1. DoD Global, Laboratory-Based, Influenza Surveillance Program
United States Air Force School of Aerospace Medicine (USAFSAM)
Wright-Patterson Air Force Base, OH
Influenza Season
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2. DoD collaborative program initiated 1999
Introduction
DoD collaborative program initiated 1999
Funding: Armed Forces Health Surveillance Center – Division of the Global Emerging Infections Surveillance & Response System Operations (AFHSC/GEIS)
Provide lab-based influenza surveillance
season: 55 CONUS/36 OCONUS sites worldwide
Collect respiratory specimens & questionnaires from individuals with influenza-like illness
Process specimens in USAFSAM’s Epidemiology Laboratory Service
Mission & Priorities
Identify circulating viruses / detect new strains
Share data and specimens with the Centers for Disease Control and Prevention (CDC) & the World Health Organization (WHO)
Evaluate influenza vaccine effectiveness
Weekly comprehensive surveillance report
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3. Beginnings 1976-1997: General Respiratory Surveillance/Research
AF Influenza Program “Project Gargle”1
Letterman Army Institute of Research2
DoD overseas medical research labs (Brazil, Egypt, Indonesia, Kenya, Peru, Thailand) 3
1996: Presidential Decision Directive (NSTC-7) 4
1997: Global Emerging Infections Surveillance & Response System Operations (GEIS) 5
1998: Addressing Emerging Infectious Disease Threats: A Strategic Plan for the DoD6
Influenza surveillance named as the #1 priority
1999: Assistant Secretary of Defense, DoD (Health Affairs) Policy Memorandum7
Formal implementation of the DoD influenza surveillance program
Outlines program functions and surveillance goals
Appointed the Air Force Surgeon General as Executive Agent and management responsibility was given to what is now USAFSAM
Note: References available in speakers notes section.
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4. Service Influenza Policy
DoD
ASD-HA: Sentinel Sites for the Influenza Surveillance Program (24 July 2014)
Service Specific Policy
Air Force: Instruction : Surveillance, Prevention, and Control of Diseases and Conditions of Public Health or Military Significance (15 July 2014)
Army: OP-ORD ( Influenza Vaccination Program)
Reference e: ASD(HA) Memo
ANNEX C: Sentinel site list
Navy & Marine Corps: Message No (Policy for the Use of Influenza Vaccine for the Influenza Season)
Reference f: ASD(HA) Memo
Coast Guard: None
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5. Influenza-like illness (ILI) case definition Fever ≥ 100.5°F AND
Program Overview
Laboratory-based surveillance network with >80 sites across the DoD globally
Sites aim to collect 6-10 respiratory specimens/week from active duty, dependents, and retirees who present to MTF clinics and meet a specific case definition:
Influenza-like illness (ILI) case definition
Fever ≥ 100.5°F AND
Cough or sore throat
Symptom onset < 72 hours
Specimens shipped to and processed by the USAFSAM Epidemiology Laboratory Service (USAFSAM/PHE) (Shipping/testing costs covered)
Test for influenza A & B and other respiratory viruses
Select influenza viruses sequenced by molecular team
Clinical and syndromic data analyzed by epidemiologists
Weekly reporting to participating sites and DoD & civilian public health entities
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6. Program Overview CONUS Sites: 55 Air Force: 33 Army: 11
Navy & Marine Corps: 7
Coast Guard: 6
JTF CAPMED/DHA: 2
OCONUS Sites: 36
Air Force: 18
Army: 9
Navy &
Marine Corps: 7
Coast Guard: 2
Submit to USAFSAM
Submit to LRMC
Submit to TAMC
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

