1. Naval Medical Research Unit 3 (NAMRU-3) Mission
Cairo, Egypt
LCDR Nehkonti Adams, MC USN
Officer In Charge, Ghana Detachment
Naval Medical Research Unit 3 (NAMRU-3) Mission
Study, monitor, and detect emerging and re-emerging disease threats of military and public health importance; develop mitigation strategies against these threats in partnership with host nations and international and U.S. agencies in CENTCOM, EUCOM, and AFRICOM areas of responsibility.

2. NAMRU-3 Ethos
“It is to these aims and ideals – the increase of medical knowledge and the fostering of good will – that I dedicate US Naval Medical Research Unit No. 3”
CDR Robert A Philips, dedicatory address 27 Oct 1948
(as quoted in Snodgrass 2003)

3. NAMRU-3 Cairo facility

4. NAMRU-3 Activities

5. NAMRU-3 Virology Department
Military to Military Influenza Surveillance
Currently engaged with Burkina Faso, Cote D'Ivoire and Togo Armed forces to build the capacity for influenza surveillance.
This project involves multiple arms of surveillance such as, acute respiratory infection, seasonal influenza, influenza-like illness, severe acute respiratory infections and zoonotic influenza surveillance including avian influenza.
Activities include, but are not limited to, training on the proper use of related equipment, training on surveillance methods and procedures, obtaining governmental permissions, recruitment of local staff, ensuring of adherence to safety and biosafety procedures and collection and processing of study specimens.
One to five- year plan includes:
Enhancing surveillance efficiencies at current disease sentinel sites, through periodic refresher training of lab and epidemiology personnel on both the civilian and military side
Expanding to other sentinel sites within each partner country will be considered only after efficiencies are maximized at current sites
Expanding the respiratory diagnostic breadth at the reference laboratories of partner countries to include other respiratory pathogens with PHEIC potential
Establishing and sustaining sequencing capability (a key surveillance and epidemiological tool for early warning to a PHEIC) in our partner countries

6. NAMRU-3 Detachment Accra, Ghana

7. Republic of Ghana Population-25.9 million
Climate-tropical, temperature range (22-42C)
Economy- GDP $1,858 per capita (2014)
Endemic diseases
Malaria (>2.3 million cases/year report to public health facilities)
HIV prevalence 1.3% (2013)
Most common NTDs : lymphatic filariasis, schistosomiasis, buruli ulcer, yaws, leprosy, cutaneous leishmaniasis
Outbreaks
2014 cholera outbreak - >30,000 cases

8. Ghana Detachment Background
LCDR Braden Hale Dose-ranging trial of Tafenoquine for weekly malaria prophylaxis, Navrongo
CAPT Bill Rogers 1999
Research Fellow of Parasitology Department-NMIMR (Noguchi)
$5 million NIH grant to establish malaria vaccine testing sites
2001 establishment of detachment in US Embassy
2005 renewal of NIH contract ($12million, seven – year)
Officers In Charge of expanded Noguchi detachment:
LCDR Greg Raczniak
LCDR Karl Kronnman
CDR Christopher Duplessis
LCDR Nehkonti Adams current
US Navy’s objectives in mid-1990’s-early 2000’s to determine incidence of
malaria and to test vaccines and therapies to reduce disease burden among
populations in Ghana.

10. Ghana Detachment Manning
Total manning: 14 as of Feb 2015
Two NSDD-38 approved positions
Officer in Charge –infectious disease physician
Research Scientist – medical entomologist ETA Mar-Apr 2015
Twelve non-military staff
5 locally employed via Embassy
4 lab technicians employed via contract
1 data manager employed via contract
1 monitoring and evaluation technician employed via contract
1 admin assistant employed via contract

11. Ghana Detachment Assets
Space
Two adjoining rooms obtained in 2007 by agreement with Noguchi, Memorial Institute for Medical Research (NMIMR).
Lab capabilities and Instrumentation
Bacterial culture
ELISA and conventional PCR
Access to a BSL-3 laboratory, insectary and molecular suite
Storage container (CONEX Box)

