Department Of Defense

The primary mission of the DoD is to provide the military forces needed to deter war and to protect the security of the United States. The DoD employs 1.7 million active duty, Guard and Reserve personnel who receive health benefits. In addition, over 2.3 million family members and 4.5 million retirees and dependents of retirees receive medical care through the military system (U.S. Department of Defense, 2005e).

In order to maintain force health protection and medical readiness, the military has extensive programs to monitor the health and fitness of service members. Military installations around the globe perform health surveillance to determine the nature, magnitude, and distribution of health threats and to focus and evaluate preventive efforts. These threats include injuries, acute and chronic conditions (including infectious diseases), mental illnesses, and environmental exposures.

Protection against biological warfare has long been a part of force protection for the military. As the threat has evolved, protection against biological terrorism on domestic and overseas installations has also improved. As diseases do not respect installation boundaries, and the well-being of military retirees and family members is also of importance to the military, the DoD has greatly increased its surveillance efforts to identify natural or deliberate disease outbreaks at the earliest possible point in time. Presidential Decision Directive NSTC-7 (June 1996) stated that the United States will strengthen domestic infectious disease surveillance and response. It expanded the mission of the DoD to include support of global surveillance, training, research, and response to emerging infectious disease threats (White House, 2005). In response to this directive, DoD established the Global Emerging Infections Surveillance and Response System (DoD-GEIS). The DoD-GEIS is designed to strengthen the prevention of, surveillance of, and response to infectious diseases that pose a threat to military personnel, their families, and neighboring civilian communities, or present a risk to U.S. national security (U.S. Department of Defense, 2005b).Their efforts include sponsoring the development of syndromic surveillance systems and laboratory-based surveillance (Pavlin and Kelley, 2004, Canas et al., 2000).

3.1. Organization of DoD

The DoD is a large organization with an annual budget of over $370 billion (U.S. Department of Defense, 2005a). Its full organization is well beyond the scope of this book; interested readers should go to the military website www.defenselink.mil for more detailed information. Here we provide a focused overview of the organization of DoD relevant to a discussion of biosurveillance. The DoD has centralized many of its healthcare and biosurveillance functions, but there are interservice (e.g., Army, Navy) differences.

3.1.1. Centralized Functions

The Deputy Assistant Secretary of Defense for Force Health Protection and Readiness is responsible for all aspects of health care in support of military operations, military public health, and surveillance (U.S. Department of Defense Military Health System, 2005). The military health system, like the civilian healthcare system that was the topic of Chapter 6, conducts health surveillance of its own beneficiary populations. The DoD has 239 fixed military treatment facilities1 around the world to care for beneficiaries (U.S. Department of Defense, 2005d). The DoD also monitors international disease trends that may affect force readiness. DoD shares public health information of importance with local and state health departments. Each installation has medical officers responsible for the public health of those who live and work there. The DoD aggressively identifies, characterizes, and reports on 78 reportable diseases based on Centers for Disease Control and Prevention (CDC) recommendations plus additional conditions of military importance. Reports flow not only through DoD communication channels but also to the local and state health departments within which the military treatment facility is located.

The military healthcare system is run by the TRICARE Management Activity under the Assistant Secretary of Defense for Health Affairs (U.S. Department of Defense, 2005c). The DoD has developed an electronic medical record system that records demographic information of all inpatient and outpatient visits along with diagnostic information and pharmacy, radiology, and laboratory orders. A complete electronic medical record is under deployment at the time of this writing.

3.1.2. Service-Specific Functions

The DoD is divided into Army, Navy, Marine Corps, and Air Force departments. Within each are suborganizations that play a role in biosurveillance. Surveillance is performed by each of the services for beneficiaries under their responsibility. This includes public health surveillance for naturally occurring diseases and bioterrorism.

The Army, Navy, and Air Force all have organizations dedicated to the health of their service members and families. The Army runs the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM) located at Aberdeen Proving Ground (Edgewood), Maryland. The Army Medical Surveillance Activity (AMSA) is part of the USACHPPM, and

1 A fixed military treatment facility is a hospital, clinic. Unlike the civilian healthcare system, the military healthcare system has extensive capability to deploy temporary field treatment facilities.

analyzes, interprets, and disseminates information regarding the health and fitness of the Army. AMSA maintains the Defense Medical Surveillance System that contains a database of diseases and medical events, including hospitalizations, ambulatory visits, and longitudinal data on personnel and deployments. This system provides epidemiological information to policymakers, medical planners and researchers (Army Medical Surveillance Activity, 2005).

