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UNCLASSIFIED Armed Forces Health Surveillance Center: Medical Intelligence or Intelligent Medicine 21 June 2011 Sharon L. Ludwig, MD, MPH, MA CAPT, USPHS/USCG.

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Presentation on theme: "UNCLASSIFIED Armed Forces Health Surveillance Center: Medical Intelligence or Intelligent Medicine 21 June 2011 Sharon L. Ludwig, MD, MPH, MA CAPT, USPHS/USCG."— Presentation transcript:

1 UNCLASSIFIED Armed Forces Health Surveillance Center: Medical Intelligence or Intelligent Medicine 21 June 2011 Sharon L. Ludwig, MD, MPH, MA CAPT, USPHS/USCG Division Chief Epidemiology and Analysis

2 UNCLASSIFIED The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the US Army, Department of Defense, Coast Guard, or the Public Health Service. Disclaimer

3 UNCLASSIFIED Briefing Outline 1.Intelligence and Surveillance 2.Introduction to AFHSC 3.Data & Analysis 4.Public Health Practice vs Research 5.Intelligent Medicine

4 UNCLASSIFIED Military Intelligence Military Intelligence: “information and knowledge obtained through observation, investigation, analysis, or understanding Surveillance: systematic observation* for whatever data are available Reconnaissance: specific mission to obtain specific data * of aerospace, surface, or subsurface areas, places, persons, or things, by visual, aural, electronic, photographic, or other means

5 UNCLASSIFIED Military Medical Intelligence Tracking/assessing full range of global health issues, specifically those that could negatively impact U.S. military and civilian health Uses medical/public health surveillance information National Center for Medical Intelligence (NCMI)

6 UNCLASSIFIED Ongoing, systematic collection, analysis, interpretation, and reporting of health related data Purposes of detecting, characterizing, and countering threats to the health, well-being, and performance of defined populations [Military Services] Followed by timely dissemination and public health action to prevent, treat, or control disease & injury Includes –Medical Surveillance –Occ/Env Health Surv –[Military Force Health Protection] Public Health Surveillance

7 UNCLASSIFIED AFHSC Established Feb 2008 DoD Global Emerging Infections Surveillance & Response System DASD(HA) Force Health Protection & Readiness Global Health Surveillance Capability Area Army Medical Surveillance Activity Defense Medical Surveillance System (DMSS) & DoD Serum Repository (DoDSR)

8 UNCLASSIFIED AFHSC Governance Armed Forces Health Surveillance Center Force Health Protection Council Army Exec Agent ASD (Health Affairs) Functional Oversight USD (Personnel &Readiness)

9 UNCLASSIFIED AFHSC Relationships Armed Forces Health Surveillance Center PHC(P) POPM NMCPHC BUMED USAFSAM AFMSA MTFs Service Public Health Ctrs National (CDC) State Health Depts County /Metro Depts DoD HQ,USCG

10 UNCLASSIFIED AFHSC Mission & Vision Mission: To promote, maintain, and enhance the health of military and military-associated populations by providing relevant, timely, actionable, and comprehensive health surveillance information and support. Vision: To be the central epidemiological resource for the US Armed Forces and the Military Health System.

11 UNCLASSIFIED AFHSC Scope of Responsibility What We Should Do Strategic level surveillance Improve decision-making and effectiveness –Acquire, analyze, interpret, recommend and disseminate information –Develop, refine, and improve standardized surveillance methods –Serve as focal point for sharing health surveillance products, expertise and information What We Shouldn’t Do Direct installation surveillance support Healthcare systems analysis Evaluation of the quality of care at the individual provider-patient level Clinical research In-house laboratory services IAW CONOPS

12 UNCLASSIFIED PERSONNEL Uniformed: 17 FederalCiv: 4 Contract: 63 Science Advisor AFHSC Structure Director Epidemiology & Analysis Division Epidemiology & Analysis Division Communications, Standards, & Training Division GEIS Operations Division GEIS Operations Division Data Management & Tech Support Division Data Management & Tech Support Division Deputy Director HQ Staff

