Armed Forces Health Surveillance Branch

UNCLASSIFIED

Armed Forces Health Surveillance Branch Support of Epidemiologic Surveillance & Research Uniformed Services University of Health Sciences PMO 511 Course Lecture COL (Ret.) Jose L. Sanchez, MD, MPH [email protected] 22 October 2018

“Medically Ready Force…Ready Medical Force”

1

UNCLASSIFIED

AFHSB – Where are We?

11800 Tech Road, Suite 220 Silver Spring, MD 20904 Main Phone: (301) 319-3240 “Medically Ready Force…Ready Medical Force”

2

UNCLASSIFIED

AFHSB’s Organizational Structure (September 2018)

Immunization Healthcare Branch

Deployment Health Branch

Veterinary Services Branch

Public Health Division

Occupational & Environmental Health Branch

Preventive Health Branch

Armed Forces Health Surveillance Branch Data Management & Technical Support

(DMTS)

Office of the Chief

(DMSS / DoDSR)

Epidemiology & Analysis

Global Emerging Infections Surveillance

(E&A)

Navy Satellite

Air Force Satellite

Operations & Administration

(GEIS)

Army Satellite

Service Satellite Cells


Integrated Biosurveillance

(IB)

Liaison w/

CCMDs, JSS, NCMI, JPEO-CBD, NCB

3

UNCLASSIFIED

Combat Support Agency

• What is a CSA? • Combat Support Agency is a tool of the Chairman of the Joint Chiefs of Staff (CJCS) to provide reach-back & augmentation capabilities beyond the abilities/authorities organic to the Combatant Commands (CCMDs)

• What does AFHSB do as a CSA? • Coordinates efficient delivery of comprehensive health • •

surveillance information to the Joint Force This information enables enhanced readiness The end-result is operational success through globally integrated Force Health Protection “Medically Ready Force…Ready Medical Force”

4

UNCLASSIFIED

AFHSB’s Intent or Goal

• Goal: To protect those who serve our nation in uniform and allies who are critical to our national security interests

• Acquire, analyze/interpret, disseminate information, and • • •

recommend evidence-based policy Develop, refine, and improve standardized surveillance methods Serve as a focal point for sharing health surveillance products, expertise, and information Coordinate a global program of militarily-relevant infectious disease surveillance “Medically Ready Force…Ready Medical Force”

5

UNCLASSIFIED

AFHSB’s Support of Epi Surveillance & Research How Do We Do It? •

E&A – Provide actionable health surveillance information via retrospective analyses of health data

• •

•

IB – Provide near-real time biosurveillance of military threats (e.g. such as diseases of public health relevance, outbreaks or clusters of illness, new and emerging threats)

•

•

Answer ad hoc RFIs, deliver periodic recurring reports, and perform epidemiologic studies Provide access to Defense Medical Surveillance System (DMSS), DoD Serum Repository (DoDSR), Defense Medical Epidemiology Database (DMED), experienced epidemiology experts

Support GCC’s preparation of the battlespace efforts by identifying/detecting, analyzing and providing public health countermeasure control recommendations to health events of significance to military operations • Alert and Response Operations to include AHSU, HSE & other USG interagency collaborations • Innovation and Evaluation to include ESSENCE, Modeling & Predictive Surveillance efforts

GEIS – Provide “over the horizon” surveillance for infectious disease threats

•

Support GCC theater campaign plan objectives (TCPOs) and infectious disease surveillance priorities by strengthening surveillance, outbreak response, collaboration, and coordination of the global DoD laboratory network in four main areas: • Antimicrobial Resistant Infections • Enteric Infections • Febrile and Vector-borne Infections • Respiratory Infections


6

UNCLASSIFIED

DMSS: Longitudinal Database Active Duty & Reserve Component SMs Ambulatory Data 410 million records In-Patient Hospitalizations MEPS 14.9 million persons 3.3 million records 36.5 million records

Personnel Data 11 million persons 143.2 million records

Immunizations 139 million records

Periodic Health Assessments 603,448 records

PreInduction

Serum Specimens (DoD Serum Repository) 11 million persons 65 million specimens

Chemistry 104 million records

PostDischarge Deployments 6.7 million records Reportable Microbiology Diseases 9.3 million records Prescriptions 479,760 records 53.5 million records Pre/Post-Deployment Surveys 14,292,314 surveys Casualty Data 56,892 AD Deaths

