Jennifer Lake's Blog

September 12, 2009

Global Emerging Infections System

The Global Emerging Infections System (GEIS) was originally created in 1995 by the Office of the Secretary of Defense (OSD), supervised by the Pentagon‘s “top doc”, the Assistant Secretary of Defense (Health Affairs) or as the documents refer to the job, the ASD(HA), when new mandates expanded the military’s Defense Medical Surveillance System beyond its role of managing the Dept. of Defense Serum Repository (DoDSR), itself established to archive the physical specimens of military personnel in the wake of HIV/AIDS. The focus of GEIS is to maintain a worldwide state-of-the-art laboratory network with its partners –the W.H.O., the CDC, and the host nations’ research infrastructure. Part of the story is available from the federally-funded RAND study of 2008, http://www.scrbd.com/doc/15240085/usrandpandemicflustudy2008
Influenza surveillance programs sponsored by GEIS are primariliy laboratory based [with a] focus on collection and characterization of viral isolates sampled from military and civilian populations from approximately 273 participating sites in 56 countries in FY06 [Fiscal Year 2006], with an additional 38 sites in 9 countries that were added in FY07. Permanent overseas medical research laboratories are located in Egypt [the largest], Indonesia, Kenya, Peru and Thailand, and serve as collaborative centers with host nation research entities, the World Health Organization and the Centers for Disease Control and Prevention. These research centers host the GEIS surveillance functions for DoD.”

In this website, http://www.afhsc.mil/About_GEIS.asp, money to support this global network records that, “In FY06 GEIS received congressional supplemental funding for pandemic and avian influenza which represented a fivefold increase in the annual GEIS budget…” Supplemental?!! ..Meanwhile…the domestic public health laboratories were on a down-spiral of cutbacks as the APHL webpage illustrates (see Pandemic Unfolding, http://www.aphl.org/AboutAPHL/publications/Pages/LMFeatSummer2009.aspx) so much so that by Mar/Apr and the arrival of the long-awaited pandemic, the public lab system scurried to enlist the resources of other U.S. programs, “Medicare and Medicaid Services, for example, [which] delayed its routine regulatory surveys and suspended influenza proficiency testing in state labs during the crisis.”…”Fiscal downsizing cost the the Washington D.C. and 50 state labs about 185 staff positions in the first quarter of this year, on top of significant losses last year.” Back in 2006, while GEIS was quintupling its annual budget…”FY06..the federal government disseminated $225 million to states for pandemic influenza preparedness through the Public Health Emergency Preparedness Grant, although public health laboratories received few of these dollars. No funds were allocated in FY08.”…”The emergency supplemental appropriations bill signed June 24 [2009] includes 260 million of immediately available funding for state and local..activities…Unfortunately, only a portion of $65 million will be spent on laboratories…public health laboratories were substantially left out of the federal stimulus package enacted in February..[The National Institutes of Health, by comparison, rec’d $10 billion in stimulus funding].”

ABC news reported on April 29 “To fight the epidemic, the Obama administration is asking Congress for 1.5 billion…to enhance our nation’s capability to respond to the potential threat of this outbreak. The government’s request underscores how seriously US officials are treating the threat.” http://abcnews.go.com/Health/SwineFlu/story?id=7456439&page=1. Yes, it does indeed. Americans are accustomed to measuring ‘seriousness’ in dollars.

In the http://www.afhsc.mil/About_GEIS.asp page, the reason for the existence of the GEIS program is summed up by its director, CAPT Kevin Russell, MD : “The victory over infectious disease that we thought we had from the antibiotic era showed our understanding of infectious disease was arrogant, and it was incomplete.” He doesn’t mention exactly when he thinks the antibiotic era ended, or how the global system is going to resolve the incompleteness, but as the 2008 RAND study highlights, the DoD is demonstrating its preparedness by the quality of the surveillance: laboratory-based surveillance.