13 UNCLASSIFIED Science Advisor AFHSC Divisions Director Epidemiology & Analysis Division Epidemiology & Analysis Division Communications, Standards, & Training Division GEIS Operations Division GEIS Operations Division Data Management & Tech Support Division Data Management & Tech Support Division Deputy Director Communications, Standards & Training HQ Staff PERSONNEL Uniformed: 17 FederalCiv: 4 Contract: 63

14 UNCLASSIFIED AFHSC Divisions Communications, Standards & Training

15 UNCLASSIFIED Medical Surveillance Monthly Report Longitudinal surveillance of health & fitness of Service members > 100 issues Online and mailed each month Annual DoD summaries Promulgation of DOD standard case definitions AFHSC Divisions Communications, Standards & Training

16 UNCLASSIFIED AFHSC Surveillance Standards Part of AFHSC mission to provide guidelines and standardization for epidemiological purposes across DoD AFHSC maintains the Tri-Service Reportable Medical Events Guidelines and Case Definitions New “surveillance case definitions” are among first formal efforts to document methods unique to AFHSC/Defense Medical Surveillance System AFHSC Divisions Communications, Standards & Training

17 UNCLASSIFIED AFHSC Divisions Communications, Standards & Training

18 UNCLASSIFIED Resident Rotations at AFHSC Preventive and Occupational Medicine residents –Walter Reed Army Institute of Research (WRAIR) –Uniformed Services University of the Health Sciences (USUHS) 4-6 week rotation w/data analysis project using DMSS AFHSC Divisions Communications, Standards & Training

19 UNCLASSIFIED Science Advisor AFHSC Divisions Director Epidemiology & Analysis Division Epidemiology & Analysis Division Communications, Standards, & Training Division GEIS Operations Division GEIS Operations Division Data Management & Tech Support Division Data Management & Tech Support Division Deputy Director GEIS Operations HQ Staff PERSONNEL Uniformed: 17 FederalCiv: 4 Contract: 63

20 UNCLASSIFIED AFHSC Divisions Strategic Goals and Priority Pillars ARD GI DRO STI Assessment and Communication of Value Added Research, Innovation and Integration Surveillance and Response Training and Capacity Building RI GI AR STI FVBI Force Health Protection RI = Respiratory Infection GI = Gastrointestinal Infection FVBI = Febrile & Vector- borne Infection AR = Antimicrobial Resistance STI = Sexually Transmitted Infection GEIS Operations

21 UNCLASSIFIED AFHSC Divisions Peru Kenya Egypt Thailand Pacific NHRC USAFSAM WRAIR/NMRC Germany Korea USAPHC (Prov) NMCPHC DoD Partners GEIS Operations

22 UNCLASSIFIED Science Advisor AFHSC Divisions Director Epidemiology & Analysis Division Epidemiology & Analysis Division Communications, Standards, & Training Division GEIS Operations Division GEIS Operations Division Data Management & Tech Support Division Data Management & Tech Support Division Deputy Director Data Management & Tech Support HQ Staff PERSONNEL Uniformed: 17 FederalCiv: 4 Contract: 63

23 UNCLASSIFIED AFHSC Divisions Maintain Defense Medical Surveillance System (DMSS) Archive HIV test results Maintain DOD Serum Repository Support AFHSC IM/IT Needs Data Management & Tech Support

24 UNCLASSIFIED MEPS 12.1 million persons 26.6 M records Hospitalizations 2.5 M records Ambulatory Data M records Immunizations 86.9 M records Casualty Data 49 K Deaths Pre / Post-Deployment Health Assessments 8.5M Reportable Diseases 276 K records Deployments 4.9 million records Personnel Data 9.4 M persons M records As of Feb 2011 AFHSC Divisions Accession Process Discharge or Death Serum 58.2 M specimens 38.9 HIV test results DMSS—Longitudinal Database >1.5B Records Data Management & Tech Support

