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Sharon L. Ludwig, MD, MPH, MA Division Chief Epidemiology and Analysis

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1 Sharon L. Ludwig, MD, MPH, MA Division Chief Epidemiology and Analysis
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 Disclaimer 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.

3 Briefing Outline Intelligence and Surveillance Introduction to AFHSC
Data & Analysis Public Health Practice vs Research Intelligent Medicine

4 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 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) The — is an agency within the Defense Intelligence Agency (DIA) of the United States Department of Defense (DoD)[1]; its mission is to [2] 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 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] Health Surveillance Vs Medical 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 following In response, Assistant Sec Def (Health Affairs) established GEIS in1997 Presidential Decision Directive, National Science & Technology Council-7 June 1996 Expanded DoD mission to include support of global surveillance, training, research, and response to emerging infectious disease threats Strengthen 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 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) 26 Feb 08—DEPSECDEF signs memo establishing an AFHSC DOD Instruction , 7 Aug 1997 US 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 2004 Sec 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 data DSD memorandum 26 Feb 2008 AFHSC is the single source for DoD-level health surveillance DoD 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 memorandum Named AFHSC “Provisional” Director reporting to CG, USACHPPM To proceed IAW AFHSC Task Force Draft CONOPS (within limits of Army authority) US Army Executive Agent Joint organization

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

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

10 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 AFHSC Scope of Responsibility
IAW CONOPS What We Should Do What We Shouldn’t 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 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 Healthcare 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 Structure Director HQ Staff Science Advisor Deputy Director Epidemiology & Analysis Division Communications, Standards, & Training Division GEIS Operations Division Data Management & Tech Support Global 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. PERSONNEL Uniformed: 17 FederalCiv: 4 Contract:

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

14 Communications, Standards & Training
AFHSC Divisions Communications, Standards & Training

15 Medical Surveillance Monthly Report
AFHSC Divisions Communications, Standards & Training 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

16 AFHSC Surveillance Standards
AFHSC Divisions Communications, Standards & Training 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

17 Communications, Standards & Training
AFHSC Divisions Communications, Standards & Training

18 Resident Rotations at AFHSC
AFHSC Divisions Communications, Standards & Training 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

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

20 Strategic Goals and Priority Pillars
AFHSC Divisions GEIS Operations Strategic Goals and Priority Pillars 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 ARD GI DRO STI

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

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

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

24 AFHSC Divisions Data Management & Tech Support
DMSS—Longitudinal Database >1.5B Records Hospitalizations 2.5 M records Serum 58.2 M specimens 38.9 HIV test results Personnel Data 9.4 M persons 111.7 M records MEPS 12.1 million persons 26.6 M records Pre / Post-Deployment Health Assessments 8.5M Accession Process Discharge or Death Service Member Lifecycle Deployments 4.9 million records Immunizations 86.9 M records Casualty Data 49 K Deaths Focus: Active Duty & Reserve Components >1.5B Records Central health surveillance database for the Military Health System Current & historical disease and medical event data Longitudinal data on uniformed personnel and deployments System of Records Reportable Diseases 276 K records Ambulatory Data 211.7 M records As of Feb 2011

25 DMSS Data Inputs / Frequency
AFHSC Divisions Data Management & Tech Support DMSS Data Inputs / Frequency Table Source Frequency Rows Time Period Person DMDC Monthly 9.4 M Demographics 109.7 M MEPS MEPCOM 37.9 M Deploy (PGW) Single 682 K Deploy (CENTCOM) 3.5 M 1993 – 2010 Deploy Forms MEDPROS, PIMR, EDHA Daily/Weekly 8.1 M 1996 – 2010 Inpatient-MTF/TED DHSS 2.5 M 1990 – 2010 Outpatient-MTF/TED Weekdays 201.4 M Reportable Events MTFs Daily 266.8 K 1994 – 2010 Immunizations DEERS 87.0 M DoDSR Weekly 57.5 M Casualty WHS / AFIP Quarter/Month 48.7 K TMDS FHP&R 4.5M 2005 – 2010 TRAC2ES (CENTCOM) TRANSCOM/FHP&R 72.9K 2001 – 2010 MEPS, DODSR, Casualty and TMDS number of rows include non-Service members

26 Reportable Events Process
AFHSC Divisions Data Management & Tech Support 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 Navy Environmental PM Unit Within 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 Divisions Data Management & Tech Support Defense Medical Epidemiology Database

28 DMSS & Functional Relationships
AFHSC Divisions Data Management & Tech Support DMSS & Functional Relationships These numbers do not match others in this presentation because of the date prepared.