All counts current as of June 2018


7

UNCLASSIFIED

DMSS Structure and Functional Relationships (All DoD Beneficiaries) PERSONNEL DATA

MEDICAL DATA

Active Duty Since 1990 7.9 million persons 107 million records

In-patient Since 1990 21 million records Ambulatory Since 1996 2.69 billion records

Reserve Component Since 1990 3.3 million persons 39.6 million records

DEPLOYMENT DATA

Serologic Specimens Since 1985 11.2 million persons 65 million specimens

Deployment Rosters Since 1990 6.8 million records

Chemistry Since 2010 310 million records

Reportable Events Since 1995 697,292 records

Active Duty Casualty Since 1980 57,161 records

LABORATORY DATA

Microbiology Since 2010 35.5 million records

Immunizations Since 1980 140 million records Prescription Data Since 2014 65.3 million records

Military Entrance Processing Stations Since 1985 14.9 million persons 36.5 million records

Theater Medical Data INPT/Ambulatory(TMDS) Since 2008 6,701,196 records Theater Medical Data Meds (TMDS-MEDS) Since 2008 10,960,072 records

DMSS

Services of the Armed Forces Health Surveillance Center

Medical Surveillance Monthly Reports (MSMR)

Pre and Post Deployment Health Assessments Since 1994 14,992,314 surveys

Monthly Synchronization

Hospitalization Queries

Ambulatory Queries

Adhoc Requests

Studies and Analyses

Routine Reports & Summaries

DMED Version 5.0 Remote Access to DMSS data (non-privacy act only)

Reportable Events Queries

Personnel data Queries

DMSS: Defense Medic al S urv eillance S ystem DMED: Defense Medic al E pidemiology Database

Current as of June 2018


8

UNCLASSIFIED

DoD Serum Repository (DoDSR) • • •

Central archive of U.S. military sera-US military

- Periodic HIV testing - Pre- and Post-deployment sera collection

Collected for medical surveillance purposes to support force health protection, disease prevention & health pgm policy Over 65 million specimens for ~11 million individuals

• • • • •

Specimens stored in precisely documented locations in large walk-in –30 °C freezers Linked to demographic, military, & medical information via the Defense Medical Surveillance System (DMSS) Last aliquot reserved for clinical needs $20 fee per sample for >2500 specimens No lab work is conducted at AFHSB


9

UNCLASSIFIED

DoDSR –Specimens Studied (2002–2017) Total Specimens Used in Studies (bars) and Aliquots Produced (line), DoDSR Jan 2002 - Dec 2017 40,000

140,000

35,000

120,000 Automated Pipetting Pipetted by Hand Total Aliquots

100,000

25,000 80,000 20,000 60,000 15,000 40,000 10,000

Number of Aliquots Produced

Number of Specimens Processed

30,000

20,000

5,000

0

0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017


10

UNCLASSIFIED

DoDSR Supported Pubs (1985–2012)

Reference: PLoS One. 2015 Feb 27;10(2)


11

UNCLASSIFIED

E&A - Request & Approval Process Request arrives at Epi & Analysis Section

Consultation with SMaE for feasibility

Clarify question, draft analysis plan

Public Health Research

Public Health Surveillance Analysis plan presented at RAP

IRB

When approved: Coding & output Review, approval and delivery De-identified dataset

Summary table

Assessment: • Intent and authority of requester • Question related to public health • Availability of data • Use of standard (valid) methods • Appropriate level of surveillance • Appropriate use of serum

RAP Members: • Chief, Epi & Analysis Section

Process approved and monitored by DHA Privacy Office and Human Research Protection Program

• Chief, Satellite Support & Satellite Leads • Sr Managing Epidemiologists (SMaEs) • Sr Managing Analyst • Service Public Health & Epi Centers reps • DHA Human Research Protections Office

Affected by: • Complicated person-time calculations • Complex case definitions • Multiple and/or complex outputs • Prioritization with other jobs • Technical difficulties • Stated suspense


12

UNCLASSIFIED

Standard Surveillance Case Definitions

•

Surveillance, Methods, and Standards (SMS) WG meets every other week

• • • •

•

Documents and publishes standardized surveillance case definitions and methodology Includes ICD-9 and ICD-10 codes; 73 case definitions in 17 categories Promotes internal consistency and credibility Ensures comparability of health surveillance across MHS

