Presentation on theme: "Sharon L. Ludwig, MD, MPH, MA Division Chief Epidemiology and Analysis"— Presentation transcript:
1 Sharon L. Ludwig, MD, MPH, MA Division Chief Epidemiology and Analysis Armed Forces Health Surveillance Center: Medical Intelligence or Intelligent Medicine21 June 2011Sharon L. Ludwig, MD, MPH, MACAPT, USPHS/USCGDivision Chief Epidemiology and Analysis
2 DisclaimerThe 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.
3 Briefing Outline Intelligence and Surveillance Introduction to AFHSC Data & AnalysisPublic Health Practice vs ResearchIntelligent Medicine
4 Military Intelligence Military Intelligence: “information and knowledge obtained through observation, investigation, analysis, or understandingSurveillance: systematic observation* for whatever data are availableReconnaissance: 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 Military Medical Intelligence Tracking/assessing full range of global health issues, specifically those that could negatively impact U.S. military and civilian healthUses medical/public health surveillance informationNational Center for Medical Intelligence (NCMI)The — is an agency within the Defense Intelligence Agency (DIA) of the United States Department of Defense (DoD); its mission is to  As part of the DIA, this tri-service organization produces finished, all-source medical intelligence assessments, forecasts and databases on foreign military and civilian health care capabilities and trends, worldwide infectious disease risks, global environmental health risks, and militarily significant life science issues, to include biotechnology and nuclear, biological and chemical medical defense advancements
6 Public Health Surveillance Ongoing, systematic collection, analysis, interpretation, and reporting of health related dataPurposes 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 & injuryIncludesMedical SurveillanceOcc/Env Health Surv[Military ForceHealth Protection]Health Surveillance VsMedical surveillance—the ongoing, systematic collection, analysis and interpretation of data derived from instances of medical care or medical evaluation, and the reporting of population-based information for characterizing and countering threats to a population’s health, well-being, and performance.Pres. Clinton in 1996 issued the followingIn response, Assistant Sec Def (Health Affairs) established GEIS in1997Presidential Decision Directive, National Science & Technology Council-7 June 1996Expanded DoD mission to include support of global surveillance, training, research, and response to emerging infectious disease threatsStrengthen global disease reduction efforts through:centralized coordination,improved preventive health programs and epidemiological capabilities,enhanced involvement with MTFs and US and overseas laboratories”1997 Establishment of DoD Global Emerging Infections Surveillance and Response System (GEIS)
7 AFHSC Established Feb 2008DoD Global Emerging Infections Surveillance & Response SystemDASD(HA) Force Health Protection & ReadinessGlobal Health Surveillance Capability AreaArmy Medical Surveillance ActivityDefense Medical Surveillance System (DMSS)&DoD Serum Repository (DoDSR)26 Feb 08—DEPSECDEF signs memo establishing an AFHSCDOD Instruction , 7 Aug 1997US Army Center for Health Promotion & Preventive Medicine (now Public Health Command) will maintain a surveillance system to integrate, analyze, and report data…relevant to the health and readiness of military personnel”DoD Directive , 21 Oct 2004Sec of Army serves as Executive Agent for the Defense Medical Surveillance System and the Department of Defense Serum Repository.DOD Instruction , 11 Aug 2006: “Deployment Health”DMSS is the repository for all Deployment Health Surveillance forms and Tri-Service Reportable Events dataDSD memorandum 26 Feb 2008AFHSC is the single source for DoD-level health surveillanceDoD Directive E, 24 Aug 2009: “Comprehensive Health Surveillance”“AFHSC shall comply with the DoD Privacy Program and the DoD Health Information Privacy Regulation.”12 Oct 07 Acting SG of Army memorandumNamed AFHSC “Provisional” Director reporting to CG, USACHPPMTo proceed IAW AFHSC Task Force Draft CONOPS (within limits of Army authority)US Army Executive AgentJoint organization
8 AFHSC Governance Army Exec Agent USD (Personnel &Readiness)FunctionalOversightASD (Health Affairs)Force Health Protection CouncilArmy Exec AgentArmed Forces Health Surveillance Center
9 AFHSC Relationships National (CDC) DoD Service Public Health Ctrs Armed ForcesHealth SurveillanceCenterNational (CDC)DoDHQ,USCGService Public Health CtrsState Health DeptsPHC(P)POPMNMCPHCBUMEDUSAFSAMAFMSACounty /Metro DeptsMTFs
10 AFHSC Mission & VisionMission: 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 forthe US Armed Forces andthe Military Health System.