25 UNCLASSIFIED DMSS Data Inputs / Frequency TableSourceFrequencyRowsTime Period PersonDMDCMonthly9.4 M DemographicsDMDCMonthly109.7 M MEPSMEPCOMMonthly37.9 M Deploy (PGW)DMDCSingle682 K Deploy (CENTCOM)DMDCMonthly3.5 M1993 – 2010 Deploy FormsMEDPROS, PIMR, EDHADaily/Weekly 8.1 M1996 – 2010 Inpatient-MTF/TEDDHSSMonthly2.5 M1990 – 2010 Outpatient-MTF/TEDDHSSWeekdays201.4 M1996 – 2010 Reportable EventsMTFsDaily266.8 K1994 – 2010 ImmunizationsDEERSWeekdays87.0 M DoDSR Weekly57.5 M CasualtyWHS / AFIPQuarter/Month48.7 K TMDSFHP&RDaily4.5M2005 – 2010 TRAC 2 ES (CENTCOM)TRANSCOM/FHP&RWeekly72.9K2001 – 2010 AFHSC Divisions Data Management & Tech Support

26 UNCLASSIFIED Reportable Events Process Provider / Lab Report Air Force Sch of Aerospace Med Navy Marine Corps Public Health Center Armed Forces Health Surveillance Center/DMSS Regional Medical Command AFMOA / MAJCOM Army Public Health Command (P) Installation / Unit Prev Med Monthly/Weekly Weekly DRSi AFRESS Installation / Ship / Unit PM Installation / Unit Prev Med Navy Environmental PM Unit AFHSC Divisions Data Management & Tech Support

27 UNCLASSIFIED AFHSC Divisions Defense Medical Epidemiology Database Data Management & Tech Support

28 UNCLASSIFIED AFHSC Divisions DMSS & Functional Relationships Data Management & Tech Support

29 UNCLASSIFIED World’s largest serum repository Unrivaled potential for sero-epi studies ~ 40 various size sample requests/year 60M serial serum specimens from 10M individuals Linked to demographic, military, and medical information via the DMSS AFHSC Divisions Data Management & Tech Support DoD Serum Repository

30 UNCLASSIFIED Science Advisor AFHSC Divisions Director Epidemiology & Analysis Division Epidemiology & Analysis Division Communications, Standards, & Training Division GEIS Operations Division GEIS Operations Division Data Management & Tech Support Division Data Management & Tech Support Division Deputy Director Epidemiology & Analysis HQ Staff PERSONNEL Uniformed: 17 FederalCiv: 4 Contract: 63

31 UNCLASSIFIED Customers Secretary of Defense Assistant Secretary of Defense for Health Affairs [ASD(HA)] USCG Director of Health and Safety Joint Chiefs Service Surgeons General Service Public Health Hubs AFHSC Staff Epidemiology & Analysis

32 UNCLASSIFIED  Operational surveillance analysis (600/yr)  Support for: –DoD policy development –GAO investigations –Congressional Inquiries  Analysis for MSMR articles  Special Studies / Research Support Includes specialized influenza surveillance/analysis  Focused periodic reports (1450/yr) Epidemiology & Analysis Data sources: DMSS, DoDSR, others

33 UNCLASSIFIED US Military Malaria Cases Jan 02-Dec 08 Likely infection location Source: MSMR Vol 16, No. 1 Jan 09, AFHSC Epidemiology & Analysis Example of MSMR Support

34 UNCLASSIFIED Example of Serum Study: Hantavirus in Military Personnel from Four Corners Area Epidemiology & Analysis

35 UNCLASSIFIED May 2010: AFHSC Routine Reports* TypeTotal # Reports# Unique Reports Reportable Medical Events/Communicable Diseases53 7 Deployment Health Assessments28 18 Influenza11 3 H1N1 Vaccine Safety and Compliance5 2 Medical Evacuations4 1 Deployment Health Report 0 (quarterly) Malaria1 1 Smallpox Cardiac Adverse Events Report1 1 Training-related injuries1 1 Leishmaniasis1 1 Traumatic Brain Injury3 3 Post Traumatic Stress Disorder1 1 MHS Dashboard Measures1 1 FHP QA Measures1 1 Wounded Service Members1 1 Vaccine Adverse Events2 2 Special Surveillance: Amputations, DVT, Leish, ARDs1 1 Injury Installation Reports1 1 Lost duty2 2 Meningococcal Report1 1 Epidemiology & Analysis  Over 50 routine reports distributed monthly, quarterly, weekly, or daily (1448 total reports annually)  Over 600 requests performed annually

36 UNCLASSIFIED Quarterly Deployment Health Report October 2010, page 6 of 16 Epidemiology and Analysis

37 UNCLASSIFIED Request Process

38 UNCLASSIFIED Request Process Requestor Contacts AFHSC Service liaisons –Army –Navy, Marine Corps Coast Guard –Air Force Special Projects lead Residency Program Communications Center Other staff interactions

39 UNCLASSIFIED Clarify the Question Legal –DMSS is System of Records –Human Subjects Protection –Classified or Privacy Protected Scientifically Sound (Methods Valid) Data/Sera Available Request Process Can We Do It?

