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Department of Defense (DoD) Liaison to the Centers for Disease Control and Prevention (CDC)The purpose of this Joint DoD position is to enhance collaboration between DoD and CDC (throughout its centers, offices, and divisions) regarding the protection of their respective beneficiary populations from adverse national and international health impacts. The position of DoD Liaison to the CDC was the mutual idea of then Assistant Secretary of Defense for Health Affairs (ASD/HA), Dr. William Winkenwerder, and former CDC Director, Dr. Julie Gerberding. Justification and implementation of the DoD Liaison position was based on the Presidential Decision Directive on Emerging Infectious Diseases (PDD/NSTC-7, 12 June 1996), and DoD expanding its role to support global emerging infectious disease surveillance and responding to emerging infectious disease threats. Also consistent with this directive, CDC strengthened its ability to protect the health of US citizens through surveillance and response activities, including outbreak investigations and selected responses to epidemics overseas. A stronger relationship between DoD and CDC formed following the terrorist attacks of September 11, 2001, and the subsequent anthrax letter mailings later that same year. Col Don Noah, DVM, US Air Force, served as the first DoD Liaison from May 2003 through December 2006. COL Ted Cieslak, MD, US Army, served as the second DoD Liaison Officer from December 2006 through July 2010. CDR Jesse Geibe, MD, MPH, MBA, US Navy, took over the role in September 2010 serving through November 2014. CAPT Eric Sergienko, MD, MPH, US Navy, is the current liaison having come on board in November 2014. Key ActivitiesGeneral Advisory Capacity: CDC does not have a long history of direct collaboration with the military. Therefore, the DoD Liaison office serves as a ready source of critical information about the capabilities of the US military. In this advisory role, ongoing information is provided to the CDC Director, ASD/HA, and ASD/NCB for domestic and international joint planning, responses, and collaborative activities, improving civilian and military medical and public health integration. The DoD Liaison facilitates communication and coordination of sporadic interactions and occasional teleconferences or meetings to address various issues of mutual and timely interest. Combatant Command (COCOM) Initiatives and Global Health: The DoD Liaison is often called upon to foster collaboration (on various projects related to Global Health and ‘Health Diplomacy’) between various groups and individuals within CDC, USG Health Attachés, Joint Staff, and the COCOMs (e.g., NORTHCOM, PACOM, SOUTHCOM, CENTCOM, AFRICOM, STRATCOM, and TRANSCOM Surgeons’ offices). Emergency Operations: The DoD Liaison staffs the DoD seat within CDC’s Emergency Operations Center (EOC), providing a critical link to DoD assets and expertise during public health emergencies, improving civilian and military medical integration during disaster responses, such as those provided during hurricanes (e.g., Katrina, Rita, and Sandy), H1N1 influenza pandemic, Haiti earthquake and subsequent cholera outbreak, Japan earthquake with resulting radiation concerns, Northern Germany E. coli outbreak, multistate outbreak of fungal meningitis, Middle East respiratory syndrome coronavirus (MERS-CoV), etc…. Moreover, the DoD Liaison serves as “Lead Liaison Officer,” working closely with representatives of the U.S. Food and Drug Administration (FDA), the U.S. Department of Agriculture (USDA), the Environmental Protection Agency (EPA), American Red Cross (ARC), and others for coordination of activities with the CDC. In addition, the DoD Liaison facilitates the DoD Public Health emergency Management (PHEM) course for Public Health Emergency Officers (PHEOs) and Medical Treatment Facility Emergency Managers (MEMs).Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Defense and Counterterrorism Planning: Both CDC and DoD have significant responsibilities for counterterrorism planning and CBRNE defense. The DoD Liaison helps to coordinate such efforts as needed and works closely with the Assistant Secretary of Defense for Nuclear, Chemical, and Biological Defense Programs (ASD/NCB) and Defense Threat reduction Agency (DTRA).Pandemic Influenza Planning: The DoD Liaison holds a lead role through the office of the ASD/HA for pandemic and influenza issues, and attends weekly CDC influenza and pandemic preparedness strategy meetings. In accordance with the National Strategy for Pandemic Influenza, each cabinet-level Department has drafted agency specific preparedness and response guidance. The DoD Liaison office provided comments and recommendations for each revision of both the DoD and CDC operational plans and facilitated mutual coordination throughout the planning process.Advisory Committee on Immunization Practices (ACIP): The DoD Liaison holds the DoD ex-officio seat on this committee (and participates with its relevant work groups), which makes immunization policy for the nation. Clinical and Public Health Outreach: Each day, CDC receives dozens of inquiries from clinicians, public health officials, and the public. Many of these originate from military sources (including a large number from deployed