Non-Vaccine Interventions to Control Adenovirus Infections: The U.S. Army Experience

1. Non-Vaccine Interventions to Control Adenovirus Infections:The U.S. Army Experience Jeffrey D. Gunzenhauser, MD, MPH COL, MC, USA Preventive Medicine Staff Officer OTSG / POPM Mr. Terrence Lee USACHPPM Good Afternoon General Martinez, COL DeFraities and COL Gunzenhauser. As you may know, I work here at CHPPM under the COL Mallon, Directorate for Clinical Preventive Medicine and under LTC Lovell in Program 34, Disease and Injury Control. Although I am not a physician, I have a Masters in Public Health in Epidemiology and I’ve been following this topic or related topics of Non-Vaccine preventive measure or interventions to prevent Respiratory Disease during basic training for practically my whole tenure here at CHPPM: about 4 and a half years.Good Afternoon General Martinez, COL DeFraities and COL Gunzenhauser. As you may know, I work here at CHPPM under the COL Mallon, Directorate for Clinical Preventive Medicine and under LTC Lovell in Program 34, Disease and Injury Control. Although I am not a physician, I have a Masters in Public Health in Epidemiology and I’ve been following this topic or related topics of Non-Vaccine preventive measure or interventions to prevent Respiratory Disease during basic training for practically my whole tenure here at CHPPM: about 4 and a half years.

2. I’ve been asked to present to you Options for preventive measures to prevent ARDs – particularly now with the loss of the Adenovirus vaccine. I’ll give a short background on ARDs and Adenovirus Vaccine. I’ll summarize finding from our Literature Review – presented last year at FHP and brief you on what is being done now at BCT Sites in the Army and other training in the other services. Many slides from this presentation will be repackaged presented to the AFEB at the Sept 18 Meeting in Bethesda as “The Army Experience” with Non Vaccine ARD Interventions. – the other services and CDC will also present their experiences.I’ve been asked to present to you Options for preventive measures to prevent ARDs – particularly now with the loss of the Adenovirus vaccine. I’ll give a short background on ARDs and Adenovirus Vaccine. I’ll summarize finding from our Literature Review – presented last year at FHP and brief you on what is being done now at BCT Sites in the Army and other training in the other services. Many slides from this presentation will be repackaged presented to the AFEB at the Sept 18 Meeting in Bethesda as “The Army Experience” with Non Vaccine ARD Interventions. – the other services and CDC will also present their experiences.

3. 3

4. Commission on Acute Respiratory Disease (CARD) Fort Bragg - 1943 ARDs remained a problem after WWI and into WWII 1940: “Board for the Investigation of Influenza and Other Epidemic Diseases in the Army” recommended by the Surgeon General. 1942: Commission on Acute Respiratory Disease (CARD) established. Forerunner of the Armed Forced Epidemiology Board (AFEB)ARDs remained a problem after WWI and into WWII 1940: “Board for the Investigation of Influenza and Other Epidemic Diseases in the Army” recommended by the Surgeon General. 1942: Commission on Acute Respiratory Disease (CARD) established. Forerunner of the Armed Forced Epidemiology Board (AFEB)

5. CARD Investigative Efforts Etiology Clinical Classification Epidemiology Outbreak Investigation Prevention and Control Methods

6. Examples of ARD Prevention Strategies Investigated by CARD Triethylene glycol vapors Oiling of floors and bedding Double Bunks Open-Bay or Closed-Bay Barracks Chilling of Subjects Adenovirus Vaccine

7. Non Vaccine ARD Interventions (NOVARDI) Personal Hygiene Administrative Controls Engineering / Environmental Controls Medications