The Navy Environmental Health Center is located in Norfolk, Virginia, and its mission is to ensure Navy and Marine Corps readiness through leadership in prevention of disease and promotion of health. Its focus areas include global disease surveillance, clinical epidemiology, and the ability to detect, protect against and respond to lethal and nonlethal biological agents (Navy Environmental Health Center [NEHC], 2005).

The Air Force Institute for Operational Health (AFIOH) is located at Brooks City-Base, Texas, and its mission is to promote global health and protect Air Force warriors and communities. The AFIOH Surveillance Directorate provides field sampling, laboratory analysis, and data collection for assessment and management of risk (U.S. Air Force, 2005).

3.1.3. Research

Research, development, and acquisition of chemical, biological, radiological, and nuclear defense programs within the DoD are overseen by the Assistant to the Secretary of Defense for Nuclear, Chemical and Biological Defense Programs (Medical Chemical and Biological Defense Science and Technology Program, 2005). The Joint Program Executive Office for Chemical and Biological Defense (JPEO-CBD) is responsible for research, development, acquisition, and fielding of chemical, biological, radiological, and nuclear defense equipment and medical countermeasures (The Joint Program Executive Office for Chemical and Biological Defense, 2005f).

In addition, other laboratories in the DoD work on medical issues for biological defense. The U.S. Army Medical Research and Material Command (USAMRMC) operates laboratories responsible for ensuring the military forces are deployed in a state of optimal health and equipped to protect themselves from disease and injury (U.S. Army Medical Research and Material Command, 2005). Under USAMRMC, the U.S. Army Medical Research Institute for Infectious Diseases conducts basic and applied research on biological threats resulting in medical solutions to protect the warfighter (U.S. Army Medical Research Institute of Infectious Diseases, 2005). The Walter Reed Army Institute of Research (WRAIR) conducts biomedical research to deliver life saving products to sustain the combat effectiveness of the warrior (Walter Reed Army Institute of Research, 2005).

The Defense Advanced Research Products Agency previously sponsored the Bio-Event Advanced Leading Indicator

Recognition Technology (BioALIRT) project to advance research on improving timeliness of outbreak detection. This project focused on identifying new nontraditional data sources that could detect outbreaks early and the development and evaluation of detection algorithms (Buckeridge et al., 2005).

3.2. Biosurveillance Systems

DoD conducts surveillance of both human health and of the environment, especially the air.

3.2.1. Human Health Event Surveillance

The WRAIR developed the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) to capture and disseminate information on outpatient healthcare utilization for specific syndrome categories (Lewis et al., 2002). By monitoring this information both temporally and spatially, outbreaks of infectious disease of potential public health significance, including those caused by bioterrorism, can be quickly recognized and tracked. In collaboration with the Johns Hopkins University Applied Physics Laboratory, this system was expanded to include civilian health information in the Washington, DC region and is currently available for health departments in the District of Columbia, Virginia and Maryland (Lombardo et al., 2003). ESSENCE is the Military Health System's primary electronic method for outbreak detection.

3.2.2. Interoperation with Civilian Systems

Joint Services Installation Pilot Project. To improve the response capabilities for chemical, biological, radiological, and nuclear incidents, the Defense Threat Reduction Agency (DTRA) sponsored the Joint Services Installation Pilot Project at nine military installations in the United States. The project also used ESSENCE to integrate military and civilian data in regional systems by combining civilian data, such as emergency room chief complaints, with the military outpatient visit and pharmacy data and providing the web-based monitoring system to both military and civilian users.

BioNet. The integration of military and civilian surveillance systems was one of the key components of the BioNet project, which was sponsored by DHS and managed by DTRA. This program used San Diego as a test bed. This one-year project integrated detection and characterization capabilities of both civilian and military organizations to improve detection time and accuracy. Environmental sensor data from both military and civilian programs are combined and medical data are also provided to both military and civilian public health departments.

Military data collected during BioNet included outpatient ICD-9 codes categorizing the reason for the visit, text chief complaints from the Naval Medical Center San Diego emergency room and one ship, and outpatient pharmacy prescriptions. Civilian data included school absenteeism records, school nurse office visit data at select schools, chief complaint logs from hospital emergency rooms, over-the-counter medication sales from the National Retail Data Monitor, and pre-hospital ambulance transport data. The system combined data in the web-based Integrated Data Repository and Analysis Engine and made it available to both military and civilian users. Integration issues included difficulties using legacy systems in operation at the health departments and getting permission to install a new system. In post-use surveys, the users rated the system very high, thought having access to both civilian and military data helped in the performance of their job, and rated syndromic surveillance overall as an asset to public health work (Marsden-Haug et al., 2005).

