The United States Department of Defense and the International Health Regulations (2005): Perceptions, Pitfalls and Progress towards Implementation. (Perspectives)

Article excerpt

Background

The Department of Defense of the United States of America (USA) has been conducting respiratory disease surveillance among United States military personnel around the world since the mid-1970s. (1) The Department's Global Emerging Infections System began in 1997 (2) and currently includes nearly 500 sites with partners in 75 countries. The primary focus of the network is the early detection and rapid response to emerging or newly identified viruses of public health concern. (3) The World Health Organization's (WHO's) International Health Regulations (IHR) (2005) form the central guiding framework for both reporting of public health threats and potential public health emergencies of international concern.

In recent years, the Department of Defense network has established disease surveillance in collaboration with host countries and has built a core capacity within each host country for sustained monitoring of respiratory disease activity within their borders. This network has demonstrated the ability to identify and respond quickly to public health emergencies of international concern, as illustrated in the influenza pandemic of 2009-10, and has also provided multiple viral-strain contributions to influenza vaccines over the past decade. (3)

H1N1 pandemic response

In early April of 2009, two Department of Defense laboratories (the Naval Health Research Center in San Diego, California, and the Unites States Air Force School of Aerospace Medicine in San Antonio, Texas) in collaboration with the United States Centers for Disease Control, became the first public health institutions to identify the 2009 novel A/H1N1 influenza pandemic. (4) Between 15 April 2009 and 30 August 2009 (the first wave of the WHO-declared pandemic), the Department of Defense global network of influenza surveillance sites supported 14 host country partners in confirming their first cases of novel influenza A/H1N1. The Department of Defense also identified more than 1000 cases among military personnel or their family members located in 13 countries. Shortly after the onset of the pandemic, the Armed Forces Health Surveillance Center began coordinating public health centres and laboratories of the United States' Navy, Army and Air Force to aggressively respond to this new threat among beneficiaries and active duty service members worldwide.

An initial area of concern quickly became identifying the responsible party and appropriate mechanism for reporting laboratory-confirmed cases of novel influenza A/H1N1 among United States military personnel stationed in foreign countries in compliance with the IHR. Interactions between medical units of the United States military and the corresponding host countries' Ministries of Health varied widely based on established formal and informal arrangements, the nature of current missions and the host country's requirements for reporting routine medical events during outbreaks of disease and other public health emergencies. Where a collaborative relationship was established with host country counterparts, reporting of pandemic influenza A/H1N1 cases to the host country Ministry of Health was rather seamless. In cases where a relationship did not exist, and for all individuals overseas who were diagnosed through Department of Defense reference laboratories, cases were reported through the different Department of Defense service public health hubs to the Armed Forces Health Surveillance Center. Detailed case lists were then compiled and submitted to the United States Department of Health and Human Services, the designated national focal point for IHR reporting. Reports were then sent by this Department through the WHO regional offices and to the national focal points in the corresponding host country per Articles 6 and 9 of the IHR. In either circumstance, lines of meaningful bilateral communication and coordination were tested and further strengthened.

IHR issues

Two significant issues related to the IHR became rapidly apparent during the 2009 H1N1 pandemic. …