key: cord-0709558-2c8d5aqw authors: Chretien, Jean-Paul; Blazes, David L; Gaydos, Joel C; Bedno, Sheryl A; Coldren, Rodney L; Culpepper, Randall C; Fyrauff, David J; Earhart, Kenneth C; Mansour, Moustafa M; Glass, Jonathan S; Lewis, Michael D; Smoak, Bonnie L; Malone, Joseph L title: Experience of a global laboratory network in responding to infectious disease epidemics date: 2006-08-21 journal: Lancet Infect Dis DOI: 10.1016/s1473-3099(06)70556-4 sha: 4d7ea22998e30661c84ea55462d622fa3f46b0eb doc_id: 709558 cord_uid: 2c8d5aqw nan infection surveillance, outbreak response, and host country capacity building for these research-oriented laboratories. The DoD-Global Emerging Infections Surveillance and Response System (DoD-GEIS) was established to support and coordinate these activities at the Overseas Laboratories and in the Military Health System. 10 The DoD-GEIS network of Overseas Laboratories currently maintains surveillance activities in more than 20 countries. These include a global infl uenza surveillance system 11 Among human outbreaks, size ranged from fewer than ten cases (eg, Crimean-Congo haemorrhagic fever in Sudan) to thousands (eg, chikungunya in Kenya). Response to outbreaks involving animals included infl uenza A (H5N1) in Egypt, Iraq, Kazakhstan, and Turkey. Overall, the three most common diseases were chikungunya (ten outbreaks in Comoros, Indonesia, Kenya, and Somalia), dengue fever or dengue haemorrhagic fever (ten outbreaks in Eritrea, Indonesia, Peru, Sudan, and Yemen), and infl uenza (nine outbreaks in Cambodia, Egypt, Indonesia, Iraq, Kazakhstan, Kenya, Nepal, and Turkey). Laboratory testing did not identify the causal agent but excluded SARS in two outbreaks (in Iraq and Peru) where it was suspected initially because of patient travel history or clinical features. Several outbreak responses helped to identify disease emergence or re-emergence. These include infl uenza A (H5N1) in Egypt, Indonesia, Iraq, Kazakhstan, and Turkey; a large outbreak of cutaneous leishmaniasis in a forested region of Ghana (an unusual focus, since the disease usually occurs in arid or semi-arid areas); outbreaks of chikungunya in Lamu and Mombasa, Kenya (the fi rst confi rmed outbreaks along the Kenyan coast); emergence of dengue haemorrhagic fever in Iquitos, Peru; re-emergence of dengue in Lima, Peru (after a 60-year absence); and isolation of a novel virus associated with a haemorrhagic fever outbreak in Bolivia (further viral characterisation is pending). Several outbreaks involved diseases recognised by the International Health Regulations 12 as capable of rapid international spread. These include ebola and Marburg haemorrhagic fever in Sudan and Angola, respectively; cholera in Kenya; yellow fever in Peru and Sudan; and dengue and infl uenza A (H5N1) as described above. The Overseas Laboratories collaborated with WHO or the US Centers for Disease Control and Prevention in 22 outbreak responses. Host country collaborations are integral to the success of the Overseas Laboratories. Host country Overseas Laboratory staff provide understanding of local language and culture, and maintain continuity since US personnel rotate every few years. Outbreak responses provide opportunities for training and technology transfer with Ministry of Health personnel, strengthening partnerships and readiness for future outbreaks. The model presented here-broad-based laboratories with epidemiologic capabilities, links to wider networks, and strong host country collaborations-has proven useful in responding to outbreaks of epidemic, endemic, and emergent diseases. The DoD Overseas Laboratories also devote considerable resources to applied research (such as clinical trials of vaccines and drugs), development of host country surveillance systems, and training of host country and US military medical personnel, activities that facilitate outbreak response. We encourage government and public health leaders to consider establishing facilities similar to these in countries where the need is most critical. We read with interest the review by Georgios Pappas and colleagues of the new global map of human brucellosis. 1 In this review the authors stated that Croatia is free from human brucellosis, which is consistent with published data. 2,3 However, we report that human brucellosis occurred in 2004 in a rural area of southern Croatia near the border of Bosnia and Herzegovina, a country with recognised natural foci of brucellosis. 1,4 Brucellosis has been a notifi able disease in Croatia since 1960. No documented case of human brucellosis had been reported previously in southern Croatia. 5 In the area where brucellosis occurred in 2004, goat and sheep breeding is an important economic activity. The fi rst patient became ill in June 2004. He lived in the rural area of Split-Dalmatia county, and had had regular contact with sheep and goats. In the same area, a familial outbreak (father, mother, and two sons [aged 7 and 9 years]) occurred during July and August 2004. This family had a herd of 210 goats. During the spring of 2004 they observed several abortions in their goats. The sixth patient, a sheep breeder and slaughterer, lived in the most southern Croatian county, close to the Bosnia and Herzegovina border. Because brucellosis had never been observed in south Croatia, physicians were unfamiliar with the clinical features, and brucellosis initially was not recognised as a possible cause of his illness. He became ill in May, was hospitalised three times, and, fi nally, in September 2004, was diagnosed as having brucellosis. All patients presented with prolonged fevers, night sweats, body aches, arthralgias, and weakness. The patients were diagnosed by culture and/or by serological methods. All six cases were positive by the standard agglutination test for brucella antibodies, with titres ranging from 1/160 to 1/640. Brucella spp organisms were isolated by culture from the blood of all but one patient. Isolates were identifi ed by standard bacteriological techniques as Brucella melitensis. To confi rm the identity of the cultures, DNA extracted from isolated colonies was used as a template to amplify The new global map of human brucellosis Global network could avert pandemics military overseas medical research laboratories The Rift Valley fever epizootic in Egypt 1977-78. 1. Description of the epizootic and virological studies Protection against hepatitis A by an inactivated vaccine Protection against Japanese encephalitis by inactivated vaccines Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone Randomised placebo-controlled trial of primaquine for prophylaxis of falciparum and vivax malaria Presidential Decision Directive NSTC-7 Department of Defense Global Emerging Infectious Surveillance and Response System The Department of Defense laboratory-based global infl uenza surveillance system World Health Assembly. Resolution WHA58.3. Revision of the International Health Regulations. Geneva: World Health Organization