or 69, of them. Th e population size aff ected ranged from less than 10 individuals to several thousand and support eff orts were often ongoing engagements beyond the initial phase of the investigation [15].
Beginning in April of 2009, with the onset of the infl uenza pandemic, disease surveillance and investiga tive response activities were dominated by novel infl uenza A/ H1N1. Th e AFHSC-GEIS network supported the diagnostic confi rmation (directly in DoD laboratories or through support of host country laboratories) of the fi rst infl uenza A/H1N1 cases in fourteen countries (United States, Bhutan, Cambodia, Djibouti, Kuwait, Kenya, Lao People's Democratic Republic, Lebanon, Egypt, Nepal, Colombia, Ecuador, Peru and the Republic of the Seychelles), again demonstrating direct support for increas ing compliance with IHR(2005) for what was deemed at the time as a PHEIC. Th e non-U.S. activities were a result of the respective AFHSC-GEIS partner laboratory's role as the regional reference testing center and the bilateral working collaborations with host country health ministries and partner governments. Th ese bilateral relationships resulted in response to seventeen large-scale outbreaks among civilians in thirteen countries [15].
United States service members and benefi ciaries were aff ected by novel H1N1 in all regions of the world within the fi rst month of the outbreak. In the fi rst wave of the pandemic (April through August 2009), the AFHSC-GEIS network partners actively investigated eighteen diff erent outbreaks on U.S. military installations and among defi ned high-risk groups [17]. Th ese high-risk groups were defi ned as deployed or deploying personnel, shipboard personnel, new accessions (basic and advanced military trainees and service academy students), health care workers, children and staff in daycare centers and pregnant women. Stressful military environments, highlymobile missions and complex troop dynamics have proven in the past to help to propagate pandemics and have drawn the attention of the military's operational leadership and leaders of civilian sectors within host countries [18]. Th ese investigations involved anywhere from a few dozen cases to situations where greater than one thousand cases were tested at a given time.

Training
In order to achieve optimal and coordinated implemen tation of the IHR(2005), it is required that each State Party be capable of detecting, confi rming, reporting, and containing an emerging threat to public health [1] and build these capabilities by 2012. To reach the 2012 milestones, States Parties will need to signifi cantly enhance their laboratory infrastructure and more importantly, appropriately train the personnel who can perform the core capacity functions as defi ned by Article 5 of IHR(2005). Th ese core capacities include leading outbreak investigations, correctly identifying a pathogen in the laboratory, rapidly communicating the fi ndings to stakeholders at all levels and, most importantly, controlling the outbreak through tested, coordinated and exercised mitigation eff orts. Frontline public health professionals require the latest knowledge and skills to address global threats to public health.
Th e recent pandemic of novel infl uenza A/H1N1 clearly illustrates the unpredictable nature of pathogens which require dynamic and evolving public health strategies for surveillance, disease management, and eff ec tive mitigation. Training public health professionals to understand, monitor, respond to, control, and prevent emerging infections is a foundational goal of AFHSC-GEIS [19]. Since its inception, AFHSC-GEIS partners and collaborators have made available their overseas laboratory and fi eld study facilities to serve as regional focal points for public health training of staff , technicians and epidemiologists within partner host countries [2,6,20] through a growing collaborative network of U.S. Government agency partners (Figure 3). A wide range of training has been coordinated to include programs such as the CDC's Field Epidemiology Training and Laboratory Training Programs [21] and the U.S. Agency for International Development (USAID) eff orts throughout Africa and the Pacifi c [22,23,24]. Th ese opportunities through training serve as a forum for support, coordination, and collaboration with host country partners as prescribed in Article 44 of the IHR(2005).