Military outpatient data are currently used in the CDC's BioSense system, a nationwide syndromic surveillance system that combines the military data with Veteran's Administration hospitals' outpatient data and test ordering information from a nationwide commercial laboratory (Loonsk, 2004).

3.2.3. Environmental Surveillance

Under the JPEO-CBD, the Joint Project Manager for Nuclear Biological and Chemical Contamination Avoidance runs the Product Manager for Biological Detection (Joint Program Executive Office for Chemical and Biological Defense, 2005e).This area focuses on biological point detection and has a technology goal to increase detection sensitivity, lower detection thresholds, increase the specificity across threat agents, reduce false alarm rates, and integrate detectors into mapping and communication networks.

The systems currently in development or fielded include: (1) the Biological Integrated Detection System, a detection suite that is mounted on a dedicated vehicle that detects and identifies large-area biological warfare agent attacks (Joint Program Executive Office for Chemical and Biological Defense, 2005a); (2) the Joint Biological Point Detection System, a fully automated, stand-alone suite that will be capable of identifying biological warfare agents in less than 15 minutes (Joint Program Executive Office for Chemical and Biological Defense, 2005b); (3) the Joint Biological Standoff Detection System, a standoff biological detection system that will detect and track aerosol clouds out to 15 km in near real time. It will discriminate between natural and manmade aerosols (Joint Program Executive Office for Chemical and Biological Defense, 2005c); and (4) the Joint Portal Shield, an automated, modular, networked biological detection system that identifies up to eight biological warfare agents simultaneously in less than 25 minutes (Joint Program Executive Office for Chemical and Biological Defense, 2005d).

As a result of the anthrax-tainted envelopes of 2001, the USPS has added biosurveillance to its many core functions.

Biosurveillance measures in place include the Biohazard Detection System (BDS), a device that monitors mail-sorting machines and a nationwide illness surveillance program for postal workers that can be activated in response to an event.

BDS is an air monitoring system based on a DNA poly-merase chain reaction (PCR) test for B. anthracis (U.S. Postal Service, 2004, Military Postal Service Agency, 2004). BDS attaches to mail-sorting machines. A mail-sorting machine is both a single point through which all mail passes (except locally routed rural mail and larger packages) and a nearly ideal device for expressing spores from all but the most tightly sealed envelops (because the process compresses envelops), enabling the detection of spores by BDS.

BDS comprises an air-collection hood, a cabinet where the collection and analysis devices are housed, a local computer network connection, and a site controller (i.e., a networked computer). All the BDS processes are automated. The equipment continuously collects air samples from mail canceling equipment while the canceling operation is underway. It absorbs and concentrates airborne particles into a sterile water base. This creates a liquid sample that is injected into a cartridge. BDS then performs an automated polymerase chain reaction (PCR) on the liquid sample to detect the presence of anthrax (Bacillus anthracis). The system concentrates air samples for a one-hour period followed by the PCR test that takes approximately 30 minutes. While the PCR test is performed, the BDS is simultaneously concentrating particles for the next sample. So, although the first result requires approximately 1.5 hours, subsequent results are obtained every hour (U.S. Department of the Army, Headquarters, 2005).

According to published material, "If there is a DNA match, the BDS computer network conveys that information to the site controller computer. Local management is notified directly by on-site BDS personnel and also by multiple forms of electronic communication from the BDS site controller. The emergency action plan will be activated. The facility's building alarm will sound and everyone in the building will be evacuated. Upstream and downstream processing facilities will also be notified. An Emergency Notification Center at Postal Service headquarters will be notified as well as community first responders and the Department of Homeland Security. Once the postal employees are outside the building, supervisors will call the roll and make sure everyone in the building has been evacuated. They will explain the nature of the incident, and everyone will wait for direction from community emergency response personnel. An outside lab will perform multiple plate cultures using the BDS positive test sample and other environmental samples. Local public health officials will determine the need for any medication. The mail inside the plant will be retained until it is safe for delivery. The new mail that would normally be processed in this facility will be diverted to other mail processing facilities and delivery operations" (U.S. Department of the Army, Headquarters, 2005).

The military also deploys this type of monitoring, and it triggered the March 2005 anthrax alert at a Pentagon mail-handling facility. In this event, postal workers received postexposure prophylaxis (i.e., antibiotics) even though anthrax could not be confirmed by secondary testing. The lack of timely reporting of this incident and the laboratory's failure to use assays approved by the Federal Laboratory Response Network highlighted the disconnect between federal civilian and military surveillance programs even three-and-a-half years after 9/11/01.

