unclassified armed forces health surveillance center: medical intelligence or intelligent medicine...

UNCLASSIFIED

Armed Forces Health Surveillance Center: Medical Intelligence or

Intelligent Medicine

21 June 2011Sharon L. Ludwig, MD, MPH, MA

CAPT, USPHS/USCGDivision Chief Epidemiology and Analysis

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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

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Briefing Outline

1. Intelligence and Surveillance

2. Introduction to AFHSC

3. Data & Analysis

4. Public Health Practice vs Research

5. Intelligent Medicine

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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

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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)

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• 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

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AFHSC Established Feb 2008

ü DoD Global Emerging Infections

Surveillance & Response System

ü DASD(HA) Force Health Protection &

Readiness

ü Global Health Surveillance

Capability Area

ü Army Medical Surveillance

Activity

ü Defense Medical Surveillance System

(DMSS)ü &

ü DoD Serum Repository (DoDSR)

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AFHSC Governance

Armed Forces Health Surveillance Center

Force Health Protection Council

Army Exec Agent

ASD (Health Affairs)Functional Oversight

USD (Personnel &Readiness)

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AFHSC Relationships

Armed ForcesHealth Surveillance

Center

PHC(P) POPM

NMCPHCBUMED

USAFSAMAFMSA

MTFs

Service Public Health Ctrs

National (CDC)

State Health Depts

County /Metro Depts

DoD

HQ,USCG

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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.

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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

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PERSONNELUniformed: 17FederalCiv: 4Contract: 63

Science Advisor

AFHSC Structure

Director

Epidemiology & Analysis Division

Communications, Standards, &

Training Division

GEIS OperationsDivision

Data Management &Tech Support

Division

Deputy Director

HQ Staff

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Science Advisor

AFHSC Divisions

Director



Training Division



Division

Deputy Director

Communications, Standards & Training

HQ Staff


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AFHSC DivisionsW

WW

.AF

HS

C.M

ILW

WW

.AF

HS

C.M

ILCommunications, Standards & Training

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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

AFHSC DivisionsCommunications, Standards & Training

http://www.afhsc.mil/

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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


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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


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Science Advisor

AFHSC Divisions

Director



Training Division



Division

Deputy Director

GEIS Operations

HQ Staff


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AFHSC Divisions

Strategic Goals and Priority Pillars

AR

D

GI

DR

O

ST

IAssessment and Communication of Value Added

Research, Innovation and Integration

Surveillance and ResponseTraining and Capacity Building

RI

GI

AR

ST

I

FV

BI

Force Health Protection

RI = Respiratory Infection

GI = Gastrointestinal Infection

FVBI = Febrile & Vector-borne Infection

AR = Antimicrobial Resistance

STI = Sexually Transmitted Infection

GEIS Operations

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AFHSC Divisions

Peru

Kenya

Egypt

Thailand

Pacific

NHRC

USAFSAM

WRAIR/NMRC

Germany Korea

USAPHC

(Prov)

NMCPHC

DoD Partners

GEIS Operations

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Science Advisor

AFHSC Divisions

Director



Training Division



Division

Deputy Director

Data Management & Tech Support

HQ Staff


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AFHSC Divisions

• Maintain Defense Medical Surveillance System (DMSS)

• Archive HIV test results• Maintain DOD Serum Repository• Support AFHSC IM/IT Needs


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MEPS12.1 million persons26.6 M records

Hospitalizations2.5 M records

Ambulatory Data211.7 M records

Immunizations86.9 M records

Casualty Data49 K Deaths

Pre / Post-DeploymentHealth Assessments8.5M

Reportable Diseases276 K records

Deployments4.9 million records

Personnel Data9.4 M persons111.7 M records

As of Feb 2011

AFHSC Divisions

Accession Process

Discharge or Death

Serum58.2 M specimens38.9 HIV test results

Service Member Lifecycle

DMSS—Longitudinal Database >1.5B Records


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DMSS Data Inputs / FrequencyTable Source Frequency Rows Time Period