8. Personal Hygiene Measures Hand Hygiene Handwashing Antimicrobial handwipes Hand-sanitizers Hand hygiene does not prevent transmission via aerosol Masks Handwashing has been shown effective in hospital settings and for GI infections, but less proof for respiratory disease. Navy study – Handwashing intervention – 45% decline from previous year, but they didn’t really have an applicable control group – they compared to previous year – but the severity of ARDs can vary from season to season – perhaps their intervention years were mild ARD years? - they sort of controlled for this by looking at the Advanced Training groups, The Advanced Training Groups – where the researchers did not implement the handwashing program – had the same rates of ARDs in all the years – not really the best “control” group, but it does give some indication that the years of handwashing intervention were not too different from the previous year of no intervention. The handwashing intervention was NOT able to stop an ARD outbreak in 1998 – perhaps it attenuated it – the outbreak could have even been larger and maybe it controled the outbreak, but it did not prevent itHandwashing has been shown effective in hospital settings and for GI infections, but less proof for respiratory disease. Navy study – Handwashing intervention – 45% decline from previous year, but they didn’t really have an applicable control group – they compared to previous year – but the severity of ARDs can vary from season to season – perhaps their intervention years were mild ARD years? - they sort of controlled for this by looking at the Advanced Training groups, The Advanced Training Groups – where the researchers did not implement the handwashing program – had the same rates of ARDs in all the years – not really the best “control” group, but it does give some indication that the years of handwashing intervention were not too different from the previous year of no intervention. The handwashing intervention was NOT able to stop an ARD outbreak in 1998 – perhaps it attenuated it – the outbreak could have even been larger and maybe it controled the outbreak, but it did not prevent it

9. Administrative Controls Minimum space requirements Sleeping head-to-toe Double bunking Cohorting Cohorting refers to separating groups on some sort of variable. As far as ARD prevention, there are two options: Isolating those with ARD symptoms: this is done already, those who are sick, go to sick call – but this has limitations and is not really a practical method of preventing spread of disease since an individual is usually contagious before symptoms appear Isolation of Outbreaks by preventing units from mixing and interacting: therefore, if one person has contagion – instead of him spreading it to his bunkmate – then squad – then platoon –and eventually company and battallion, you limit contact that all inviduals have with other inviduals eg. right now, for the most part, individuals within companies interact and there is very little interaction with other companies – but there is mixing in the Dining Facilites and companies may use some of the same equitment or training areas. It is possible, but probably not practical to try to improve the current cohorting. If it is changed, it would require institutional changes: eg. staggared or more segregated dining facilites or changing the trainng structure such that instead of training as a company, recruits are trained only within a platoon – such an extreme change may not go over too well with TRADOCCohorting refers to separating groups on some sort of variable. As far as ARD prevention, there are two options: Isolating those with ARD symptoms: this is done already, those who are sick, go to sick call – but this has limitations and is not really a practical method of preventing spread of disease since an individual is usually contagious before symptoms appear Isolation of Outbreaks by preventing units from mixing and interacting: therefore, if one person has contagion – instead of him spreading it to his bunkmate – then squad – then platoon –and eventually company and battallion, you limit contact that all inviduals have with other inviduals eg. right now, for the most part, individuals within companies interact and there is very little interaction with other companies – but there is mixing in the Dining Facilites and companies may use some of the same equitment or training areas. It is possible, but probably not practical to try to improve the current cohorting. If it is changed, it would require institutional changes: eg. staggared or more segregated dining facilites or changing the trainng structure such that instead of training as a company, recruits are trained only within a platoon – such an extreme change may not go over too well with TRADOC

10. Engineering/Environmental Controls Dust Control Ventilation Dilutional approaches Open windows or doors Minimum number of air exchanges Filtration approaches Air Sterilization Ultraviolet (UV) Glycol Vapor Other Methods

11. Antibiotic, Antiviral and Other Medications Antibacterial Benzathine Penicillin G (BPG) Antiviral Amantadine and Rimantadine Zanamivir and Oseltamivir Zinc Vitamins A or C Echinacea

12. 12 Army Basic Training PostsPopulation Sizes (1000s)