What follows are highlights from 33 pages of a meeting address given by Col. Loren Erickson to a professional military-associated audience on May 23, 2007 describing the scope and activities of GEIS (pages 14-47)
http://www.docstoc.com/docs/2601521/THE-DEPARTMENT-OF–DEFENSE-TASK-FORCE-ON-THE-FUTURE-OF-MILITARY

—[presenting a photo slide show]…”this is our new home..just outside the beltway [in Wash.DC] within site of the Mormon Temple…This in fact will be probably the first home of the Armed Forces Health Surveillance Center, a new entity which is expected to take shape in the coming months. This will not be an operations center, but rather a communications center which will handle the flow of information for outbreak investigations…
…just to let you know, we are working at an interagency level on a weekly basis, working a lot of very strategic issues…

We have a collaboration going on with NASA at the present time where they use a variety of modalities of satellite imagery and modeling..

…and we’re looking again at respiratory disease…In Afghanistan..we might have pertussis…Adenovirus as you’ve been previously briefed by Kevin Russell, continues to be a problem at our basic training posts…hepatitis E is a concern of ours in deployed forces…these are just some of the ticklers…

[page 20] Let me talk about some of the relationships that GEIS is forming…
..with France [tropical medicine institute in Marseilles, part of Pasteur]…Places like French Guiana in the northern part of South America is actually considered part of the country of France. It’s called a Departement. It’s not a colony…
…[Africa] last year, 20,000 cases of meningococcal disease in the Ivory Coast, and this included 1,600 deaths…

…work that GEIS is doing also with the State Health Department in Bavaria…the Germans’ work is nearly always with the U.N. They have some very interesting lab capabilities with the Microbiology Institute in Munich. The director is Colonel Dr. Finke…[who] prior to reunification of Germany was actually head of the BW Program for East Germany so he has tremendous background in plague…

Let me move on and talk in particular about flu very quickly…documents that many of you are aware of from the White House, the National Strategy. Stemming from that was the National Implementation Plan which had a total of 323 tasks that were given to the cabinet-level secretaries. Of those 323 tasks, 114 of those came to the Dept. of Defense [DoD]…six of those relate to the work of GEIS.

[page 25] We do 3 types of lab-based surveillance for flu, and I am going to go through each of these very quickly. We are collecting isolates from 56 countries [9 more countries were added in 2007] and I can tell you that I think that’s more than any other entity on the face of the planet right now…
…We also do special population-based surveillance at the basic training sites…In addition we now are putting PCR machines aboard some of the ships that are part of these three different fleets…we need to know what’s going on, and we need good answers.

..Central Europe [EUCOM] is now participating in laboratory base surveillance. They do ILI surveillance [InfluenzaLike Illness]…isolates are sent to the Primary Reference Lab which is now at Landstuhl.

A couple of things that were different in terms of seasonal flu epidemiology this year, the predominant strain of flu in the States was an H1 whereas in Europe it was an H3…

…internationally..I’ll just talk about flu…[there’s] work that’s going on regionally in Nepal and Thailand…a new effort going on in Cebu City in the Philippines…
There’s a big question as to why have we not seen bird flu yet in the Philippines…everything is there…Maybe we haven’t been looking hard enough…we’re building up a BSL-3 lab there for their use as well.

In Indonesia..exactly a year ago..[in] the northern part of Sumatra, not so far as Banda Aceh where the tsunami was, but a part of the same island..this family..died of H5N1…
…obviously of international concern because we went to look, and this was a team effort with W.H.O., C.D.C. and members of the Navy lab, at the chickens and the pigs, they were not able to isolate H5N1…this may be a lead for future research, that there may be certain genetic elements to who gets sick and how severe their illness is…

There’s a lot of work that we’re doing in South America. We went to Buenos Aires…in the Andean Ridge countries, helping them to build their own capacity…but in addition to collecting isolates. Beyond that, new effort is in fact working with Billy Koresh with the Wildlife Conservancy doing bird surveillance…but in addition looking for other new novel influenza viruses.