Reportable Medical Events (RME) WG meets quarterly

•

Maintains Armed Forces RME Guidelines & Case Definitions


13

UNCLASSIFIED

Standard Surveillance Case Definitions


14

UNCLASSIFIED

E&A – Types of Requests

•

Operational Health (Epi) Surveillance • Submitted by the requester to the E&A Chief, Chief designee, or SMaE • Requester should be from the same Service as the population of interest • Requests from echelons above the Services are normally handled by the E&A Chief • Physicians and other medical personnel involved in patient care may make specific individual requests using an Individual Clinical Data Request Form

•

Support for Research • • • • • •

DoD (Military/GS) Primary Investigator/military Institutional Review Board (IRB) Protocol reviewed at the Research Protocol Review (RPR) meeting If supportable, a letter of support will be issued IRB and DHA Data Sharing Agreement approval required Studies involving >2,500 DoDSR specimens require DD1144 support agreement PII only released with informed consent


15

UNCLASSIFIED

E&A – Examples of Types of Requests

•

Operational Health (Epi) Surveillance • Prevalence, incidence & risk factors for Arthropod-Borne infections (including JEV, DENV, ZIKV & CHIKV) • Melioidosis exposure in Darwin, Australia • Risk of JEV infections among Soldiers in Korea

•

Research Support • Cancer “Moonshot” studies • Influenza vaccine effectiveness, immunogenicity & antibody persistence studies • Rheumatoid and Reactive Arthritis biomarkers


16

UNCLASSIFIED

Seroprevalence of Zika Virus (ZIKV) Operational Study with two different population groups:

•

Service members stationed in Puerto Rico (2014-2015)

• • •

•

500 subjects with pre/post DoDSR specimens Specimens tested for Zika, Dengue, CHIKV Testing ongoing at WRAIR, analyses forthcoming

Recruits coming from Zika-endemic counties

• • • •

Marshall Islands, American Samoa, Micronesia, US Virgin Islands, Puerto Rico, Guam, Philippines 500 subjects with an accession specimen in DoDSR Specimens tested for both Zika and Dengue Preliminary testing shows ~ 3% seroprevalence, other analyses forthcoming “Medically Ready Force…Ready Medical Force”

17

UNCLASSIFIED

National Cancer “Moonshot” Initiative Research Study with multiple planned cancer studies:

• •

Murtha Cancer Center and Pacific Northwest National Laboratory collaboration Cutting-edge proteomics used to identify serum biomarkers indicative of oropharyngeal squamous cell cancers

• •

• • • •

Develop early diagnostic tools and prognostic indicators Better inform treatment decisions / improve survival

Automated Central Tumor Registry (ACTUR) used to identify confirmed cases DMSS used to identify controls (matched on DoB, gender, serum) Up to 2 pre and 2 post specimens per subject from DoDSR Laboratory testing ongoing “Medically Ready Force…Ready Medical Force”

18

UNCLASSIFIED

Environmental Exposure Studies Recent efforts to quantify utility of the DoDSR in addressing environmental exposures (particularly during deployment):

•

Detection of Serum microRNAs from 30 Samples

• • •

•

Successfully quantified over 200 potential biomarkers of occ exposure Correlation of mRNA with Cotinine, Cytokine, and PAH Levels DoDSR samples represents a powerful tool for biomarker discovery

Detection of free benzo(a)pyrene (BaP) and high-resolution metabolomics (HRM) from 30 Samples

• • •

Correlation of mRNA with Cotinine, Cytokine, and PAH Levels Represents a powerful tool for biomarker discovery DoDSR samples are of sufficient quality for chemical profiling of DoD personnel and identification of the BaP-associated metabolic perturbations


19

MSMR

UNCLASSIFIED

Provides evidence-based estimates of incidence, distribution, impact and trends of illness and injury among U.S. military service members and associated populations

• • • • • •

Launched in 1995 Peer-reviewed monthly journal Articles available through MEDLINE since Jan 2011 Over 1,500 subscribers About 500 online hits per month on MEDLINE FY2014, 28% of articles submitted by nonMSMR staff/external authors