13. Historical Weekly ARD Rates at Army BT Posts in Cases per 100 Trainees per Week (1990-2000) Here is a graph of the ARD rates for the 5 training sites from 1990 to 2000. The green section of the graph represents when Adeneovirus vaccine was using regularly through training - in the Fall of 96, vaccine supplies were rationed and only given during the “peak” season 1 Sep to 31 Mar – this time period I have highlighted as amber. The Red period is after early 2000 when supplies were depleted. As you can see, when we had the vaccine, rates were relatively stable – when we started rationing the vaccine, you do see two increases in rates – which were probably controled by the administration of vaccine on Sep 1 of that year. You can see this for Ft. Jackson and probably for Fort Lwood. However, for the period with no vaccine, rates have markedly increased particularly at Benning, Jackson and Lwood to and a smaller extent at Sill Here is a graph of the ARD rates for the 5 training sites from 1990 to 2000. The green section of the graph represents when Adeneovirus vaccine was using regularly through training - in the Fall of 96, vaccine supplies were rationed and only given during the “peak” season 1 Sep to 31 Mar – this time period I have highlighted as amber. The Red period is after early 2000 when supplies were depleted. As you can see, when we had the vaccine, rates were relatively stable – when we started rationing the vaccine, you do see two increases in rates – which were probably controled by the administration of vaccine on Sep 1 of that year. You can see this for Ft. Jackson and probably for Fort Lwood. However, for the period with no vaccine, rates have markedly increased particularly at Benning, Jackson and Lwood to and a smaller extent at Sill

14. Recent Weekly ARD Rates at Army BT Posts in Cases per 100 Trainees per Week September 2000 - August 2001 ARD rates have increased, especially at Fort Jackson, Fort Benning and Fort Leonard Wood (three largest training sites) Fort Leonard Wood had large outbreak in August – probably Adenovirus – This is active surveillance that is being done by CHPPM, through the Army Medical Surveillance ActivityARD rates have increased, especially at Fort Jackson, Fort Benning and Fort Leonard Wood (three largest training sites) Fort Leonard Wood had large outbreak in August – probably Adenovirus – This is active surveillance that is being done by CHPPM, through the Army Medical Surveillance Activity

15. Army Policy Released Jan 00 and July 01 Specified the Following Interventions as “Probably Effective”: Hand washing Minimum bunk spacing requirements Other Interventions – no proof of benefit Other Countermeasures and Preparations Increase education during outbreaks Obtain additional resources during outbreaks Surveillance vigilance

16. What is Currently Being Done at Army Training Posts to Decrease ARDs?

17. Current Interventions: Summary for Army Training Posts Handwashing is generally emphasized. Barriers: Training discipline, time, lack of facilities No Army-wide approaches adopted or planned Space requirements are not always met. “Summer Surge” No studies done to measure effect of crowding There are no Army-wide plans to implement engineering interventions.

18. Further Directions Assess and ensure adequate ventilation (fresh air) and clean filters Possible investigations Observational study of the effect of crowding in barracks during “Summer Surge” Update clinical recommendations Ensure adequate ventilation Scientific evidence of health effects are not strong, but we should stress that minimum engineering recommendations (eg. ASHRAE standards) should be met – unpublished reports from an Epicon at Ft. Jackson show that new handlers were associated with a higher hospitalization rate (Cervosky) among the possible explanations the authors attribute this to new handlers possibly being more efficient at distributing air containing virus and insufficient fresh air. Ensure adequately clean filters Again, evidence of health effects are not strong, but we have heard of anecdotal reports of sand encrusted dirt crusted filters – at minimum, standards from the manufacturer of the air handler should be met - Adenovirus has been detected (via PCR not via culture) in filters at Ft. Jackson (J Clin MicroAug 2000 Echavarria et. all) Possible Investigations Observational study on effect of crowded barracks during “Summer Surge” Improve clinical recommendations Ensure adequate ventilation Scientific evidence of health effects are not strong, but we should stress that minimum engineering recommendations (eg. ASHRAE standards) should be met – unpublished reports from an Epicon at Ft. Jackson show that new handlers were associated with a higher hospitalization rate (Cervosky) among the possible explanations the authors attribute this to new handlers possibly being more efficient at distributing air containing virus and insufficient fresh air. Ensure adequately clean filters Again, evidence of health effects are not strong, but we have heard of anecdotal reports of sand encrusted dirt crusted filters – at minimum, standards from the manufacturer of the air handler should be met - Adenovirus has been detected (via PCR not via culture) in filters at Ft. Jackson (J Clin MicroAug 2000 Echavarria et. all) Possible Investigations Observational study on effect of crowded barracks during “Summer Surge” Improve clinical recommendations