12. NAMRU-3 Ghana Detachment Accomplishments 2014
Assisted with a nationwide training on influenza surveillance
Provided training on ethics in human subject research
Conducted national avian and swine sampling exercise
Influenza testing on 340 returning Hajj pilgrims
Influenza surveillance capacity building in Togo
Presentation at The West African Conference on Research, Diagnostics, Epidemic Preparedness and Response to Lassa Fever and other Viral Hemorrhagic Fevers held in Benin City, Nigeria

13. NAMRU-3 Disease Surveillance in Ghana
Sexually Transmitted Infections surveillance
Military to Military Influenza surveillance
Non-malarial Acute Febrile Illness surveillance
Integrated Human Animal Vector surveillance
Cutaneous Leishmaniasis
Integrated Hospital-Based Infectious Diseases Surveillance

14. Characterizing Gonorrhea and Chlamydia Prevalence and Gonorrhea Resistance Profiles in Military Populations
Problem: Emergence and spread of multi-drug resistant Neisseria gonorrhea is a major health issue globally
Objectives:
Identify disease burden among patients at three sites
Elucidate circulating strains of N. gonorrhea
Determine antibiotic resistant profiles
Study Progress:
>700 subjects enrolled, 30 multidrug resistant isolates recovered, >35% pre-presentation antibiotic use

15. STI/AFI Training at Military Clinics Takoradi/Sekondi

16. Military-to-Military Influenza Surveillance
Problem: There are several respiratory pathogens with the ability to cause a pandemic. Pandemic planning to include established surveillance around the world is paramount. Militaries are especially susceptible to outbreaks of respiratory pathogens.
Primary Objective: To establish and maintain influenza surveillance at military bases in Ghana. Clinical sites: Five Medical Reception Stations (MRS) and 1 Military Hospital and 10 civilian sites.
Ghana NIC: WHO reference laboratory for H5N1
Activities:
Weekly and semiannual reports on surveillance data are shared with the CDC and WHO
Annual troop education and avian sampling exercise carried out in all the major barracks.

17. Mil-Mil Investigation: Acute Febrile Illness (AFI) Characterization
Problem: Acute Febrile Illness (AFI) is a common presentation to health care facilities globally including Ghana. The clinical presentation of most febrile illnesses are nonspecific. Most cases are empirically treated for malaria. This contributes to under-diagnosis and lack of epidemiological knowledge of other infectious etiologies of fever. Primary objective: To improve surveillance and laboratory capacity for diagnosis of non-malarial etiologies of AFI. Clinical sites: 37 Military Hospital and 3 clinics in Sekondi-Takoradi

18. Pathogens of interest:
Malaria
Coxiella burnetti
Rickettsia spp
Leptospira interrogans
Salmonella typhi
Dengue
Chikungunya
West Nile Virus
Hantavirus
Henipaviruses

19. Integrated Human- Animal-Vector- Surveillance (IHAVS)
Problem: a high percentage of etiology of fevers are unknown in Africa. A percentage of these cases are attributed to zoonotic diseases.
Objective: To establish a surveillance system for evaluation of a panel of vector-borne and zoonotic pathogens in a population where there is high density co-mingling activities of humans and animals.
Progress: Initial surveillance activities was conducted in Kumasi Abattoir among humans (abattoir employees), slaughtered animals and trapped vectors. There is ongoing sample collection at another abattoir in Greater Accra Region.
108 abattoir workers were enrolled; Blood samples were collected from 149 cattle, 149 goats and 130 sheep.
Collected specimens identified evidence of Rift Valley Fever, West Nile Fever, Dengue Fever, Crimean-Congo Hemorrhagic Fever, Hepatitis E virus, Coxiella Burnetti, Leptospira spp.

