Armed Forces Health Surveillance Center: Medical Intelligence or Intelligent Medicine

1. 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)

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]

7. AFHSC Established Feb 2008

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

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

10. AFHSC Mission & Vision • Mission: Topromote, 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 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 • 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

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

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

14. Communications, Standards & Training AFHSC Divisions www.afhsc.mil www.afhsc.mil

15. 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 www.afhsc.mil

16. 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. AFHSC Divisions Communications, Standards & Training

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

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

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

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

23. 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 Hospitalizations 2.5 M records MEPS 12.1 million persons 26.6 M records Deployments 4.9 million records Pre / Post-Deployment Health Assessments 8.5M Casualty Data 49 K Deaths Data Management & Tech Support DMSS—Longitudinal Database >1.5B Records Personnel Data 9.4 M persons 111.7 M records Immunizations 86.9 M records Discharge or Death Accession Process Service Member Lifecycle Reportable Diseases 276 K records Serum 58.2 M specimens 38.9 HIV test results Ambulatory Data 211.7 M records As of Feb 2011

25. AFHSC Divisions Data Management & Tech Support DMSS Data Inputs / Frequency

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

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

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

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

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)

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. Epidemiology & Analysis • Over 50 routine reports distributed monthly, quarterly, weekly, or daily (1448 total reports annually) • Over 600 requests performed annually

36. Epidemiology and Analysis Quarterly Deployment Health ReportOctober 2010, page 6 of 16

37. Request Process

38. 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 • Legal • DMSS is System of Records • Human Subjects Protection • Classified or Privacy Protected • Scientifically Sound (Methods Valid) • Data/Sera Available Can We Do It?

40. Request Process Clarify the Question • 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 Should We Do It?

41. Request Process

42. Types of Requests • “Operational” • 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. 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