29 Data Management & Tech Support
AFHSC Divisions Data Management & Tech Support 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 DoD Serum Repository

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

31 Epidemiology & Analysis
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

32 Epidemiology & Analysis
Data sources: DMSS, DoDSR, others 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) Operational surveillance analyses Support MSMR articles Special Studies including specialized influenza surveillance and analysis Focused periodic reports—Develop, maintain, & distribute monthly, quarterly, weekly, or daily

33 Epidemiology & Analysis
Example of MSMR Support US Military Malaria Cases Jan 02-Dec 08 Likely infection location Source: 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 & Analysis May 2010: AFHSC Routine Reports*  Type Total # Reports # Unique Reports Reportable Medical Events/Communicable Diseases 53 7 Deployment Health Assessments 28 18 Influenza 11 3 H1N1 Vaccine Safety and Compliance 5 2 Medical Evacuations 4 1 Deployment Health Report 0 (quarterly) Malaria Smallpox Cardiac Adverse Events Report Training-related injuries Leishmaniasis Traumatic Brain Injury Post Traumatic Stress Disorder MHS Dashboard Measures FHP QA Measures Wounded Service Members Vaccine Adverse Events Special Surveillance: Amputations, DVT, Leish, ARDs Injury Installation Reports Lost duty Meningococcal Report Over 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 Analysis Quarterly Deployment Health Report October 2010, page 6 of 16

37 Request Process

38 Requestor Contacts AFHSC
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 Request Process Clarify the Question Can We Do It? Legal
DMSS is System of Records Human Subjects Protection Classified or Privacy Protected Scientifically Sound (Methods Valid) Data/Sera Available System of records (SOR) A group of paper/electronic records authorized by a statute/order Personal 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 procedures Notifies the public regarding rights and procedures for accessing or amending data Privacy 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 research Exempt from common rule--Non-research activities

40 Request Process Clarify the Question Should We Do It?
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

41 Request Process

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

43 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 Public Health Practice
Primary intent 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.

45 Public Health Research
Primary intent 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

46 Request Process

47 Request Process Draft Analysis Plan

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

49 Request Process R-3 Presentation (“Morning Rounds”)
S: Requestor, Question O: Background material, supporting literature, military relevance, etc. A: Public Health Practice or Research P: 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 it Should we do it New R3 approval process, if needed

51 Request Process

52 Request Process Analysis 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

53 Request Process

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

55 AFHSC Example H1N1 Influenza Response

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

57 Pandemic Influneza 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!!!

58 Communication: DoD Global Influenza Activity
Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week Period USAFSAM TOTAL (NEW) 6, Flu A: ,289 (164) H1N1: H3N2: pH1N1 1, (80) Flu B: (1) LRMC/CHPPM TOTAL (NEW) Flu A: H1N1: H3N2: pH1N1: (92) Flu B: USF Korea TOTAL (NEW) 1, Flu A: H1N1: H3N2: pH1N1 : (21) Flu B : USF Japan TOTAL (NEW) Flu A: (1) H1N1: H3N2: pH1N1 : 17 Flu B: (1) NHRC TOTAL (NEW) 3, Flu A: H1N1: H3N2: pH1N1 1,122 (165) Flu B: CENTCOM-Mil TOTAL (NEW) Flu A: H1N1: H3N2: pH1N1: (30) Flu B: CONUS MEDCENs TOTAL (NEW) 8, ,740 Flu A: 2,576 (508) H1N1: H3N2: pH1N1: (122) Flu B: NAMRU-3 TOTAL (NEW) 562 Flu A: H1N1: H3N2: pH1N1: H5N1: Flu B: AFRIMS TOTAL (NEW) Flu A: (96) H1N1: (2) H3N2: (12) pH1N1: Flu B: (3) Guam TOTAL (NEW) Flu A: H1N1: H3N2: pH1N1: Flu B: TAMC TOTAL (NEW) 1, Flu A: H1N1: H3N2: pH1N (11) Flu B: (1) USAMRU-K TOTAL (NEW) Flu A: (53) H1N1: H3N2: (4) pH1N1: (29) Flu B: (7) NMRC-Lima TOTAL (NEW) Flu A: H1N1: H3N2: pH1N1 Flu B: NAMRU-2 TOTAL (NEW) 1503 Flu 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 Labs Medical Centers/Clinics DoD Research Labs

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

60 Communication: Network Summary Available at: http://www.afhsc.mil

61 2009 pH1N1: AFHSC Coordination
Attributes Combined Under One Roof Laboratory network: Global visibility Reportable Medical Events: Uniformed personnel visibility Conference call coordination Daily/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

65 Questions


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