20. Etiology of cutaneous leishmaniasis in Volta Region of Ghana
Problem: Leishmaniasis is a disease with significant global impact affecting more than 88 countries in the world. There is a lack of POC test in endemic areas.
Primary objective: To optimize and prospectively evaluate a deployable point-of-care field diagnostic test for cutaneous leishmaniais. The diagnostic test will utilize recombinase polymerase amplification coupled with lateral flow test strip to detect leishmaniasis.
Partners: NAMRU-6 ,University of Texas Medical Branch, NMIMR
Clinical sites: Ghana-Ho and Peru-Madre de Dios

21. Integrated Hospital Based Infectious Disease surveillance (IHBIDS)
Primary Objective: To identify the number of hospitilized and outpatient cases due to acute respiratory illness (ARI), acute diarrheal illness (ADI) and acute febrile illness (AFI) in four referral hospitals in Ghana.
Progress: Syndromic Surveillance system established in August 2009 at 4 referral hosp. (Tema General Hosp., 37 MH, Tamale Teaching Hosp., and Korle-Bu Teach. Hosp.)
3,163 patients enrolled in the study
ARI:
7% were Influenza A positive, out of which 4% are Flu A subtypes H3 (4%) and 3% of pH1N1 strains circulating
2% Influenza B positives identified.
AFI:
Pathogens identified thus far are: Dengue Fever, Yellow Fever, Chikungunya, West Nile Fever, Brucella, Salmonella, Leptospira, Q-Fever, Rickettsia.
ADI:
Viral Pathogens Identified: Rotavirus (24%), Noroviruses (6%), astrovirus (5%) and adenovirus (5%).
Parasitic Pathogens identified: Giardia (2%) and Crysporidium (3%).

22. Integrated Hospital Based Infectious Disease surveillance (IHBIDS)
Capacity building:
ARI surveillance transitioned as non-research into the local surveillance system at 37 MH and Tamale Teaching Hospital

23. Relationship between antibody recognition by Plasmodium falciparum pre-erythrocytic vaccine candidate antigens and clinical parasitological protection against malaria
Problem: Malaria remains one of the important tropical infectious diseases in sub-Saharan Africa. Global estimates of the burden due to malaria showed that in 2013, about 198 million cases and 584,000 deaths were recorded The development of an effective malaria vaccine remains a global health priority. Less than 0.5% of the 5300 proteins expressed by P. falciparum genome during the multistage parasite lifecycle has been evaluated as vaccine candidates.
Primary Objective: To test the hypothesis that naturally induced humoral immunity to novel P. falciparum sporozoite surface antigens currently being explored as malaria vaccine candidates is associated with protection from infection and or clinical disease in malaria endemic areas.
Approach: We propose to screen eight antigens for antibody responses using archived banks of plasma from longitudinal specimens acquired at monthly intervals (irrespective of infection) in a cohort of 1 – 5 year old children who were followed up for one year.
The results obtained will contribute to the final down selection of new vaccine candidates for further clinical development.

24. Malaria Drug Resistance Studies NMIMR
A SYBR Green 1-based in vitro test of susceptibility of Ghanaian Plasmodium falciparum clinical isolates to a panel of antimalarial drugs.
Primary objective: To use SYBR Green 1 fluorescent-based in vitro drug sensitivity assay to assess the susceptibility of clinical isolates of P. falciparum to a panel of 12 antimalarial drugs in three distinct eco-epidemiological zones in Ghana.
Approach: The P. falciparum isolates were obtained from children visiting health facilities in sentinel sites located in Hohoe, Navrongo and Cape Coast municipalities.
Results: The study concluded that Ghanaian P. falciparum isolates have become susceptible to chloroquine but may be losing its sensitivity to artesunate.
Characterization of Molecular Markers of Drug Resistance in Plasmodium falciparum from Ten Regions of Ghana over a 3-year period.
Primary objective: To investigate the Plasmodium falciparum multidrug resistance gene (pfmdr1) copy number, mutations and the chloroquine resistance transporter gene (pfcrt) mutations in Ghanaian isolates collected in seven years to detect the trends in prevalence of mutations.
Results: The study found a decreasing trend in the prevalence of chloroquine resistance markers after change of treatment policy. This presents the possibility for future introduction of chloroquine as prophylaxis for malaria risk groups such as children and pregnant women in Ghana.