11 AFHSC Scope of Responsibility IAW CONOPSWhat We Should DoWhat We Shouldn’t DoStrategic level surveillanceImprove decision-making and effectivenessAcquire, analyze, interpret, recommend and disseminate informationDevelop, refine, and improve standardized surveillance methodsServe as focal point for sharing health surveillance products, expertise and informationDirect installation surveillance supportHealthcare systems analysisEvaluation of the quality of care at the individual provider-patient levelClinical researchIn-house laboratory servicesHealthcare systems analysis; i.e., resource management and efficient business practices such as access, cost of care, bed-occupancy, customer satisfaction, etc.Evaluation of the quality of care at the individual provider-patient level, e.g., adherence to practice guidelines, etc.
12 Communications, Standards, & Training Division AFHSC StructureDirectorHQ StaffScience AdvisorDeputy DirectorEpidemiology& Analysis DivisionCommunications, Standards, & Training DivisionGEIS OperationsDivisionData Management &Tech SupportGlobal Emerging Infections Surveillance and Response System (GEIS) is integrated throughout the Center. Dir, GEIS remains responsible for managing AI/PI Surveillance Program and the other GEIS accountabilities.PERSONNELUniformed: 17FederalCiv: 4Contract:
13 Communications, Standards, & Training Division AFHSC DivisionsCommunications, Standards & TrainingDirectorHQ StaffScience AdvisorDeputy DirectorEpidemiology& Analysis DivisionCommunications, Standards, & Training DivisionGEIS OperationsDivisionData Management &Tech SupportGlobal Emerging Infections Surveillance and Response System (GEIS) is integrated throughout the Center. Dir, GEIS remains responsible for managing AI/PI Surveillance Program and the other GEIS accountabilities.PERSONNELUniformed: 17FederalCiv: 4Contract:
14 Communications, Standards & Training AFHSC DivisionsCommunications, Standards & Training
15 Medical Surveillance Monthly Report AFHSC DivisionsCommunications, Standards & TrainingMedical Surveillance Monthly ReportLongitudinal surveillance of health & fitness of Service members> 100 issuesOnline and mailed each monthAnnual DoD summariesPromulgation of DOD standard case definitions
16 AFHSC Surveillance Standards AFHSC DivisionsCommunications, Standards & TrainingAFHSC Surveillance StandardsPart of AFHSC mission to provide guidelines and standardization for epidemiological purposes across DoDAFHSC maintains the Tri-Service Reportable Medical Events Guidelines and Case DefinitionsNew “surveillance case definitions” are among first formal efforts to document methods unique to AFHSC/Defense Medical Surveillance System
17 Communications, Standards & Training AFHSC DivisionsCommunications, Standards & Training
18 Resident Rotations at AFHSC AFHSC DivisionsCommunications, Standards & TrainingResident Rotations at AFHSCPreventive and Occupational Medicine residentsWalter Reed Army Institute of Research (WRAIR)Uniformed Services University of the Health Sciences (USUHS)4-6 week rotation w/data analysisproject using DMSS
19 Communications, Standards, & Training Division AFHSC DivisionsGEIS OperationsDirectorHQ StaffScience AdvisorDeputy DirectorEpidemiology& Analysis DivisionCommunications, Standards, & Training DivisionGEIS OperationsDivisionData Management &Tech SupportGlobal Emerging Infections Surveillance and Response System (GEIS) is integrated throughout the Center. Dir, GEIS remains responsible for managing AI/PI Surveillance Program and the other GEIS accountabilities.PERSONNELUniformed: 17FederalCiv: 4Contract:
20 Strategic Goals and Priority Pillars AFHSC DivisionsGEIS OperationsStrategic Goals and Priority PillarsAssessment and Communication of Value AddedResearch, Innovation and IntegrationSurveillance and ResponseTraining and Capacity BuildingRIGIARSTIFVBIForce Health ProtectionRI = Respiratory InfectionGI = Gastrointestinal InfectionFVBI = Febrile & Vector-borne InfectionAR = Antimicrobial ResistanceSTI = Sexually Transmitted InfectionARDGIDROSTI
22 Communications, Standards, & Training Division AFHSC DivisionsData Management & Tech SupportDirectorHQ StaffScience AdvisorDeputy DirectorEpidemiology& Analysis DivisionCommunications, Standards, & Training DivisionGEIS OperationsDivisionData Management &Tech SupportGlobal Emerging Infections Surveillance and Response System (GEIS) is integrated throughout the Center. Dir, GEIS remains responsible for managing AI/PI Surveillance Program and the other GEIS accountabilities.PERSONNELUniformed: 17FederalCiv: 4Contract:
23 Data Management & Tech Support AFHSC DivisionsData Management & Tech SupportMaintain Defense Medical Surveillance System (DMSS)Archive HIV test resultsMaintain DOD Serum RepositorySupport AFHSC IM/IT Needs
24 AFHSC Divisions Data Management & Tech Support DMSS—Longitudinal Database >1.5B RecordsHospitalizations2.5 M recordsSerum58.2 M specimens38.9 HIV test resultsPersonnel Data9.4 M persons111.7 M recordsMEPS12.1 million persons26.6 M recordsPre / Post-DeploymentHealth Assessments8.5MAccession ProcessDischarge or DeathService Member LifecycleDeployments4.9 million recordsImmunizations86.9 M recordsCasualty Data49 K DeathsFocus: Active Duty & Reserve Components>1.5B RecordsCentral health surveillance database for the Military Health SystemCurrent & historical disease and medical event dataLongitudinal data on uniformed personnel and deploymentsSystem of RecordsReportable Diseases276 K recordsAmbulatory Data211.7 M recordsAs of Feb 2011
25 DMSS Data Inputs / Frequency AFHSC DivisionsData Management & Tech SupportDMSS Data Inputs / FrequencyTableSourceFrequencyRowsTime PeriodPersonDMDCMonthly9.4 MDemographics109.7 MMEPSMEPCOM37.9 MDeploy (PGW)Single682 KDeploy (CENTCOM)3.5 M1993 – 2010Deploy FormsMEDPROS, PIMR, EDHADaily/Weekly8.1 M1996 – 2010Inpatient-MTF/TEDDHSS2.5 M1990 – 2010Outpatient-MTF/TEDWeekdays201.4 MReportable EventsMTFsDaily266.8 K1994 – 2010ImmunizationsDEERS87.0 MDoDSRWeekly57.5 MCasualtyWHS / AFIPQuarter/Month48.7 KTMDSFHP&R4.5M2005 – 2010TRAC2ES (CENTCOM)TRANSCOM/FHP&R72.9K2001 – 2010MEPS, DODSR, Casualty and TMDS number of rows include non-Service members
26 Reportable Events Process AFHSC DivisionsData Management & Tech SupportReportable Events ProcessProvider / Lab ReportAir Force Sch of Aerospace MedNavy Marine Corps Public Health CenterArmed Forces Health Surveillance Center/DMSSRegional Medical CommandAFMOA / MAJCOMArmy Public Health Command (P)Installation / Unit Prev MedMonthly/WeeklyWeeklyDRSiAFRESSInstallation / Ship / Unit PMNavy Environmental PM UnitWithin the military each service runs its own reportable events system. Investigation of cases is supposed to be by local PM assets first, followed by regional assets, then the Service Public Health Hubs. Eventually all the cases get reported to the Armed Forces Health Surveillance Center which is the first time all the reports for an area may be collated. Is a significant weakness that this collation may take months.As far as reporting to the civilians, the local assets are required to report according to the local jurisdictional laws.
27 Data Management & Tech Support AFHSC DivisionsData Management & Tech SupportDefense Medical Epidemiology Database
28 DMSS & Functional Relationships AFHSC DivisionsData Management & Tech SupportDMSS & Functional RelationshipsThese numbers do not match others in this presentation because of the date prepared.