40 UNCLASSIFIED Requestor’s Intent & Authority Militarily Relevant Military Sponsor Level of Surveillance (Strategic vs Unit) Intent –Related to Public Health –Purpose (Scope of Responsibility) –PH Practice v Research Request Process Should We Do It? Clarify the Question

41 UNCLASSIFIED Request Process

42 UNCLASSIFIED Types of Requests “Operational” –Strategic –DoD-wide –Public Health Practice Research –Support –Internal research

43 UNCLASSIFIED Public Health Practice Specific authorization Accountability to the public May legitimately involve persons who did not volunteer to participate Draws on the principles of public health ethics by focusing on populations while respecting the dignity and rights of individuals May be distinguished from research on the basis of general legal authority, specific intent, responsibility, participant benefits, experimentation, and subject selection

44 UNCLASSIFIED Public Health Practice Prevent or control disease or injury and improve health Benefit is to the population from which information is gathered Military PH Practice –Commanders, supervisors, individual Service members, and MHS shall promote, improve, conserve, and restore physical/mental well- being…across the full range of military activities and operations –Conduct activities common to other public health agencies, including disease/injury surveillance, “reportable medical event” case reporting, outbreak investigation, program evaluation etc. Primary intent

45 UNCLASSIFIED Public Health Research If to generate or contribute to generalizable knowledge, then research If to prevent or control disease or injury or improve a public health program, then non-research (= PH practice = “operational”) If changes from prevention or control to generating generalizable knowledge, then it becomes research Primary intent

46 UNCLASSIFIED Request Process

47 UNCLASSIFIED Request Process Draft Analysis Plan

48 UNCLASSIFIED Present to Request/Report Review (R-3) Team Request Process Epidemiology & Analysis Chief E & A Asst Chief Service liaisons Science advisor Senior Epidemiologists Senior Biostatisticians MSMR staffer Others ad hoc

49 UNCLASSIFIED Request Process S: Requestor, Question O: Background material, supporting literature, military relevance, etc. A: Public Health Practice or Research P: Analysis Template R-3 Presentation (“Morning Rounds”)

50 UNCLASSIFIED Request Process R-3 Team questions the presenter Presenter may need to further clarify the question (to R-3 or with customer) –Can we do it –Should we do it New R3 approval process, if needed R-3 Team Review

51 UNCLASSIFIED Request Process

52 UNCLASSIFIED Once approved by R-3, assignment to analyst Coding –Complicated person-time calculations –Complex case definitions –Multiple/complex outputs –Modifications to original request –Prioritization with other requests –Technical difficulties May need to return to R-3 Request Process Analysis

53 UNCLASSIFIED Request Process

54 UNCLASSIFIED Request Process Output –De-identified data set –Summary table Deliver to customer Analysis

55 UNCLASSIFIED AFHSC Example H1N1 Influenza Response

56 UNCLASSIFIED Detection of Pandemic Flu (pH1N1) 37 Sailors present in San Diego Navy FM (1 st case) presents in San Diego 2 Army FM present in San Antonio First ESSENCE Alert (26 Apr 09) 2009JulyJuneMayAprilMarch ESSENCE Cases

57 UNCLASSIFIED First four cases of pandemic H1N1 detected in two AFHSC/GEIS funded laboratories –Specimens and information provided to CDC Three DoD pH1N1 strains used by WHO as potential seed strains; one was selected Supported the diagnostic confirmation of the first H1N1 cases in 14 different countries (US, Bhutan, Cambodia, Djibouti, Kuwait, Kenya, Lao People’s Democratic Republic, Lebanon, Egypt, Nepal, Colombia, Ecuador, Peru, Republic of the Seychelles) Numerous pH1N1 laboratory capacity building for diagnosis –NAMRU-3: 30 countries and 70 participants in 3 weeks!!! Pandemic Influneza