7. Military members and their families:
Influenza and Military Populations
Even with modern medical advances, influenza and influenza- like illness can cause high morbidity rates, undermining readiness
Military members and their families:
Are stationed where new strains are likely to appear
Are highly mobile across the globe and could quickly spread a pandemic strain
May live in areas that represent “gaps” in the CDC influenza surveillance network
Training environments are well suited for the spread of emerging respiratory pathogens
Highly immunized military plus electronic vaccination data registry facilitate rapid assessment of vaccine protection against emerging strains
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8. Examples 1918 Spanish Flu at Ft. Riley 1976 Swine Flu at Ft. Dix
2009 H1N1 at Randolph AFB
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9. Evolves rapidly & responsible for most epidemics and pandemics
Refresher
Influenza A
Evolves rapidly & responsible for most epidemics and pandemics
Divided into subtypes (Example: H5N1, H3N2) based on two surface proteins:
Hemagglutinin (HA)
Neuraminidase (NA)
Influenza B
Gradually changing virus
Classified by strains based on their lineage:
Currently Yamagata or Victoria
Found primarily in humans
Immunity-related changes to influenza A virus
Changes to regions of the HA surface protein (called antigenic shift & drift) can affect human antibody responses to the virus
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10. Antigenic Drift & Shift
Small gradual changes that occur over time and create a new strain that may not be recognized by immune system
Reason that new influenza vaccine is manufactured and distributed each year
Antigenic Shift
Abrupt major change that produces a novel virus (not previously seen in humans)
Result of direct animal-to-human transmission or mixing of human and animal viral genes within the same individual (reassortment)
Most people have little or no protection against the new virus
USAFSAM monitors these changes using molecular sequence analysis on influenza specimens. What does that look like?
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11. Distribution A: Approved for public release; distribution is unlimited
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12. NORTHERN SEASONAL INFLUENZA VACCINE PRODUCED
Surveillance Process and Vaccine Development
FDA’s VRBPAC* meets to decide strains for annual flu vaccine
USAFSAM DoD Global Lab-Based Sentinel Surveillance
Sentinel Sites
Participating Non-Sentinel Sites
CDC/Viral Surveillance
National Respiratory & Enteric Virus Surveillance System Labs (U.S.)
WHO Influenza Labs
NORTHERN SEASONAL INFLUENZA VACCINE PRODUCED
DoD System
Civilian System
*Food and Drug Administration, Vaccines and Related Biological Products Advisory Committee
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13. Seed Viruses and Reference Strains from DoD Surveillance
Contribution
Reasons to participate:
Constant changes to the influenza virus require ongoing collection and characterization of the strains
Strains can undergo rapid changes, leading to pandemics of influenza; surveillance of viruses will detect these changes
Updates to seasonal influenza vaccine based on surveillance findings
National and international responses to emerging pandemic strains are triggered by surveillance data
The DoD surveillance network helps fill surveillance gaps for parts of the world that civilian surveillance systems do not reach
Offer surge / outbreak support
RT-PCR results available in 48 hours after arrival at laboratory. Viral culture and, if negative, additional molecular testing may be performed
Support for testing of novel viruses (e.g., MERS-CoV)
Seed Viruses and Reference Strains from DoD Surveillance
A/PR8/1945, an A strain isolated from a recruit in May 1943, plus B/Lee (Army)
A/Texas/1/77(H3N2) (USAF)
A/Philippines/2/82(H3N2) (USAF)
A/Panama/2007/99 (H3N2) (USAF)
A/California/4/2005 (H3N2) (USN)
A/South Dakota/06/2007(H1N1) (USAF Base, Army Case)
A/Texas/05/2009 (H1N1) (USAF)
A/Iraq/18529/2009 (H1N1) (USAF)
A/California/07/2009 (H1N1) (USN)
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14. Novel respiratory virus
Early detection essential for control of emerging, reemerging, and novel infectious diseases (natural or intentional)
Highly interconnected and transitive environment
Expanding detection capabilities to a network of state and reference laboratories are critical
Viral respiratory illness caused by a coronavirus not previously identified in humans
Understanding of the virus and the disease continuing to evolve
First reported September 2012 in the United Kingdom from a patient who recently traveled to Saudi Arabia and Qatar
Secretary of Health and Human Services has declared that circumstances exist to justify authorization of emergency use of in vitro diagnostic tests for detection
USAFSAM’s Epidemiology Laboratory Service has this testing capability, along with other DoD reference laboratories
Middle East respiratory syndrome coronavirus (MERS-CoV)
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15. Surveillance Program Goals
Prevent Influenza Infections
Reduce Morbidity & Mortality
Force Health Protection
Identify current strains & outbreaks
Analyze vaccine effectiveness
Track genetic changes of viruses in circulation (molecular sequence analysis)
Detect and monitor antiviral resistance
Monitor severity trends
Contribute to annual vaccine selection
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16. Site Specifics
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17. Cough AND/OR sore throat WITH symptom onset/duration < 72 hours
Decision Tree for Influenza-Like Illness
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Cough AND/OR sore throat WITH symptom onset/duration < 72 hours
Yes
Fever ≥ ̊ F
ILI No
Not ILI
ILI Case Definition: Fever ≥ 100.5°F (38°C) with Cough OR Sore Throat ≤ 72 hours
Not ILI: Not recommended to collect a specimen. However, there is flexibility for clinical judgment. If you suspect influenza or other respiratory viral infection, you can collect a specimen for testing.
ILI: Collect nasal wash specimen (preferred method) or nasopharyngeal swab and submit to USAFSAM in viral transport medium (VTM) for testing.
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

