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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. Disclaimer.

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armed forces health surveillance center medical intelligence or intelligent medicine

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

slide2

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.

briefing outline
Briefing Outline
  • Intelligence and Surveillance
  • Introduction to AFHSC
  • Data & Analysis
  • Public Health Practice vs Research
  • Intelligent Medicine
military intelligence
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

military medical intelligence
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)
public health surveillance
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]

afhsc governance
AFHSC Governance

USD (Personnel &Readiness)

Functional

Oversight

ASD (Health Affairs)

Force Health Protection Council

Army Exec Agent

Armed Forces Health Surveillance Center

afhsc relationships
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

afhsc mission vision
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.

afhsc scope of responsibility
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
slide12

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

slide13

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

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

www.afhsc.mil

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
slide17

AFHSC Divisions

Communications, Standards & Training

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

slide19

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

strategic goals and priority pillars

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

afhsc divisions1

GEIS Operations

AFHSC Divisions

WRAIR/NMRC

DoD Partners

USAPHC

(Prov)

Germany

Korea

NHRC

Egypt

USAFSAM

Thailand

NMCPHC

Kenya

Peru

Pacific

slide22

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

slide23

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
slide24

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

dmss data inputs frequency

AFHSC Divisions

Data Management & Tech Support

DMSS Data Inputs / Frequency
slide26

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

slide27

AFHSC Divisions

Data Management & Tech Support

Defense Medical Epidemiology Database

slide28

AFHSC Divisions

Data Management & Tech Support

DMSS & Functional Relationships

slide29

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

slide30

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

customers

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
slide32

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)
slide33

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

slide35

Epidemiology & Analysis

  • Over 50 routine reports distributed monthly, quarterly, weekly, or daily (1448 total reports annually)
  • Over 600 requests performed annually
request process1
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
clarify the question

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?

clarify the question1

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?

types of requests
Types of Requests
  • “Operational”
    • Strategic
    • DoD-wide
    • Public Health Practice
  • Research
    • Support
    • Internal research
public health practice
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
public health practice1
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.
public health research
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
request process4
Request Process
  • Draft Analysis Plan
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
request process5
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
request process6
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
request process8
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
request process10
Request Process

Analysis

  • Output
    • De-identified data set
    • Summary table
  • Deliver to customer
afhsc example
AFHSC Example

H1N1 Influenza Response

detection of pandemic flu ph1n1

First ESSENCE Alert (26 Apr 09)

Detection of Pandemic Flu (pH1N1)

Navy FM (1st case) presents in San Diego

37 Sailors present in San Diego

2 Army FM present in San Antonio

ESSENCE Cases

2009

March

April

May

June

July

slide57

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!!!
slide58

Communication: DoD Global Influenza Activity

Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week Period

USAFSAM

TOTAL (NEW)

6,293 472

Flu A: 1,289 (164)

H1N1:

H3N2: 1

pH1N1 1,885 (80)

Flu B: 13 (1)

LRMC/CHPPM

TOTAL (NEW)

Flu A: 167

H1N1:

H3N2:

pH1N1: 162 (92)

Flu B:

USF Korea

TOTAL (NEW)

1,098 164

Flu A:91

H1N1:

H3N2:

pH1N1 : 342 (21)

Flu B : 2

USF Japan

TOTAL (NEW)

46 3

Flu A:22 (1)

H1N1:

H3N2:

pH1N1 : 17

Flu B: 2 (1)

NHRC

TOTAL (NEW)

3,495 507

Flu A:

H1N1:

H3N2:

pH1N1 1,122 (165)

Flu B:

CENTCOM-Mil

TOTAL (NEW)

615 48

Flu A:

H1N1:

H3N2: 5

pH1N1: 363 (30)

Flu B: 2

CONUS MEDCENs

TOTAL (NEW)

8,2791,740

Flu A: 2,576 (508)

H1N1:

H3N2:

pH1N1: 793 (122)

Flu B: 15

NAMRU-3

TOTAL (NEW)

562

Flu A: 37

H1N1: 8

H3N2: 24

pH1N1: 5

H5N1:

Flu B: 11

AFRIMS

TOTAL (NEW)

733288

Flu A: 260 (96)

H1N1: 3 (2)

H3N2: 21 (12)

pH1N1: 68

Flu B: 4 (3)

Guam

TOTAL (NEW)

11 3

Flu A: H1N1:

H3N2:

pH1N1: 2

Flu B:

TAMC

TOTAL (NEW)

1,729369

Flu A:

H1N1:

H3N2:

pH1N1 30 (11)

Flu B: 4 (1)

USAMRU-K

TOTAL (NEW)

1666 101

Flu A: 284 (53)

H1N1: 5

H3N2: 16 (4)

pH1N1: 147 (29)

Flu B: 70 (7)

NMRC-Lima

TOTAL (NEW)

Flu A:

H1N1:

H3N2:

pH1N1

Flu B:

NAMRU-2

TOTAL (NEW)

1503

Flu A: 225

H1N1:

H3N2: 58

pH1N1: 107

H5N1:

Flu B: 60

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

communication surveillance partner reporting
Communication: Surveillance Partner Reporting

Sentinel Surveillance

Population-Based/Recruit

Electronic Military Health Surveillance

DOS Embassy

Lab-Specific

Regional

slide61

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
intelligent medicine
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

intelligent medicine1
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

intelligent military medicine
Intelligent Military Medicine
  • Evidence based policy and prevention strategies for the United States Armed Forces