Person DMDC Monthly 9.4 M 1985 -- 2010

Demographics DMDC Monthly 109.7 M 1985 -- 2010

MEPS MEPCOM Monthly 37.9 M 1985 -- 2010

Deploy (PGW) DMDC Single 682 K 1990 -- 1991

Deploy (CENTCOM) DMDC Monthly 3.5 M 1993 – 2010

Deploy Forms MEDPROS, PIMR, EDHA Daily/Weekly 8.1 M 1996 – 2010

Inpatient-MTF/TED DHSS Monthly 2.5 M 1990 – 2010

Outpatient-MTF/TED DHSS Weekdays 201.4 M 1996 – 2010

Reportable Events MTFs Daily 266.8 K 1994 – 2010

Immunizations DEERS Weekdays 87.0 M 1980 -- 2010

DoDSR DoDSR Weekly 57.5 M 1985 -- 2010

Casualty WHS / AFIP Quarter/Month 48.7 K 1985 -- 2010

TMDS FHP&R Daily 4.5M 2005 – 2010

TRAC2ES (CENTCOM) TRANSCOM/FHP&R Weekly 72.9K 2001 – 2010

AFHSC DivisionsData Management & Tech Support

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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


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AFHSC Divisions

Defense Medical Epidemiology DatabaseData Management & Tech Support

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Active Duty Since 1990

6.6 million persons74.9 million records

Deployment RostersSince 1990


ImmunizationsSince 1980

51.6 million records

Active Duty Casualty

Since 198040,600 records

In-patientSince 1990

2.7 million records8.9 million records

AmbulatorySince 1996

161.8 million records556.9 million records

Reserve ComponentSince 1990


Military Entrance Processing Stations

Since 198511.1 million persons23.1 million records

Reportable EventsSince 1995

215,000 records120,000 records

Serologic SpecimensSince 1985

9.0 million persons46.1 million specimens

Pre and Post Deployment Health Assessments

Since 19946,366114 surveys

DMSS

Disease and Non-Battle Injury (aggregate)

Since 199698,900 records

PERSONNEL DATA SEROLOGIC DATA DEPLOYMENT DATA

Medical Surveillance

Monthly Reports (MSMR)

Adhoc Requests

Studies and

Analyses

Routine Reports &

Summaries

DMED

Hospitalization Queries

Personnel data Queries

Reportable Events Queries

Ambulatory Queries

Services of the Armed Forces Health Surveillance CenterMonthly

Synchronization

DMSS: Defense Medical Surveillance SystemDMED: Defense Medical Epidemiology Database

MEDICAL DATA

Version 3.6Remote Access to DMSS data

(non-privacy act only)

AFHSC Divisions

DMSS & Functional Relationships


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• 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

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Science Advisor

AFHSC Divisions

Director



Training Division



Division

Deputy Director

Epidemiology & Analysis

HQ Staff


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


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Operational surveillance analysis (600/yr)Support for:

–DoD policy development

–GAO investigations

–Congressional InquiriesAnalysis for MSMR articlesSpecial Studies / Research Support

Includes specialized influenza surveillance/analysisFocused periodic reports (1450/yr)


Data sources: DMSS, DoDSR, others

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45

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Other

Korea

Afghanistan

Nu

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of

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2002 2003 2004 2005 2006 2007 2008

Peacekeeping mission in Liberia

US Military Malaria Cases Jan 02-Dec 08Likely infection location

Source: MSMR Vol 16, No. 1 Jan 09, AFHSC

Epidemiology & AnalysisExample of MSMR Support

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Example of Serum Study:Hantavirus in Military Personnel from Four Corners Area


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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) 0 (quarterly)

Malaria 1 1 Smallpox Cardiac Adverse Events Report 1 1 Training-related injuries 1 1 Leishmaniasis 1 1 Traumatic Brain Injury 3 3 Post Traumatic Stress Disorder 1 1 MHS Dashboard Measures 1 1 FHP QA Measures 1 1 Wounded Service Members 1 1 Vaccine Adverse Events 2 2 Special Surveillance: Amputations, DVT, Leish, ARDs 1 1 Injury Installation Reports 1 1 Lost duty 2 2 Meningococcal Report 1 1


Over 50 routine reports distributed monthly, quarterly, weekly, or daily (1448 total reports annually)

Over 600 requests performed annually

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Quarterly Deployment Health ReportOctober 2010, page 6 of 16

Epidemiology and Analysis

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Request Process

Status determination

Assign to Liaison

Request arrives at AFHSC

Clarify question, draft analysis plan

RESEARCHPUBLIC HEALTH

PRACTICE

Review, approval and delivery

IRB

De-identified dataset

Analysis plan presented at R3

Coding & output

Summary table

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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

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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?