personnel, dependents or family members) or concern military matters. The DoD Liaison fields these questions or inquires from CDC’s Clinician Outreach and Communication Activity (COCA), as well as other telephonic and web-based public service programs, thereby providing an opportunity for uniformity of message between CDC and DoD. Examples of topics of interest include influenza, tuberculosis, rabies, dengue fever, Methicillin-resistant Staphylococcus aureus (MRSA), vaccine adverse events (e.g., smallpox), vaccine policy and availability, and toxic exposures.CDC’s Office of Public Health Preparedness and Response (OPHPR) Board of Scientific Counselors (BSC): The DoD Liaison serves as the alternate DoD representative on this Board, as well as the Office of Infectious Disease (OID) BSC.Hosting of Official Visitors: Due to the nationwide scope of its mission, CDC is a frequent host to military medical and public health officials. The DoD Liaison helps to coordinate these visits (e.g., ASD/NCB, DTRA, USAMRIID, COCOM Surgeons, USG Health Attachés’ to Papua New Guinea and Vietnam, etc.) and ensure follow-up on items discussed during the meetings.Connectivity: The DoD Liaison provides significant input and helps coordinate mutual CDC and DoD efforts and resources for the nation’s Laboratory Response Network (LRN), its surveillance activities (e.g., BioSense and ESSENCE), its National Interagency Biodefense Campus (NIBC), its select agent work, and many other DoD and CDC collaborative endeavors to include Navy Medical Research Unit (NAMRU) work with CDC, DTRA collaborative projects (e.g., the Republic of Georgia biosafety level-3 laboratory project), Strategic National Stockpile (SNS) connectivity, containment care transport and repatriation issues (e.g., contaminated/contagious patients), global health and ‘health diplomacy’ initiatives, DoD participation in the CDC’s Epidemic Intelligence Service (EIS) program, infectious diseases and sexually transmitted infections, suicide and psychological health issues, traumatic brain injury, mortuary affairs, base realignment and closures, reproductive health, entomology efforts, healthy lifestyle issues (e.g., tobacco cessation, alcohol issues, obesity), etc…. Laboratory Response Network (LRN): The DoD Liaison helps coordinate and follows-up on nuances in biosurveillance collaborative efforts between CDC and DoD, to include work with the DTRA. DoD provides a large number of laboratories to CDC’s LRN (e.g., 2 of the 3 National labs, 20+ reference labs, and 92 sentinel labs). There has been an effort to bring LRN labs, as well as a similar series of veterinary labs, into a more standardized, coordinated organization. Navy Medical Research Unit (NAMRU) Collaboration with CDC: The DoD Liaison assists with fostering collaboration between CDC and the NAMRUs and laboratories in Cairo and Lima, as well as with the Army laboratories in Bangkok and Kenya.ASD/NCB and DTRA Collaborative CDC Projects (e.g., Global Health Security pilot program expansion, Republic of Georgia project, etc.): The DoD Liaison has been involved in assisting with and coordinating communication between the CDC and DoD on collaborative ASD/NCB and DTRA related projects. Examples would be the joint implementation of DoD/CDC Global Health Security (GHS) activities and expanding pilot/demonstration programs, as well as the Republic of Georgia project. The GHS pilot programs in Uganda and Vietnam will be expanded to include 10 additional countries (e.g., Ethiopia, Tanzania, Kenya, S. Africa, Jordan, Indonesia, Philippines, Thailand, Georgia, and Kazakhstan), emphasizing accomplishable opportunities in EOCs and Lab and Information Systems development resulting in tangible outcomes, and will better leverage and align collaborative GHS activities between DoD and CDC. DoD and CDC were also involved in planning of a state-of-the-art biosafety level (BSL)-3 laboratory in the Republic of Georgia. The lab was initially envisioned as akin to DoD overseas labs elsewhere, with plans to be staffed by Georgians without significant US DoD presence. This issue is also rolled up with other related issues involving DTRA’s Biological Threat Reduction Program (BTRP). The laboratory in Georgia remains a joint effort, and CDC has established a Field epidemiology and Laboratory Training Program (FELTP) there. Strategic national Stockpile (SNS) Connectivity: The DoD Liaison assists at a tactical level, addressing questions and issues surrounding SNS connectivity between CDC, DoD, and communicates with the National Association of City and County Public Health Officials (NACCHO). Open and Closed Points of Dispensing (PODs), Receipt and Storage Sites (RSS), and DoD access to SNS materials continues to be an important DoD issue. The DoD provides its own stockpiles of critical supplies and pharmaceuticals, but only possesses adequate stocks to meet operation needs. Dependents in local communities, ‘non critical’ civilian base employees, and non-activated Title 32 (Reserve and Guard) forces rely on access to CDC-controlled SNS assets, in the same manner as any other citizen would. Select Agent Program and National Interagency Biodefense Campus (NIBC): The DoD Liaison serves as a point of contact between DoD and CDC on issues regarding select agents. The DoD liaison is