In Kenya we have..the largest influenza surveillance effort in sub-Sahara Africa…We intend in the coming months to expand to Uganda and Cameroon…in the month of June I’ll be making a trip..to confirm the preparation…We’re also looking to go to Nigeria. As many of you know, we have an extensive DoD HIV presence in many countries as far as PETFAR and DEHAP…

[page 31] A real workhorse for us is the Cairo lab in Egypt, working in many countries. They have the unique position of being the Eastern Mediterranean Regional office for W.H.O. for influenza. So when you hear about flu in Turkey or the Stans or in Egypt, any of those EMROC related countries, the Cairo lab is the one that has done the the diagnostic work, period…they are the ones..to actually do the investigation…They are the ones to detect and confirm H5N1 in poultry in Ghana…in this next year they’ll be collecting even more specimens. It’s becoming quite an industry for them.

…we have an ongoing collaboration with Global Health, with Dr. Steve Blount at the Centers for Disease Control…we talk to them on the phone on a regular basis. They have a parallel program called Global Disease Detection which looks alot like GEIS, but it’s CDC. We are collaborating with them. In fact, they have an individual who is now assigned to the Cairo lab to help the CDC start to build some of their efforts in that country and in that region…[and] other isolates and other work that is occurring along the Nile.

[Question and Answer segment]:
…they do have the ability in many of these labs to do their own virology work, higher-level diagnostics. But we work closely with the CDC to make sure that we’re matching…
…the only place that we’ve had any issues right now have been Jakarta…Of course, the international health regulations that the W.H.O. is promulgating call for the sharing of isolates…It certainly hasn’t stopped our progress, but it underscores the importance of having a full-functioning BSL-3 in a country so that if the isolates can’t leave, at least we’re able to work with the virus locally…But..that’s a burgeoning issue.

[regarding numbers of GEIS personnel, Col. Erickson replies]..At my immediate reach I’ve got about 15 people at the GEIS headquarters…you won’t see a whole lot of people, but very senior people who are managing the network. Across the network..literally thousands of individuals…there is not a set training for people to belong to GEIS. There are training programs for those who are working in the labs…

[regarding the inclusion of China]..We’ve had a number of good contacts..

[the Questioner says] I had an opportunity to look at [the new GEIS command facility] with Dr. Poland and it’s one of those gee-whiz–wow things..very state-of-the-art…at what point would you activate that COM center..in other words, the size of the outbreak?
[Col. Erickson response]..In the coming months we’re going to be practicing with the technology…we’ll be doing some notional exercises. My sense is when we reach the point where we have an outbreak, and it could be any emerging infectious disease but flu is the one for which it is funded, at that point..where we need to have situational awareness 24/7, that’s really the point…

[page 42, the Questioner says]..the other thing that’s happening now, there is a movement afoot politically and legislatively for something called One Medicine which is really the notion of veterinary medicine and human medicine [that] have been separated far too long…is there a way to standardize this?
[Col. Erickson replies]..I’ll have to slip you a $20 bill later..you giving me this plug…Three of..my immediate staff are veterinarians. I’ve mentioned Billy Koresh with the Wildlife Conservancy, one of our people brought over from USDA….In fact, this was one of our goals for 2007…it may very well be that within animal populations..would be our early warning.

[regarding the fleet capability of PCR testing, Col Erickson replies]..Just so you know, we’re talking about LightCycler machines, standard PCR methodologies. Not every ship would have them…

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The LightCycler PCR, made by Roche [Hoffman-LaRoche]https://www.roche-applied-science.com/lightcycler-online/

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In May of 2007, Col. Loren Erickson said, “We have a collaboration going on with NASA at the present time..” which has been bearing fruit for epidemic surveillance. The January 2010 issue of the American Journal of Tropical Medicine and Hygiene reported that the “collaboration between NASA, USAMRU-K and DoD-GEIS headquarters has developed an effective, satellite-based early warning tool…and is now working to expand its applicability to other climate-dependent epidemic diseases.” http://www.ajtmh.org/content/82/1/23.full

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