A regional approach to training has been underway by the Uniformed Services University of the Health Sciences (USUHS) Center for Disaster and Humanitarian Assistance Medicine (CDHAM). Educational eff orts in support of fi ve combatant commands have been bolstered with AFHSC-GEIS funding and provide much-needed professional expertise and the latest technical informa tion to U.S. military and civilian health care providers as well as to host country of health, agriculture, defense ministries and other civilian agency collaborators. Th ese initiatives result in professional engagement for host country offi cials as well as further enhancing the U.S. government's role as a key stakeholder in the global health community. Training initiatives are broadly based to encom pass such topics as planning and preparedness, outbreak investigation, surveillance and response and include curriculum for a wide spectrum of disease or syndrome causing agents [19].
Over the past full year of partner funding, 18 diff erent organizations conducted 123 training initiatives in 40 countries reaching approximately 3,130 U.S. military and civilian personnel as well as host country personnel. Th e most common categories covered were EID laboratory techniques (41%), pandemic infl uenza (24%), and disease surveillance techniques (19%). Training tools included work shops (defi ned here as hands-on, interactive training), academic courses, conferences, tabletop exercises, and distance learning. Training duration ranged from 0.5 hours to 6 months, with the majority of education eff orts lasting 2 to 5 days. Respiratory infections (namely infl u enza) represented the majority of training initiatives (68%), followed by febrile and vector-borne infections (11%), gastrointestinal infections (5%), and antimicrobial resistance (2%) with an additional 14% represented by various other topics (Geographic Information Systems, EpiInfo, Field Epidemiology, Principles and Practice of Clinical Research, Outbreak Investigation, Emerging Infectious Diseases, Lab Safety Precautions, Ecological Niche Modeling, and Tropical Medicine Student Rotations). Training initiatives occurred in each of the six regional Combatant Commands with most occurring in the Pacifi c Command, or PACOM [19].

Communication tools
Communication and central coordination remains a primary role of AFHSC and involves a substantial amount of eff ort from all divisions and areas, including GEIS. In a given month during the Northern Hemisphere respiratory season, the AFHSC creates, on average, 139 individual reports for a wide spectrum of disease-causing agents or matters of public health concern. Th is includes routine reportable medical event reports that are noted in the Medical Surveillance Monthly Reports [25]. Many of the reports generated by AFHSC are available on the program website and are open to access by the general public. Other reports are provided to the individual services and are usually part of specifi c data request agreement with that service.
Respiratory surveillance, and more specifi cally infl uenza surveillance, remains the primary area of funding and focus for many of the global network partners. Th e central coordination and analysis of aggregated infl uenza surveillance data and summarizing of all partner reports is a function unique to AFHSC central headquarters. AFHSC-GEIS partners are highly encouraged to create program-specifi c reports that are accurate, timely, concise, openly available, and provide meaningful public health interpretation of the fi ndings. AFHSC-GEIS staff analyze and summarize all partner reports weekly and provide a DoD-wide summary to stakeholders across the network through the AFHSC website [26]. In addition to timely reporting, partners are required to participate and communicate their recent fi ndings through network calls and a bi-monthly teleconference called Epi Chiefs. Th is provides a forum for reporting the latest outbreak activity and interesting fi ndings from all regions of the global network. It also allows program management staff to communicate outward of notable changes in trends in specifi c regions or areas of concern.
Conclusions Th e Armed Forces Health Surveillance Center's Division of Global Emerging Infections Surveillance and Response network continues to expand internationally to eff ectively identify and respond to threats from a wide range of disease agents and syndromes. Th e growth and enhancement of this surveillance system in anticipation of pandemic/avian infl uenza allowed the DoD to identify the recent infl uenza pandemic [21,22] and a number of other infectious disease outbreaks in communities around the world. A global system with defi ned goals and pillars of focus, the AFHSC-GEIS network has evolved to become a model for emerging infectious surveillance platforms at the local, regional and international level. By utilizing this established global system and the IHR(2005) as a guide, the DoD is able to provide a common and systematic approach to disease surveillance, human capacity building and a framework for eff ective public health response. As emerging and re-emerging threats develop in areas where partners work with host country collaborators and global health institutions, the AFHSC-GEIS network stands ready to respond and support.