29 Data Management & Tech Support AFHSC DivisionsData Management & Tech SupportWorld’s largest serum repositoryUnrivaled potential for sero-epi studies~ 40 various size sample requests/year60M serial serum specimens from 10M individualsLinked to demographic, military, and medical information via the DMSSDoD Serum Repository
30 Communications, Standards, & Training Division AFHSC DivisionsEpidemiology & AnalysisDirectorHQ StaffScience AdvisorDeputy DirectorEpidemiology& Analysis DivisionCommunications, Standards, & Training DivisionGEIS OperationsDivisionData Management &Tech SupportGlobal Emerging Infections Surveillance and Response System (GEIS) is integrated throughout the Center. Dir, GEIS remains responsible for managing AI/PI Surveillance Program and the other GEIS accountabilities.PERSONNELUniformed: 17FederalCiv: 4Contract:
31 Epidemiology & Analysis CustomersSecretary of DefenseAssistant Secretary of Defense for Health Affairs [ASD(HA)]USCG Director of Health and SafetyJoint ChiefsService Surgeons GeneralService Public Health HubsAFHSC Staff
32 Epidemiology & Analysis Data sources: DMSS, DoDSR, othersOperational surveillance analysis (600/yr)Support for:DoD policy developmentGAO investigationsCongressional InquiriesAnalysis for MSMR articlesSpecial Studies / Research SupportIncludes specialized influenza surveillance/analysisFocused periodic reports (1450/yr)Operational surveillance analysesSupportMSMR articlesSpecial Studies including specialized influenza surveillance and analysisFocused periodic reports—Develop, maintain, & distribute monthly, quarterly, weekly, or daily
33 Epidemiology & Analysis Example of MSMR SupportUS Military Malaria Cases Jan 02-Dec 08Likely infection locationSource: MSMR Vol 16, No. 1 Jan 09, AFHSC
34 Epidemiology & Analysis Example of Serum Study: Hantavirus in Military Personnel from Four Corners Area
35 May 2010: AFHSC Routine Reports* Epidemiology & AnalysisMay 2010: AFHSC Routine Reports* TypeTotal # Reports# Unique ReportsReportable Medical Events/Communicable Diseases537Deployment Health Assessments2818Influenza113H1N1 Vaccine Safety and Compliance52Medical Evacuations41Deployment Health Report0 (quarterly)MalariaSmallpox Cardiac Adverse Events ReportTraining-related injuriesLeishmaniasisTraumatic Brain InjuryPost Traumatic Stress DisorderMHS Dashboard MeasuresFHP QA MeasuresWounded Service MembersVaccine Adverse EventsSpecial Surveillance: Amputations, DVT, Leish, ARDsInjury Installation ReportsLost dutyMeningococcal ReportOver 50 routine reports distributed monthly, quarterly, weekly, or daily (1448 total reports annually)Over 600 requests performed annually
36 Quarterly Deployment Health Report October 2010, page 6 of 16 Epidemiology and AnalysisQuarterly Deployment Health Report October 2010, page 6 of 16
39 Request Process Clarify the Question Can We Do It? Legal DMSS is System of RecordsHuman Subjects ProtectionClassified or Privacy ProtectedScientifically Sound (Methods Valid)Data/Sera AvailableSystem of records (SOR)A group of paper/electronic records authorized by a statute/orderPersonal information retrieved by unique identifier (e.g. SSN)Systems of records notice (SORN)Identifies the SOR’s purpose, individuals included, categories of records, and information sharing proceduresNotifies the public regarding rights and procedures for accessing or amending dataPrivacy protection: the “Common Rule” Title 45 CFR 46 (1991) Federal policy for protection of human subjects“DoD Rule” Title 32 CFR 219 (1991)Mostly intended to differentiate clinical practice from researchExempt from common rule--Non-research activities
40 Request Process Clarify the Question Should We Do It? Requestor’s Intent & AuthorityMilitarily RelevantMilitary SponsorLevel of Surveillance (Strategic vs Unit)IntentRelated to Public HealthPurpose (Scope of Responsibility)PH Practice v Research
42 Types of Requests “Operational” Research Strategic DoD-wide Public Health PracticeResearchSupportInternal research
43 Public Health Practice Specific authorizationAccountability to the publicMay legitimately involve persons who did not volunteer to participateDraws on the principles of public health ethics by focusing on populations while respecting the dignity and rights of individualsMay be distinguished from research on the basis of general legal authority, specific intent, responsibility, participant benefits, experimentation, and subject selection
44 Public Health Practice Primary intentPrevent or control disease or injury and improve healthBenefit is to the population from which information is gatheredMilitary PH PracticeCommanders, supervisors, individual Service members, and MHS shall promote, improve, conserve, and restore physical/mental well-being…across the full range of military activities and operationsConduct activities common to other public health agencies, including disease/injury surveillance, “reportable medical event” case reporting, outbreak investigation, program evaluation etc.
