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Backgrounder on Military Health Surveillance
April 1, 2015
Public Health Overview
Our Vision:
Reshaping a cutting-edge, word-class Public Health capability that is lean, efficient,
effective, forward leaning and strategically positioned to fully meet MHS and
customer needs.
Our Mission:
•Support the move from a health care system to a system of health by focusing on
the prevention of disease, disability, and death in garrison and while deployed
•Create timely, standardized execution guidance, in collaboration with the Services
•Increase effectiveness and efficiencies (e.g., manpower and cost savings) through
consolidation/re-engineering of functions
•Develop a comprehensive portfolio management and DHA Public Health structure
to best integrate the evolution of additional product lines
14 December 2011 Pre-decisional FOUO
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Armed Forces Health Surveillance Center
Our Vision:
To be the central epidemiological resource and a global health surveillance
proponent for the U.S. Armed Forces.
Our Mission:
Provide timely, relevant, actionable, and comprehensive health surveillance
information in order to promote, maintain, and enhance the health of military and
military-associated populations
• Acquire, analyze/interpret, disseminate information, and recommend
evidence-based policy
• Develop, refine, and improve standardized surveillance methods
• Serve as focal point for sharing health surveillance products, expertise, and
information
• Coordinate a global program of militarily relevant infectious disease
surveillance
14 December 2011 Pre-decisional FOUO
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AFHSC Overview: Key Capabilities and Products
•
Data Management and Technical Support
– Design, operation and management of the Defense Medical Surveillance System (DMSS)
– Operation of the DoD Serum Repository
•
Epidemiology and Analysis
– Utilizes the DMSS
– Periodic reporting of DoD health statistics and surveillance
– Customized analysis and reports for military leadership
•
GEIS
– Management of DoD global infectious disease and surveillance portfolio
– Coordination among overseas laboratories and other partners in the global surveillance
network
– Response to outbreak alerts and emergency notifications
•
Integrated Biosurveillance
– Serves a key role in biosurveillance; augment operational health surveillance information
– Focuses on detecting disease in people, plants, and animals, to understand the threats
from emerging infectious diseases and other hazards relevant to U.S. DoD, allies, and
civilians for offensive, defensive, and stability operations
– Single Source for Biosurveillance data activities –integration of DoD “one health” data
Health Surveillance Responsibilities
All Hazards!
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Physical Injuries
Mental Health
Mortality
Cold/heat-related injuries
Motor vehicle accidents
Traumatic brain injury
Exertional hyponatremia
PTSD
Alcohol abuse
Depressive disorders
Anxiety
Combat
Training
Suicide
Natural
Infectious Diseases
Chronic Diseases
Tuberculosis
Gastrointestinal infections
Malaria
All manner of STIs
Diabetes
Malignancies
Arthritis
Obesity
Epidemiology & Analysis Division
The Division performs comprehensive surveillance and analysis of health-related
information regarding DoD Service members (AD, reserves, separated), and
military-associated populations (government civilians (garrison or deployed),
contractors (deployed), family members/retirees (garrison, previous deployment)
as pertains to public health/outbreaks.
• Single source for DoD-level health surveillance information
• Unify surveillance efforts across the Military Health System
• Acquire and integrate population, health event, and exposure data from
across the Services
• Products support and inform active military operations, medical
readiness
22 February 2013
CAPT
Sharon L.standardize
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• Normalize surveillance data
collection,
methods, delineate
Divisionamong
Directorall MHS health surveillance
roles and supporting relationships
Epidemiology and Analysis Division
activities
Defense Medical Surveillance System (DMSS)
Structure and Functional Relationships
All DoD Beneficiaries
DMSS: Longitudinal Database
Active Duty / Reserve Component
Ambulatory Data
319 million records
MEPS
13.6 million persons
31 million records
Immunizations
111 million records
In-Patient
Hospitalizations
3.0 million records
Personnel Data
10.4 million persons
134.9 million records
Health Risk
Assessments
575,000 records
Chemistry
54.1 million records
PostDischarge
PreInduction
Deployments
5.5 million records
Serum Specimens
(DoD Serum Repository)
58.4 million specimens
All counts current as of December 2014