5. PLANES, TRAINS,AND SHIPS_

Transportation systems have a long history of transporting not only goods and people but also disease. In fact, the word quarantine (derived from the Latin word quadraginta meaning "forty") was first used between 1377 and 1403 to refer to a 40-day period of isolation enforced by Venice and the other chief maritime cities of the Mediterranean for all vessels entering their ports from areas suspected to harbor plague (Bolduan and Bolduan, 1941).

Modern transportation systems make it possible for people, vectors, and microorganisms to travel between any two cities on the earth in less than a day. This situation, however, is relatively recent. It was not until the steamship network arose in the 1870s, for example, that plague could reach seaports in Asia, the Americas, and South Africa (McNeill, 1989).

In general, biosurveillance of a transportation system can involve multiple approaches, such as monitoring of the transportation vehicle itself (e.g., its air, water, and food systems);

screening of passengers and cargo for disease; post-travel monitoring of recent travelers; and investigation of outbreaks. At present, it is rare for all of these modalities to be in use together for cost or feasibility reasons, although they are complementary. In the future, we expect their combined use to be the rule rather than the exception.

5.1. Ships

Cruise ships are miniature cities with their own water systems, food systems, and medical facilities.They resemble hospitals in having many of the prerequisites for outbreaks to develop: close quarters, and steady influx of new individuals into the population.

In the year 2001, CDC's Vessel Sanitation Program, which conducts surveillance for gastrointestinal illness on cruise ships with foreign itineraries sailing into U.S. ports, received reports of 21 outbreaks of acute gastrointestinal illness on 17 cruise ships (CDC, 2002), at least half of them due to norovirus.2 These outbreaks sickened up to 31% of passengers and occasionally recurred on subsequent trips despite sanitary efforts. Other biological agents that have caused outbreaks on cruise ships include influenza (Uyeki et al., 2003, Brotherton et al., 2003),staphylococcal enterotoxin (Waterman et al., 1987, CDC, 1983), E. coli (Daniels et al., 2000, Snyder et al., 1984, Lumish et al., 1980), Legionella pneumophila (Kobayashi et al., 2004, Regan et al., 2003, Castellani Pastoris et al., 1999, Rowbotham, 1998, Health Protection Agency, 1998, Jernigan et al., 1996), Shigella sp. (Gikas et al., 1996, CDC, 1994, Lew et al., 1991, Merson et al., 1975) and Variola minor (rubella) (Hoey, 1998, CDC, 1998).Table 12.2 presents a catalog of the gastrointestinal table 12.2 International Cruise Ship Gastrointestinal Outbreaks Reported to Centers for Disease Control and Prevention Vessel Sanitation

Program, January—June 2005

table 12.2 International Cruise Ship Gastrointestinal Outbreaks Reported to Centers for Disease Control and Prevention Vessel Sanitation

Program, January—June 2005

Cruise Line

Ship Name

Sailing Dates

Causative Agent

Princess Cruise Line

Sun Princess

5/9-5/16/2005

Norovirus

Princess Cruise Line

Dawn Princess

4/29-5/14/2005

Norovirus

Celebrity Cruise Line

Horizon

4/23-4/30

Unknown

Crystal Cruise

Crystal Symphony

4/14-4/25

Unknown

Norwegian Cruise Line

Norwegian Crown

3/13-3/28

Unknown

Princess Cruise Line

Royal Princess

3/7-3/24

Unknown

Holland America Cruise Line

Veendam

3/5-3/12

Norovirus

Celebrity Cruises

Zenith

2/27-3/13

Norovirus

Carnival Cruise Line

Celebration

2/21-2/26 and 2/17-2/21

Norovirus

Radisson Seven Seas Cruises

Seven Seas Mariner

2/12-2/24

Salmonella

Royal Caribbean Cruise Line

Empress of the Seas

1/17-1/28

Norovirus

Royal Caribbean Cruise Line

Mariner of the Seas

1/26-1/23

Norovirus

Holland America Cruise Line

Ryndam

1/13-1/29

Norovirus

Princess Cruise Line

Sun Princess

1/8-1/18

Norovirus

Holland America Cruise Line

Veendam

1/3-1/15 and 1/15-1/29

Norovirus

Royal Caribbean Cruise Line

Enchantment of the Seas

1/3-1/8

Norovirus

Source: Centers for Disease Control and Prevention, 2005. Vessel Sanitation Program. National Center for Environmental Health (http://www.cdc.gov/nceh/vsp/surv/ GIlist.htm#2005).