18. What to do if…. There is an increase in ILI patients
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
There is an increase in ILI patients
Continue submitting up to 10 per week, giving priority to the sickest or hospitalized patients and those presenting with respiratory distress (shortness of breath)
Fewer than six patients meet the ILI case definition in a given week
Send specimens for those who meet the ILI case definition
You want to make sure specimens arrive at USAFSAM on a weekday
Consider sampling patients early in the week
You are in a busy clinic and would like to simplify case selection
It may be convenient to designate 1 day a week for patient sampling to meet the 6-10 samples per week, for example, “Flu Mondays”
A specimen has already been submitted for a patient in the past 14 days
One specimen per patient is recommended; use clinical judgment in these situations
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

19. Nasal Wash (NW) Kits USAFSAM NW collection kit includes:
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
USAFSAM NW collection kit includes:
Sterile saline, collection cup, & bib
VTM
Biohazard bag
Influenza Surveillance Questionnaire
USAFSAM also provides:
Shipping containers
Shipping costs via FedEx
To request collection kits:
Use the current version of the “Supply Order Form” available (under Shipping/Training) at:
consult/influenza/lab
NOTE: If an urgent public health need arises, contact the program via for more kits at:
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

20. Collection instructions are on the back of each questionnaire
Nasal Wash
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Nasal wash collection method is preferred as it captures adequate volumes of original specimen for:
Diagnostic testing
Sequence analysis
Specimen sharing
Collection instructions are on the back of each questionnaire
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

21. Influenza Surveillance Questionnaire
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Use the current season questionnaire included in each nasal wash kit and available on the influenza surveillance program website
Complete the questionnaire for each patient specimen
Submit a hard copy of the questionnaire with each specimen
Make a copy of each questionnaire for your records
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

22. Potential for specimen to be tested on multiplex respiratory panel
Why are questionnaires important?
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Provide valuable epidemiological data such as vaccination and travel history
Identify severe illness and hospitalized cases, which could signal important changes in the virus
Can be used as a worksheet when you need to report hospitalized influenza case information in DRSi
Potential for specimen to be tested on multiplex respiratory panel
Specimen must test negative for influenza on PCR and meet ILI case definition
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

23. You can order the test in AHLTA/CHCS
Ordering the Test
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
You can order the test in AHLTA/CHCS
Order the RESPIRATORY CULTURE PNL (EPI), or panel with a similar name designated by your installation, in AHLTA/CHCS where available. If you have questions, consult your lab officer
Two (or three) types of tests are performed as part of this panel:
INFLUENZA VIRUS A/B PCR
Reflex test (Multiplex Respiratory Panel) – Criteria must be met prior to performing this
test (negative PCR, questionnaire submitted
and meets ILI case definition)
VIRAL CULTURE RESPIRATORY
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