Reportable
Diseases
432,760 records
Microbiology
5.5 million records
Prescriptions
12.9 million records
Pre / Post-Deployment
Surveys
12,129,412 surveys
Casualty Data
54,202 AD Deaths
Periodic Reports
• Weekly
– Influenza Surveillance Report
– USFK Biosurveillance Report
– DoD Communicable Disease Report
• Monthly
– Injury Installation Reports
– Malaria Case-Finding Report
• Quarterly
– DoD Eye Injury Report
– DoD Hearing Injury Report
– FHP&R Council Metric (includes DD2795, DD2796, DD2900 completion,
and MH and TBI referrals and follow-up health encounters)
– MHS Dashboard (includes PTSD and depression screen, referrals)
• Annually
– AFPMB Arthropod-borne Hemorrhagic Fever Report (WNV, Dengue,
Leishmaniasis)
– Annual Injury, Eye Injury, Hearing Reports
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Customized Reports
• USS REAGAN analysis on adverse health outcomes (Report to
Congress)
• DoD Japanese Encephalitis cases 10 years: 2004-2013
(MILVAX, USAPHC)
• Incidence of erectile dysfunction, 2012-2013 (FHP & R)
• Service members receiving dialysis, U.S. Armed Forces, 20112013 (Army OTSG)
• Acute hepatitis in active component, 1 Jan 2008-30 Nov 2013
(outbreak investigation related to association between dietary
supplement and hepatic injury)
Medical Surveillance Monthly Report
–
–
–
The MMWR of the military
health system
Over 150 issues since April 1995
• First full-color issue—
August 2011
1,067 subscribers to the print
edition
• 175 new requests per year
• 500 email subscribers
–
–
–
–
21% of 2011 articles were
outside submissions
Archives accessible online
Average MSMR issue viewed
1,483 times during its first 60
days online
Indexed in MEDLINE since Jan
2011
• Searchable using PubMed
Percentage distribution, burden “conditions” that accounted for the
most medical encounters among U.S. service members, 2014
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Defense Medical Epidemiology Database
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•
•
•
•
•
•
•
•
Remote access (via internet) to a subset of data contained
within the DMSS
No personal identifiers or link to specific individuals
allowed
Software distributed via Armed Forces Health Surveillance
Center Web site http://www.AFHSC.mil
Active duty only
Monthly updates
Rapid query response
Inpatient data
Outpatient data
Reportable Events
DoD Serum Repository (DoDSR)
•Central archive of US Armed Forces sera collected
for medical surveillance purposes
•Specimens stored in large walk-in –30 °C freezers,
precisely documented locations
•Over 57 million serum specimens on >10 million
individuals
•Specimens linked to demographic, military, &
medical information via the DMSS
Total Specimens Used in Studies (bars)
Aliquots Produced (line), DoDSR, Jan 2002-Dec 2014
Standard Surveillance Case Definition
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ESSENCE is…
Electronic
Surveillance
System for the
Early
Notification of
Community-based
Epidemics
• Web-based disease surveillance information system
developed to alert Health Authorities of infectious disease
outbreaks and provide situational awareness of population
health
DoD ESSENCE operational scope
• Surveys the entire direct care Military Health
population, excluding deployed forces
• Used at approximately 500 Military Treatment
Facilities and 100 regional sites
• Receives and analyzes data for nearly 90,000 daily outpatient visits and
pharmacy transactions from DoD health care facilities worldwide
• Receives approximately 50,000-2 million outpatient files, 200,000-600,000
pharmacy records, and 100,000-300,000 lab and rad orders per day
• Updates outpatient data 6 times every 24 hours on average
• Updates pharmacy data every 24 hours
• Demographics data updated monthly
Case Definitions for Syndromic
Surveillance
• International Classification of Disease – Version 9 – Clinical
Modification (ICD9)
– Used by US military in the electronic healthcare record
– Outpatient codes entered by provider (doctor, nurse, therapist) at
the time the patient is seen
– Update to ICD-10 ready when US converts in 2015
• Grouped to describe multiple disease presentations and diagnostic
variability
– Early signs/symptoms of disease often non-specific
– Availability of confirmatory testing highly variable
• Chief complaints, pharmacy transaction data, laboratory orders and
radiology orders help to inform alerts
• Besides syndromes, also used for routine Disease & Injury surveillance
and notification of potential Reportable Medical Events
Comparison of Lab-based Surveillance
with Syndromic Surveillance
Syndromic
surveillance
LaboratoryConfirmed
From Marsden-Haug N, Foster VB, Gould PL, Elbert E, Wang H, Pavlin JA. Code-based syndromic surveillance for influenzalike illness by
International Classification of Diseases, Ninth Revision. Emerg Infect Dis. Feb 2007;13(2):207-216.