Source: Centers for Disease Control and Prevention, 2005. Vessel Sanitation Program. National Center for Environmental Health (http://www.cdc.gov/nceh/vsp/surv/ GIlist.htm#2005).

2 Norovirus is a family of viruses that cause vomiting and diarrhea, for which humans have little immunity, and which spread extremely efficiently between people by hand-to-mouth, environmental surfaces and even via the air.

outbreaks reported to the CDC vessel sanitation program from January through May 2005.

Cruise ships are also mobile cities. When they are in port, they become a temporary extension of larger cities. During the Olympic Games in Sydney and Athens, cruise ships served as floating hotels and biosurveillance for these special events included measures for monitoring the ship-hotels (Jorm et al., 2003, Waples et al.,2000).

Airplanes often carry communicable disease between cities and countries. In 1978, poliovirus was imported into Canada by people traveling from the Netherlands (White et al., 1981). In 1996, a health worker in South Africa died from Ebola transmitted by a physician who had entered the country from Gabon, which was experiencing an Ebola outbreak (WHO, 2005a). In 1987, meningococcal meningitis was spread to several continents by tourists returning from the Haj (Novelli et al., 1987) (Figure 12.1). Similarly, air travel quickly spread SARS throughout the world in 2003. There have been reports of malaria deaths in northern countries possibly related to mosquitoes transported by airplanes from endemic regions (Isaacson, 1989). Brussels, Geneva, and Oslo have all had cases of "airport" malaria (WHO, 1999).

Airplanes and airports themselves represent a risk to air travelers because of crowding, although the risk is low because contact time is limited. Diseases such as pneumonic plague, influenza, and TB, nevertheless, can spread in airports and on airplanes (Roberts, 1996,Wenzel, 1996, Ritzinger, 1965, CDC, 1995, Driver et al., 1994). In 1977, over 70% of the passengers on board an airliner grounded for several hours were infected with influenza by a fellow passenger (Moser et al., 1979). In 1994, a person with active TB is believed to have infected six fellow passengers on a flight from Chicago to Honolulu (Miller et al., 1996, Kenyon et al., 1996).

At present, there is little "dedicated" biosurveillance of air transportation systems. Rather, outbreaks are detected through conventional biosurveillance methods such as disease reporting and astute observers. The role of airports and airlines at present is largely to cooperate during outbreak investigations by providing investigators with passenger lists and cargo manifestos. There are exceptions, however. For example, air monitoring devices similar to those used in the BioWatch program were in place at the Salt Lake City airport during the 2002 Winter Olympic Games. In Taiwan and other Asian countries, the SARS outbreak of 2003 led to large scale screening of passengers arriving and departing from airports (Chapter 3, Figure 3.5). Taiwan continues to routinely screen at airports for febrile patients using infrared thermal imaging devices, followed by stages of clinician assessment and laboratory testing. Shu and colleagues reported the Taiwan experience with finding cases of dengue fever (Shu et al., 2005). Of more than 8 million inbound travelers arriving at the two international airports (Chiang Kai-Shek and Kaohsiung) between July 2003 and June 2004, infrared thermal camera and confirmation by ear temperature identified approximately 22,000 passengers with fever. After clinical screening, 3011 passengers were tested for dengue virus. Forty of 3011 serum samples tested were positive for dengue by real-time PCR and E/M-specific capture IgM and IgG ELISA.

During the SARS outbreak of 2003, the Taiwan CDC also routinely monitored for post-travel illness in recent arrivals. It linked arrival data from passport control with national health insurance claims data to identify individuals who had received medical care for selected diagnoses within a week of arrival. The Taiwan CDC has plans to automate and continue this process as there is significant business travel between Taiwan and China (approximately 20,000 arrivals from China per day). This strategy is not only a general approach for detecting an outbreak that has been imported into a country

http://www.who.int/infectious-disease-report/pages/ graph39.html). Reproduced by permission of World Health Organization (WHO)."/>
figure 12.1 Spread of meningococcal meningitis by pilgrims returning from the Haj, 1987 (http://www.who.int/infectious-disease-report/pages/ graph39.html). Reproduced by permission of World Health Organization (WHO).
table 12.3 Passenger Traffic at 30 Major Airports in 2004

City (Airport)

Total Passengers

% Change

ATLANTA (ATL)

83,606,583

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