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• 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

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Request Process


Assign to Liaison




PRACTICE


IRB



Coding & output

Summary table

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Types of Requests

• “Operational”– Strategic– DoD-wide– Public Health Practice

• Research – Support– Internal research

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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

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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

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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

UNCLASSIFIED

Request Process


Assign to Liaison




PRACTICE


IRB



Coding & output

Summary table

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Request Process

• Draft Analysis Plan

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

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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”)

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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

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Request Process


Assign to Liaison




PRACTICE


IRB



Coding & output

Summary table

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• 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

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Request Process


Assign to Liaison




PRACTICE


IRB



Coding & output

Summary table

UNCLASSIFIED

Request Process

• Output– De-identified data set– Summary table

• Deliver to customer

Analysis

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AFHSC Example

H1N1 Influenza Response

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Detection of Pandemic Flu (pH1N1)

16000

18000

20000

22000

24000

26000

28000

30000

32000

34000

US

500

1000

1500

2000

2500

3000

3500

4000

Week Ending

CaliforniaTexasNCR

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)

2009 July June MayApril March

ES

SE

NC

E C

ases

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• 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

Communication: DoD Global Influenza Activity Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week Period

NMRC-LimaTOTAL (NEW)

Flu A:

H1N1:

H3N2:

pH1N1

Flu B:

USAMRU-KTOTAL (NEW)

1666 101Flu A: 284 (53)

H1N1: 5

H3N2: 16 (4)

pH1N1: 147 (29)

Flu B: 70 (7)

TAMCTOTAL (NEW)

1,729 369

Flu A: H1N1:

H3N2:

pH1N1 30 (11)

Flu B: 4 (1)

LRMC/CHPPMTOTAL (NEW)

Flu A: 167

H1N1:

H3N2:

pH1N1: 162 (92)

Flu B:

AFRIMSTOTAL (NEW)

733 288Flu A: 260 (96)

H1N1: 3 (2)

H3N2: 21 (12)

pH1N1: 68

Flu B: 4 (3)

NAMRU-2TOTAL (NEW)

1503 Flu A: 225

H1N1:

H3N2: 58

pH1N1: 107

H5N1:

Flu B: 60

NAMRU-3TOTAL (NEW)

562 Flu A: 37

H1N1: 8

H3N2: 24

pH1N1: 5

H5N1:

Flu B: 11

USAFSAMTOTAL (NEW)

6,293 472Flu A: 1,289 (164)

H1N1:

H3N2: 1

pH1N1 1,885 (80)

Flu B: 13 (1)NHRC

TOTAL (NEW)

3,495 507

Flu A:

H1N1:

H3N2:

pH1N1 1,122 (165)

Flu B:

DoD Service Labs Medical Centers/Clinics DoD Research LabsNote: H5N1 (positives/tested or pending) results are cases that have been confirmed and reported through WHO in compliance with the International Health Regulations 2005.

GuamTOTAL (NEW)

11 3

Flu A: H1N1:

H3N2:

pH1N1: 2

Flu B:

CENTCOM-MilTOTAL (NEW)

615 48

Flu A: H1N1:

H3N2: 5

pH1N1: 363 (30)

Flu B: 2

USF JapanTOTAL (NEW)

46 3

Flu A: 22 (1) H1N1:

H3N2:

pH1N1 : 17

Flu B: 2 (1)

USF KoreaTOTAL (NEW)

1,098 164

Flu A: 91 H1N1:

H3N2:

pH1N1 : 342 (21)

Flu B : 2CONUS MEDCENs

TOTAL (NEW)

8,279 1,740Flu A: 2,576 (508)

H1N1:

H3N2:

pH1N1: 793 (122)

Flu B: 15

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Communication: Surveillance Partner Reporting

Sentinel Surveillance

Population-Based/Recruit

Electronic Military Health Surveillance

DOS Embassy

Lab-Specific

Regional

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Communication: Network SummaryAvailable at: http://www.afhsc.mil

ü60

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• 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

UNCLASSIFIED


• “…‘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

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• “…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

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Intelligent Military Medicine

• Evidence based policy and prevention strategies for the United States Armed Forces

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Questions

unclassified armed forces health surveillance center: medical intelligence or intelligent medicine...

Documents

health of military

health surveillance

military health system

public health service

public health action

analysis slide

range of global health

strategic level surveillance