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Statistical Alert Notifications
Based on Expected Case Counts
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Individual-level Data Available for
Certified Public Health Officers
MTF name
removed for
privacy
Syndromic Surveillance Alert List
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Time Series
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Data Details
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Rep Event Surveillance
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Lab Results
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Upcoming Upgrade with
ESSENCE “Fusion”
• Automatically merge data streams to provide a more specific signal
• Use additional data sources that provide an indication of severity
• Look over a very short time range vs. a whole (incremental) day
• Facilitate in-depth investigation of individual data sources
• Reduce the alert burden by corroborating weighted evidence
• Current studies indicated reduction of false alerts could be as much
as 97% each year
Fusion Results
• Detection algorithms run
on individual data sources
can generate a large
number of alerts
• By combining evidence
from multiple data
sources, it is possible to
reduce alerts and more
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easily identify outbreaks
ICD-9 Counts for ILI 01May09 to 04Jul09
ILI Syndromic Alert
6 July 2009
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Fusion Elements
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Fusion Elements
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Progression of the ILI Event in the Summer of 2009
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Additional ESSENCE Capabilities
Features of Enterprise ESSENCE
not currently in DoD ESSENCE
myESSENCE
Dashboard
GIS Maps &
Spatial Detection
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myAlerts
Crosstab &
Pivots
Overview
Graphs
Event
Communication
Time of Arrival
Detection
Multi-Datasource &
Denominator Queries
Free-text &
Advanced
Querying
Data Quality
Reports
Statistical
Report Builder
Report
Generation
DoD/VA Joint Incentive Fund
Section 721 of the FY 2003 NDAA required establishment of JIF to identify, provide incentives to,
implement, fund and evaluate creative DoD/VA coordination and sharing initiatives at the facility,
regional and national levels.
Analysis of combined datasets
DoD data
dominant
VA data
dominant
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DoD alert
earlier
VA alert
earlier
Summary
• Coverage demonstrates 2 complementary
surveillance systems
• VA has higher patient volume and better
geographic coverage
• DoD has younger population, better metropolitan
area coverage and more pre-diagnostic ILI coding
• Relative timeliness could be improved by
combining systems in 92% of regions that have
coverage by both
Extended-NCR-BSP Prototype Project
Extended-NCR ESSENCE
AFHSC ESSENCE
E-NCR-BSP
Data Sharing Access Control
E-NCR-BSP
– Knowledge Sent to E-NCR-BSP
– Federated Query Request
– Federated Query Result
Architecture: Data flow from the
perspective of ESSENCE
The role of the E-NCR-BSP
ESSENCE Module
National Syndromic Surveillance Program
Vision
A collaboration among local, state, and national public health programs that
supports timely exchange of syndromic data and information for nation-wide
and regional situational awareness and enhanced response to hazardous
events and disease outbreaks.
Some Major Dimensions of the NSSP
1. Syndromic Surveillance Platform (SyS-Platform)
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Cloud based collaborative workspace where syndromic surveillance tools exist
2. Governance
•
•
Leadership group representing BioSense users
Advise CDC on platform enhancements
3. National Syndromic Surveillance Community of Practice (NSSCoP)
•
Supplement and support a national community focused on the science of syndromic
surveillance
4. Future Development
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Emerging technology, EHRs, Meaningful Use, etc.
DoD Sharing with BioSense 2.0 –
Connected Health
As of 15 Oct 14
• Number of users: 901
• Number of jurisdictions
sharing data with CDC/other
jurisdictions:
– County-level: 21/33
– State-level: 28/25
– Visit-level: 5/9
•
Number of facilities actively
contributing: 4,050
Shared
Spaces
Lab
State
County
City
VA/DoD
BioSense
Environment
Hospital
Public-Access
Current Status of Civilian
Syndromic Data
10 September 2013 Pre-decisional FOUO
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10 September 2013 Pre-decisional FOUO
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Plan for Data Integration
Indicator-based surveillance
(e.g. ESSENCE)
Share queries and results across apps
Raw Structured Data
Data
Identified risks
DoD Reportable events
Laboratory surveillance
CDC Weekly MMWR trends
Reports
Capture
Filter
Collect
Analyze
Interpret
Non-healthcare based
Vector surveillance
Veterinary surveillance
Raw Unstructured Text
and/or Aggregate Data
Open source
Media scanning/social media
Health authority websites
Published literature
DoD/USG partners
Emerging risks
Syndromic surveillance of chief
complaints and ICD codes
NCR-BSP civ. syndromic data
Pharmacy data
Nurse call data
TMDS
Event-based surveillance
(e.g. BSVE/BSP)
Evaluate
Verify
Descriptive
epidemiologic analysis
Identify signal
Coordinate/
Investigate
Summary
report/visualizations
AFHSC/GEIS partners
DoD epicom concept
DHS-NBIC
State public health entities
(outbreak/HAN reports)
International agencies
Public
health alert
WHO and regional offices
Ministries of health
Dissemination/Collaboration
Diagram is adapted from an ECDC report on epidemic intelligence
Summary
• DoD extensively uses the military Electronic Health Record
and ancillary systems for disease surveillance
• Surveillance includes robust retrospective and prospective
studies in addition to near real-time monitoring
• Multiple efforts to merge with civilian data to include
– Efforts with the Veteran’s Administration
– Extended surveillance in the National Capital Area with
civilian public health
– Sharing with the National Syndromic Surveillance Platform
• Discussions on merging DoD and CDC platforms
14 December 2011 Pre-decisional FOUO
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