Emerging Infectious Disease Surveillance and Response US Army Medical Research Unit - Kenya

African Partner Outbreak Response Alliance (APORA) COL Rodney Coldren 22 April 2015

UNCLASSIFIED

Basis of US Involvement

• The US National Security Strategy, February 2015, lists increasing global health security as a key security component “We will save lives by … developing a global system to prevent avoidable epidemics, detect and report disease outbreaks in real time, and respond more rapidly and effectively.” • US Global Health Security Agenda Objectives (selected) o Prevent the emergence and spread of antimicrobial drug resistant o o o organisms and emerging zoonotic diseases Reduce the number and magnitude of infectious disease outbreaks Launch, strengthen and link global networks for real-time biosurveillance Train and deploy an effective disease surveillance workforce • Presidential Directive NSTC-7 (1996) “The mission of the DoD will be expanded to include support of global surveillance, training, research, and response to emerging infectious disease threats.”

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USAMRU-K Background

• An overseas activity of the Walter Reed Army Institute of Research • USAMRU-K was established in 1969 at the invitation of the Kenyan Government; initial collaboration was with the Kenya Trypanosomiasis Research Institute. Shifted to Kenya Medical Research Institute in 1979.

• Based in Nairobi with major field stations in Kisumu and Kericho • USAMRU-K executes its mission through cooperative agreements with the Kenya Medical Research Institute (KEMRI) and the Henry M. Jackson Foundation-Medical Research International (HJF-MRI).

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USAMRU-K Mission

• Develop and test improved means for predicting, detecting, preventing, and treating infectious disease threats important to the U.S. military and the host nation • Conduct surveillance, training, research, and response activities related to emerging infectious disease threats • Partner in executing the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI) • Support the AFRICOM Commander’s health-related Theater Security Cooperation activities through engagement of nations in the region in conducting our mission

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Surveillance Strategy in Kenya

• Highly capable central laboratories o Antimicrobial Resistance/STI (Nairobi/Kericho) o Arbovirology Laboratory (Nairobi) o Basic Sciences Laboratory (Kisumu) o Entomology (Kisumu) o Malaria Diagnostics Center of Excellence (Kisumu) o o o Malaria Drug Resistance (Kisumu) Microbiology Hub (Kericho) Respiratory Laboratory (Nairobi) • Multiple small footprint surveillance sites

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USAMRU-K Central Laboratories [email protected] 22 April 2015 UNCLASSIFIED 6

USAMRU-K DEID Surveillance Sites [email protected] 22 April 2015 UNCLASSIFIED

MOH Site KDF Site

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Antimicrobial Resistance

• Examine cause and antibiotic susceptibility of wound and other infections of military significance • Collect samples from both military and civilian sites • Examine both community- and health-care acquired infections

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Acute Febrile Illness Surveillance

• Determine the etiology of febrile illnesses that may be of local or military significance • Leishmaniasis surveillance • Dengue endemicity studies • Rickettsia in humans and domestic animals • Define epidemiology of these pathogens in Kenya

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Enterics

• Highly capable, CAP-certified laboratory with ability to do both traditional microbiologic work and molecular diagnosis • Examines bacterial, parasitic, and viral etiologies • Significant work in antimicrobial susceptibility

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Malaria

• The Malaria Diagnostic Center of Excellence provides world-class malaria smear reference reading and training o Provides training for the East Africa Malaria Task Force supported by the US AFRICOM Surgeon’s Office • The Malaria Drug Resistance Laboratory performs in vitro and in vivo analysis of antimalarial drug resistance patterns and emergence • The Clinical Trials Center performs regulated trials of antimalarial countermeasures

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Respiratory

• Look at both Influenza-Like Illness (ILI) and Severe Acute Respiratory Illness (SARI) cases • Pathologies identified o Influenza (A most common) o Adenoviruses o o o Enteroviruses Human parainfluenza viruses Human coronaviruses o o Human respiratory syncytial viruses Human rhinoviruses o Human metapneumoviruses

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STI

• Look for prevalence and risk factors for gonorrhea and chlamydia • Antimicrobial susceptibility of gonorrhea isolates • Samples will be sent to USUHS/IDCRP for further characterization and inclusion in their repository

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Viral Hemorrhagic Fever / Arbovirology

• KEMRI laboratory operated collaboratively • Serves as regional reference laboratory • Combined unit of microbiologists, entomologists, and veterinarians o True OneHealth approach o Both laboratory and field elements

[email protected] 10 March 2015 UNCLASSIFIED 14

USAMRU-K Regional Efforts Emerging Infectious Disease Surveillance

• Tanzania o Managed by non-profit PharmAccess o Human influenza surveillance at Tanzania People’s Defense Force hospitals o Testing at National Influenza Center • Uganda o Managed by non-profit Makerere Univeristy Walter Reed Project (MUWRP) o Human influenza surveillance and antimicrobial resistance work at Uganda People’s Defense Force (UPDF) hospitals o Migratory waterfowl influenza surveillance o SAGES – Suite for Electronic Global Biosurveillance for the UPDF

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Examples of Recent Outbreak Engagements by USAMRU-K

• 2013 – Coastal Dengue (in collaboration with the KDF and MoH) o Laboratory confirmation o Entomologic investigation and intervention • 2014 – Q Fever in northern Kenya • 2014/15 – EVD/Marburg o Served as national reference laboratory for Kenya o Trained KDF, MoH, and UNISOM on PPE use and safe sample shipping o Advised KDF on construction/establishment of an isolation ward • 2015 - Cholera

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Area of Potential Support for APORA’s Outbreak Response Pillars

• Early Detection o Highly capable laboratories for confirmatory testing  Antimicrobial Resistance  Arbovirus/VHF    Enterics Febrile Illnesses Malaria   Respiratory Illnesses STIs o Training    Malaria diagnostics PPE use Safe laboratory sample shipment

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Area of Potential Support for APORA’s Outbreak Response Pillars

• Early and Efficient Response o With a validated request approved by higher headquarters, can field a limited response team to assist in the investigation of outbreaks  Clinicians  Entomologists  Laboratory scientists

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