involved in significant discussion with CDC regarding oversight of DoD select agent programs, and facilitates communication with CDC’s Division of Select Agents and Toxins (DSAT) and Environmental Microbiology Working Group regarding concerns and collaborative efforts for the US Army Medical Research Institute for Infectious Diseases (USAMRIID) and the NIBC. CDC regulates use of select agents by laboratories throughout the US, including DoD labs. The USAMRIID, US Army Medical Research Institute of Chemical Defense (USAMRICD), and Walter Reed Army Institute of Research (WRAIR) are the three largest DoD users of select agents, but many other laboratories handle them as well. The CDC and DoD have mutual involvement with the NIBC at Ft. Detrick, and DoD leadership engages CDC’s DSAT expertise as needed. Containment Care and Transport/Repatriation: The DoD Liaison assists with overarching Memorandums of Understanding (MOUs) which will set forth the conditions under which CDC, DoD, Emory University, NIH, and the University of Nebraska will collaborate and provide mutual support for transport and treatment of contaminated patients (with BSL-3 and 4 type agents). High-level containment care (defined as a capability greater than that found in a negative-pressure hospital infection control ward) consists of a transport piece and a hospitalization piece. Only three such hospitalization facilities exist in the US (two beds at Emory, five beds at NIH, and 10 beds at University of Nebraska). USAMRIID’s aeromedical isolation team (AIT) provides an analogous transport capability. The US Transportation Command (TRANSCOM) has developed a capability (the Patient Isolation Unit or PIU), as has CDC (the Biological Containment system or BCS). Work on CDC’s BCS transport capability and TRANSCOM’s Concept of Operations (CONOPS) for the Air Force’s PIU continues. DoD Participation in Epidemic Intelligence Service (EIS): The DoD Liaison meets with the DoD tri-service EIS Officers to discuss the program, as well as attends the weekly Tuesday conference when possible. The DoD has provided input into CDC’s EIS program, averaging 1.5 ‘starts’ per year over the past decade, with the vast majority of those coming from the Air Force. There has been an increased push asking Army and Navy to provide trainees, but the services’ consultants have been reluctant to part with bodies. Infectious Diseases and Sexually Transmitted Infections (STI): The DoD Liaison facilitates coordination for collaborative efforts to address various issues of mutual interest for infectious diseases and STIs. DoD has long been a recognized leader in infectious diseases and STI research and prevention, as has CDC, which makes this a fruitful area for collaborative work. Examples of continued DoD specific issues with respect to STIs include: (1) most DoD labs use genetic probes to screen for Gonorrhea and Chlamydia, and do not culture, limiting ability to detect cephalosporin resistance; (2) certain prohibitions on use of healthcare dollars to purchase condoms; (3) prohibitions against non-DoD-beneficiary partner therapy; and (4) difficulties in screening beyond initial entry onto active duty. Healthy Lifestyle Issues (e.g., tobacco cessation, alcohol issues, obesity, etc.): The DoD Liaison facilitates communication and coordination to address various issues of mutual interest on healthy lifestyle issues. An example is alcohol concerns. This initially became a ‘hot-button’ issue when CDC investigators published a paper (Stahre et al, Binge Drinking among U.S. Active-Duty Military Personnel, AJPH 2009) dealing with Binge drinking in the military. CDC’s intent was not to assert that rates within DoD were any higher than among demographically-matched civilian subjects. However, CDC’s study focused on the military since they had access to good DoD data, and some of the investigators were former active duty service members. CDC’s suggested remedies involve the curtailment of alcohol sales on military bases (very difficult), and the partnering with civilian authorities to limit the number of alcohol establishments near bases. Suicide, Psychological Health, and ‘Resilience’: The DoD Liaison facilitates/coordinates communication to address various issues or concerns related to suicide and psychological health, ensuring enhanced collaborative efforts. Psychological health and ‘resilience’ is an area where CDC has benefitted from DoD expertise. As CDC regularly deploys personnel into dangerous situations and environments, and has seen cases of Post Traumatic Stress Disorder (PTSD) among returning scientists, they were interested in learning from DoD experience in this arena. Dr. Klomp developed the CDC’s Deployment Safety and Resiliency Team (DSRT) training, which is a collaborative effort between CDC’s Office of Safety, Health and Environment, the CDC Workforce and Responder Resiliency Team, and Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences . This DSRT program is designed to create a cadre of individuals trained to assess and address the physical and emotional safety and well being of their coworkers and themselves during a deployment. The training approach is consistent with core principles of the ICS (Incident Command System). ................
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