25. Vector Biology Focus, AFRICOM
Evaluation of spatial repellent (SR) products under semi-field conditions in Liberia and profiling hybrid molecular form of Anopheles gambiae in Ghana.
Primary objective: To evaluate commercial and advanced developed spatial repellant products in semi-field conditions for the control of mosquito disease vectors in Liberia.
Secondary objective: To determine the need for SR products with regional military partners and establish product testing capabilities in the region.
Progress: We have established a laboratory strain of Anopheles gambiae M/S hybrid molecular form by crossing M form mosquitoes with S form at Noguchi Memorial Institute for Medical Research (NMIMR) insectary located in Accra, Ghana.
“Push/Pull”
Primary objective: To develop an integrated Push-pull system which will be used to test various repellents and attractants for their ability to push or pull blood feeding insects from one area to another.
Progress: Two fifty meter tunnels for treatment and control have been constructed and several cycles of testing have been completed.

26. Lassa Fever
Problem: Ghana has had several imported cases of Lassa Fever in their peacekeeping forces deployed to Liberia and Sierra Leone. In recent years there has been two cases of laboratory confirmed Lassa Fever in patients who did not have a significant travel history.
Primary objective: To assess the prevalence of Lassa virus in the rodent reservoir, Matomys, in high risk areas of Ghana.
Progress: NAMRU-3 GD captured and necropsied rodents for arenavirus and other rodent-borne pathogen screening based on a predicted Lassa virus risk map (Fichet-Calvet and Rodgers 2009). Rodent tissues and human sera were collected from ten villages throughout the country. Results:
Only two of the 764 rodents belonging to Mus (Nannomys) species tested positive for arenaviruses.
Using an in-house enzyme-immunoassay (ELISA), human serum showed evidence of arenavirus antibodies in 34 samples (5%). Antibodies to Puumala and Dobrava serotypes and Leptospira were also detected in 11%, 12% and 21%, respectively, with commercial kits.
Our findings support the idea that Lassa virus is not widely prevalent in Ghana, and the M. natalensis reservoir is not as common as in more highly endemic countries.

27. Lassa Fever Outbreak, Liberia August 2013
Location: Bong and Lofa County, Liberia
Partners: US Military (personnel from Operation Onward Liberty (OOL)) and Armed Forces Liberia (AFL)
NAMRU-3 created a transport SOP and case report form for Lassa fever testing
Provided environmental inspection and infection control training

28. West African Ebola Outbreak
LCDR Nehkonti Adams, OIC of the NAMRU-3 Ghana detachment was called upon
by Chief Medical Officer of Operation Onward Liberty for educational materials to provide to troops deployed to Liberia.
to serve on Ghana Health Service (GHS) Ebola National Technical Coordinating Committee (NTCC) as a member of the Case Management subcommittee.
to lead an Interagency Ebola Team comprised of members from NAMRU-3, CDC, USAID West Africa, USAID Ghana, and various other DoD agencies to coordinate WHO, Government of Ghana, local NGOs, foreign donors, UNMEER and USG aid agencies preparedness.
to participate and provide technical expertise in an Ebola simulation exercise at Kotoka International Airport with WHO, Ghana Health Services and Noguchi Memorial institute for Medical Research.

29. Pending Engagements in West Africa in Wake of 2014 Ebola Outbreak
Liberia
Liberia Institute for Biomedical Research (LIBR)
Expand surveillance and pathogen discovery projects in the context of USAID, CDC, other DoD footprint.
Develop laboratory and outbreak response capability at LIBR
Lofa County
Hemorrhagic fever and arbovirus surveillance
Bong County
Acute infectious causes of neurologic diseases
Nimba County
Xenosurveillance
Collect and analyze blood fed mosquitoes in and around the frontier/trade route town of Ganta on the main road linking Liberia to Guinea and Cote d’Ivoire
Utilizing novel vector surveillance protocol, link human and animal febrile illness to pathogens found in blood meals of collected mosquitos.
Correlate arboviruses and other pathogens in collected blood fed mosquitos with infected human population.

30. Pending Engagements in West Africa in Wake of 2014 Ebola Outbreak
Nigeria – Calabar Institute of Tropical Disease and Prevention (CITDP), University of Calabar, Cross River State 
Capacity building and malaria vector surveillance including insecticide resistance

31. Outbreak Response Pillars
Early Detection
Disease surveillance that provides accurate and complete information on the nature of the disease, location, population, etc.
Early and Efficient Response
Recovery