45 Public Health Research Primary intentIf to generate or contribute to generalizable knowledge, then researchIf 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
48 Present to Request/Report Review (R-3) Team Request ProcessPresent to Request/Report Review (R-3) TeamEpidemiology & Analysis ChiefE & A Asst ChiefService liaisonsScience advisorSenior EpidemiologistsSenior BiostatisticiansMSMR stafferOthers ad hoc
49 Request Process R-3 Presentation (“Morning Rounds”) S: Requestor, QuestionO: Background material, supporting literature, military relevance, etc.A: Public Health Practice or ResearchP: Analysis Template
50 Request Process R-3 Team Review R-3 Team questions the presenter Presenter may need to further clarify the question (to R-3 or with customer)Can we do itShould we do itNew R3 approval process, if needed
52 Request Process Analysis Once approved by R-3, assignment to analyst CodingComplicated person-time calculationsComplex case definitionsMultiple/complex outputsModifications to original requestPrioritization with other requestsTechnical difficultiesMay need to return to R-3
56 Detection of Pandemic Flu (pH1N1) 37 Sailors present in San DiegoNavy FM (1st case) presents in San Diego2 Army FM present in San AntonioFirst ESSENCE Alert (26 Apr 09)ESSENCE Cases2009MarchAprilMayJuneJuly
57 Pandemic InflunezaFirst four cases of pandemic H1N1 detected in two AFHSC/GEIS funded laboratoriesSpecimens and information provided to CDCThree DoD pH1N1 strains used by WHO as potential seed strains; one was selectedSupported 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 diagnosisNAMRU-3: 30 countries and 70 participants in 3 weeks!!!
58 Communication: DoD Global Influenza Activity Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week PeriodUSAFSAMTOTAL (NEW)6,Flu A: ,289 (164)H1N1:H3N2:pH1N1 1, (80)Flu B: (1)LRMC/CHPPMTOTAL (NEW)Flu A:H1N1:H3N2:pH1N1: (92)Flu B:USF KoreaTOTAL (NEW)1,Flu A:H1N1:H3N2:pH1N1 : (21)Flu B :USF JapanTOTAL (NEW)Flu A: (1)H1N1:H3N2:pH1N1 : 17Flu B: (1)NHRCTOTAL (NEW)3,Flu A:H1N1:H3N2:pH1N1 1,122 (165)Flu B:CENTCOM-MilTOTAL (NEW)Flu A:H1N1:H3N2:pH1N1: (30)Flu B:CONUS MEDCENsTOTAL (NEW)8, ,740Flu A: 2,576 (508)H1N1:H3N2:pH1N1: (122)Flu B:NAMRU-3TOTAL (NEW)562Flu A:H1N1:H3N2:pH1N1:H5N1:Flu B:AFRIMSTOTAL (NEW)Flu A: (96)H1N1: (2)H3N2: (12)pH1N1:Flu B: (3)GuamTOTAL (NEW)Flu A: H1N1:H3N2:pH1N1:Flu B:TAMCTOTAL (NEW)1,Flu A:H1N1:H3N2:pH1N (11)Flu B: (1)USAMRU-KTOTAL (NEW)Flu A: (53)H1N1:H3N2: (4)pH1N1: (29)Flu B: (7)NMRC-LimaTOTAL (NEW)Flu A:H1N1:H3N2:pH1N1Flu B:NAMRU-2TOTAL (NEW)1503Flu A:H1N1:H3N2:pH1N1:H5N1:Flu B:Note: H5N1 (positives/tested or pending) results are cases that have been confirmed and reported through WHO in compliance with the International Health Regulations 2005.DoD Service LabsMedical Centers/ClinicsDoD Research Labs
59 Communication: Surveillance Partner Reporting Sentinel SurveillancePopulation-Based/RecruitElectronic Military Health SurveillanceDOS EmbassyLab-SpecificRegional
60 Communication: Network Summary Available at: http://www.afhsc.mil
61 2009 pH1N1: AFHSC Coordination Attributes Combined Under One RoofLaboratory network: Global visibilityReportable Medical Events: Uniformed personnel visibilityConference call coordinationDaily/weekly reporting for chain of command
62 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 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 Intelligent Military Medicine Evidence based policy and prevention strategies for the United States Armed Forces