20

UNCLASSIFIED

Support to DoD Medical Education & Training

•

USU (WRAIR until 2018)

•

Rotations and Practicum Opportunities

•

Training Goals:

•

Deliverables

• • • • • • • • • • • •

Preventive Medicine residents MPH/MSPH/DrPH students 5-6 weeks at AFHSB One-on-one mentoring

Observe organization and operation of AFHSB Understand complexities of health surveillance systems Design and execute data analysis project using DMSS Enhance knowledge of epidemiology and surveillance Obtain guidance on military preventive medicine career Draft and present project proposal Present their study and the findings to AFHSB leadership and staff Draft a publishable manuscript


21

UNCLASSIFIED

Defense Medical Epidemiology Database DMED is a subset of data contained within the DMSS • Remote access (via internet) / CAC enabled • No personal identifiers or link to specific individuals allowed • https://www.afhsc.mil/dmed • • • • • • •

Active duty only Monthly updates Rapid query response Inpatient data Outpatient data Reportable Events ICD-9 and ICD-10 Not a research tool!


22

UNCLASSIFIED

Health Surveillance Explorer (HSE)

• • •

The AFHSB Health Surveillance Explorer went live on 10 July 2018 The HSE map contains GEIS data as well as open source biosurveillance data from AFHSB’s Integrated IB Section The HSE is FOUO and is located on a CAC-enabled site: https://portal.geo.nga.mil/portal/apps/webappviewer/index.html?id=d50524e41fcf46c0bb3a2af735ecf55e


23

UNCLASSIFIED

AFHSB Health Surveillance Update Map 22 – 28 August 2018


24

UNCLASSIFIED

FY18 GEIS Surveillance Sites

* Country-level sites

• •

The AFHSB Global Emerging Infections Surveillance (GEIS) section coordinates a global infectious disease surveillance network of DoD laboratories and other USG partners Militarily-relevant surveillance data is provided to the Geographic Combatant Commands and other DoD stakeholders in monthly summaries and immediate threat reports


25

UNCLASSIFIED

GEIS Surveillance Priorities •

Antimicrobial Resistant and Sexually Transmitted Infections

•

•

Enteric Infections

•

•

Surveillance for enteric pathogens associated with acute gastroenteritis (AGE) and travelers’ diarrhea (TD) to understand disease burden and geographic distribution

Febrile and Vector-borne Infections

•

•

Surveillance for resistant wound and healthcare-associated bacterial infections (HAI) and Neisseria gonorrhoeae

Surveillance for vector-borne and zoonotic pathogens associated with febrile illness in humans or associated with arthropod vectors and reservoir hosts

Respiratory Infections

•

Surveillance for respiratory pathogens, especially those with pandemic potential


26

UNCLASSIFIED

Armed Forces Health Surveillance Branch (AFHSB) POCs Chief, Armed Forces Health Surveillance Branch Deputy Chief, AFHSB Chief, Operations & Administration Chief, Epidemiology and Analysis Section Chief, Global Emerging Infections Surveillance Section Chief, Integrated Biosurveillance Section AFRICOM/NORTHCOM Epidemiologist EUCOM/INDOPACOM Epidemiologist CENTCOM/TRANSCOM Epidemiologist SOUTHCOM/STRATCOM Epidemiologist NCMI Liaison Epidemiologist

COL Douglas Badzik: [email protected] 301-319-3245 COL (Ret.) Jose (Toti) Sanchez; [email protected] Desk: 301-319-2242 Mr. O. Sean Friendly: [email protected] SIPR: [email protected] Desk: 301-319-3247 COL James (Jamie) Mancuso: [email protected]

Desk: 301-319-3272

CDR Franca Jones: [email protected]

Desk: 301-319-3268

Mr. Juan Ubiera: [email protected] Desk: 301-319-3241 Mr. Francis Catalfumo: [email protected] Desk: 301-319-2249 Ms. Maura Metcalf-Kelly: [email protected] Desk: 301-319-2226 Ms. Erica Meillier: [email protected] Desk: 301-319-3273 Mr. Michael Goulart: [email protected] Desk: 301-319-2260 Lt Col Paul Lewis: [email protected] Desk: 301-319-2235 / 301-619-3755


27

UNCLASSIFIED

https://www.health.mil/AFHSB


28