24. Storage & Shipping Best: Freeze specimen at -70°C and ship on dry ice:
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Best: Freeze specimen at -70°C and ship on dry ice:
Specimens frozen at -20°C are not acceptable due to loss of viability of the viruses
Please contact USAFSAM if dry ice or a -70°C freezer is not available at your site prior to the start of the season
Use dry ice blocks or pellets rather than “snow” form
For each 24-hour period of travel, each standard shipping box should contain a minimum of:
5 lb of dry ice for CONUS sites
15 lb of dry ice for OCONUS sites
Acceptable: A specimen may be shipped on frozen gel packs at refrigerated temperature (2-8°C) only if received at the USAFSAM lab within 48 hours of collection from patient:
Specimens received over 8°C or over 48 hours from collection cannot be accepted
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

25. Epidemiology Laboratory Service 2510 Fifth Street, Bldg 20840
Shipping
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Use the FedEx number (for surveillance testing only) and ship FedEx Priority Overnight to:
USAFSAM/PHE
Epidemiology Laboratory Service
2510 Fifth Street, Bldg 20840
WPAFB, OH
If you have laboratory or shipping questions, request your lab staff to call customer service at:
(937) , DSN
For the comprehensive USAFSAM/PHE Laboratory Guide, please visit: or
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

26. Responses to Frequently Asked Questions
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
Be sure to ship FedEx Priority or Standard Overnight®
Do not ship FedEx First Overnight
VTM tube should have at least two identifiers on the label, i.e., SSN/FMP, DOB, or name
Package each specimen individually in biohazard bags with the questionnaire in the front pocket
Specimens can be received M-F with limited Saturday hours
If specimens must be shipped for Saturday delivery, please call USAFSAM lab at or DSN to make arrangements before shipping
A Continuity Binder can help when passing procedures on after personnel PCS or rotate
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

27. Checking Results Test name: Influenza virus A/B PCR
Test Name on Multiplex
Usually available within 48 hours from receipt into laboratory
Coronavirus (229E, HKU1, NL63, & OC43)
Positive results:
Influenza A or B
Pandemic influenza A/H1N1
Human metapneumovirus
Seasonal influenza A/H1
Parainfluenza 1-4
Influenza A/H3
RSV
Influenza B
Rhinovirus/enterovirus
Negative result:
Bordetella pertussis
No influenza detected
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Test name: Final viral culture respiratory
Positive result:
Influenza A and B
Detected (Organism specified)
Adenovirus
Enterovirus
Not detected
Parainfluenza 1-3
Respiratory syncytial virus (RSV)
No respiratory virus isolated (after 10 days)
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28. Website Resources Site-specific surveillance dashboard Submission data
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Site-specific surveillance dashboard
Submission data
POC information
Shipping/storage
Welcome packet
Weekly reports
Other sentinel site resources
Novel virus information
Historical data
Program publications
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29. Influenza Dashboard
SELECT CASES COLLECT SPECIMENS COMPLETE QUESTIONNAIRES ORDER TEST STORAGE & SHIPPING CHECK RESULTS CHECK WEBSITE
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30. Weekly Surveillance Report
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Distributed via and websites:
Sentinel sites
AF bases
Offices of the Surgeon General (all Services)
Public health organizations
DoD Health Affairs
AFHSC/GEIS
Collaborators
CDC collaborators
CDC Epi-X Distribution (local and state health departments)
All who are interested
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014

31. USAFSAM Epidemiology Laboratory Service (PHE)
The End
<INSERT YOUR INSTALLATION POINT OF CONTACT INFO HERE>
USAFSAM Epidemiology Laboratory Service (PHE)
Website:
Commercial (937)
DSN
USAFSAM Epidemiology Consult Service (PHR)
Website:
(CAC-required)
Commercial (937)
DSN
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 19 Aug 2014