58 Communication: DoD Global Influenza Activity Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week Period NMRC-Lima TOTAL (NEW) Flu A: H1N1: H3N2: pH1N1 Flu B: USAMRU-K TOTAL (NEW) Flu A: 284 (53) H1N1: 5 H3N2: 16 (4) pH1N1: 147 (29) Flu B: 70 (7) TAMC TOTAL (NEW) 1, Flu A : H1N1: H3N2: pH1N1 30 (11) Flu B: 4 (1) LRMC/CHPPM TOTAL (NEW) Flu A: 167 H1N1: H3N2: pH1N1: 162 (92) Flu B: AFRIMS TOTAL (NEW) Flu A: 260 (96) H1N1: 3 (2) H3N2: 21 (12) pH1N1: 68 Flu B: 4 (3) NAMRU-2 TOTAL (NEW) 1503 Flu A: 225 H1N1: H3N2: 58 pH1N1: 107 H5N1: Flu B: 60 NAMRU-3 TOTAL (NEW) 562 Flu A: 37 H1N1: 8 H3N2: 24 pH1N1: 5 H5N1: Flu B: 11 USAFSAM TOTAL (NEW) 6, Flu A: 1,289 (164) H1N1: H3N2: 1 pH1N1 1,885 (80) Flu B: 13 (1) NHRC TOTAL (NEW) 3, Flu A: H1N1: H3N2: pH1N1 1,122 (165) Flu B: DoD Service LabsMedical Centers/ClinicsDoD Research Labs Note: H5N1 (positives/tested or pending) results are cases that have been confirmed and reported through WHO in compliance with the International Health Regulations Guam TOTAL (NEW) 11 3 Flu A : H1N1: H3N2: pH1N1: 2 Flu B: CENTCOM-Mil TOTAL (NEW) Flu A: H1N1: H3N2: 5 pH1N1: 363 (30) Flu B: 2 USF Japan TOTAL (NEW) 46 3 Flu A: 22 (1) H1N1: H3N2: pH1N1 : 17 Flu B: 2 (1) USF Korea TOTAL (NEW) 1, Flu A: 91 H1N1: H3N2: pH1N1 : 342 (21) Flu B : 2 CONUS MEDCENs TOTAL (NEW) 8,279 1,740 Flu A: 2,576 (508) H1N1: H3N2: pH1N1: 793 (122) Flu B: 15

59 UNCLASSIFIED Communication: Surveillance Partner Reporting Sentinel Surveillance Population-Based/Recruit Electronic Military Health Surveillance DOS Embassy Lab-Specific Regional

60 UNCLASSIFIED Communication: Network Summary Available at: ü60

61 UNCLASSIFIED Laboratory network: Global visibility Reportable Medical Events: Uniformed personnel visibility Conference call coordination Daily/weekly reporting for chain of command 2009 pH1N1: AFHSC Coordination Attributes Combined Under One Roof

62 UNCLASSIFIED Intelligent Medicine “…‘intelligent medicine’ that will give physicians the tools they need to regain control over medical decisions made for their patients.” “A Path to Intelligent Medicine” Walter Eisner, from Rick Guyer, MD; outgoing President of the North American Spine Society, farewell speech at annual meeting, October, 2007

63 UNCLASSIFIED Intelligent Medicine “…bringing real thought to bear on our prevention and treatment strategies, not just falling back on the conventional treatment, whether high-tech or alternative, in a knee-jerk reaction;” – …in charge or your own health and fitness” –A guide for patients to “help their doctors” and wisely use the medical and preventive options available in the current environment. Ronald Hoffman, MD Intelligent Medicine: A Guide to Optimizing Health and Preventing Illness for the Baby-Boomer Generation, 1997, Simon and Schuster

64 UNCLASSIFIED Intelligent Military Medicine Evidence based policy and prevention strategies for the United States Armed Forces

65 UNCLASSIFIED Questions


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