Chapter 13 GLOBAL ZOONOTIC DISEASE SURVEILLANCE AND

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Global Zoonotic Disease Surveillance and Control

Chapter 13

GLOBAL ZOONOTIC DISEASE

SURVEILLANCE AND CONTROL

KELLY G. VEST, DVM, MPH, DRPH

; ROBERT S. DOLE, DVM, MPH

†

; KAY D. BURKMAN, DVM, MPH

‡

; ANDREW L.

MCGRAW, DVM, MS

; BORIS BRGLEZ, DVM, MPH

; MARTIN M. LAGODNA, DVM

; and RONALD L. BURKE, DVM,

DRPH

††

INTRODUCTION

Background of the One Medicine, One Health Concepts

Implementation of the One Health Concept

NATIONAL VETERINARY ACCREDITATION AND THE MILITARY VETERINARIAN

Program Background, Mission, and Veterinary Accomplishments

Accreditation Process, Requirements, and Credentialing

VETERINARY ELECTRONIC HEALTH RECORDS AND HEALTH EXAMS

DEPLOYMENT SURVEILLANCE AND DISEASE CONTROL

THE ARMED FORCES HEALTH SURVEILLANCE CENTER AND DEPARTMENT OF

DEFENSE LABORATORY NETWORK

Background and Overview

Zoonotic Disease Surveillance and the Military Veterinarian

US NORTHERN COMMAND CIVIL SUPPORT AND THE ONE HEALTH

CONFERENCE

VETERINARY CORPS PARTICIPATION IN INTERAGENCY AND EMERGENCY

RESPONSE

Venezuelan Equine Encephalomyelitis Outbreak, Texas, 1971

H5N2 Highly Pathogenic Avian Influenza Outbreak, 1983

SUMMARY

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Military Veterinary Services

*Lieutenant Colonel, Veterinary Corps, US Army (Retired); formerly, Deputy Chief of Staff, Armed Forces Health Surveillance Center, 11800 Tech Road,

Silver Spring, Maryland 20904; currently, Science Director, Cooperative Biological Engagement Program, Center for Global Health Engagement, 11300

Rockville Pike, Suite 707, Rockville, Maryland 20852-3065

†

Lieutenant Colonel, Veterinary Corps, US Army; Chief, Veterinary Services Division, US Army Public Health Command Region-South, 2899 Schofield

Road, Joint Base San Antonio-Fort Sam Houston, Texas 78234

‡

Lieutenant Colonel, Veterinary Corps, US Army (Retired); Subject Matter Expert, US Army Public Health Command, Veterinary Services Systems

Management Program, 4270 Gorgas Circle, San Antonio, Texas 78234-2639

Lieutenant Colonel, Veterinary Corps, US Army; formerly, Chief, Internal Medicine and Outpatient Clinics, Department of Defense Military Working

Dog Center, Joint Base San Antonio-Lackland Air Force Base, Texas; currently, Commander, 218

Medical Detachment (Veterinary Service Support),

Joint Base Lewis-McChord, Washinton 98433

Lieutenant Colonel, Veterinary Corps, US Army; Veterinary Plans Officer, 248th Medical Detachment Small Animal Veterinary, Fort Bragg, North

Carolina 28310

**Lieutenant Colonel, Veterinary Corps, US Army (Retired); formerly, Command Veterinarian, Office of the Command Surgeon, US Army Europe, Unit

29351 Box 95, APO, AE 09014-9355

††

Lieutenant Colonel, Veterinary Corps, US Army; formerly, Deputy Director, Division of Global Emerging Infections Surveillance and Response System,

Armed Forces Health Surveillance Center, Silver Spring, Maryland; currently, Chief, Veterinary Services Division, Public Health Command Region

West, Box 339500, MS 115, Joint Base Lewis-McChord, Washington 98433.

369

Global Zoonotic Disease Surveillance and Control

INTRODUCTION

Implementation of the One Health Concept

Although many associations and institutions con-

tinue to promote One Health, perhaps no organization

is better able to implement the concept than the US

military, particularly the US Army. In the civilian sec-

tor, the practice of medicine is generally fragmented

by patient species. Physicians tend to care for humans,

veterinarians care for nonhuman animals, and neither

doctor interacts with the other on a regular basis.

However, within the military, even though military

physicians and military veterinarians still care for the

same separate populations, the two professions tend

to interact more than their civilian counterparts for

several reasons, including more collaborative training.

Collaboration begins on day one of their military

careers when medical and veterinary officers attend

the same Basic Officer Leaders Course and continues

throughout the military education cycle, fostering

close working relationships and information sharing

between the two professions. Officers and enlisted

service members may also have multiple assignments

with their counterparts throughout their careers, par-

ticularly at research organizations (eg, Walter Reed

Army Institute of Research or the overseas research

laboratories), further promoting cross-professional

relationships and information sharing.

In addition to greater collaboration, the One Health

concept may succeed more in the military than in the

civilian sector because the military treats a relatively

closed population, using a consolidated health system.

Not only are human and veterinary medicine separate

in the civilian sector, but the civilian human health

care system also tends to be fragmented. The high

degree of specialization in human medicine results

in patients being seen by multiple physicians, often

at several, individual institutions, which may result

in each physician only seeing a portion of a patient’s

medical history. While military medicine is equally

specialized, military patients generally receive all or

the majority of their care within the military health

system, which allows military providers to view a

more comprehensive patient record.

Veterinary care is similarly consolidated, especially

at remote or overseas installations where the majority

of privately owned animals receive their care from

the military veterinary treatment facility. This com-

prehensive care, combined with the development of

cross-profession relationships, facilitates the rapid

communication of mutual concerns and, potentially,

Background of the One Medicine, One Health

Concepts

Although many credit the late Dr Calvin Schwabe

with coining the term “One Medicine” in 1964, the

recognition that healthy animals are important to hu-

man health is far from new.

Nearly 90 years earlier,

Rudolf Virchow, popularly acknowledged as the father

of modern comparative pathology, and Sir William

Osler, a Canadian physician who is often called the

father of modern medicine, both supported the One

Medicine concept (ie, the well-being of humans is af-

fected by disease control in animals).

Historically, One Medicine also symbolized the

close association between physicians and veterinar-

ians. Decades before the first veterinary school was

established in 1761, physicians were charged with

responding to animal diseases such as the 1713 out-

break of “Rinderpest” (the German word for “cattle

plague”) in Rome, and long before human medicine

was established as a formal profession, humans had

been caring for the health and welfare of animals.

Much of this attention to animal health was due to the

critical roles animals played in preindustrial society;

at this time, they were used for food, transportation,

clothing, and farming. Even today, in many develop-

ing countries, the family cow or goat is not only a

potential source of milk, meat, and clothing, but also

represents a significant savings investment or liquid

asset against future needs and expenses. The loss or

death of the animal can negatively impact the health

and welfare of the family.

Although most people today do not depend so

heavily on animals for their basic needs, attention

still must be paid to animal health because of the

significant role animals play in disease transmission:

over 60 percent of the infectious diseases affecting

humans are zoonotic.

Since 1964, One Medicine has

evolved into the global concept “One Health,” an

initiative that continues to recognize the connection

between human and animal diseases and strives to

emphasize the more recent, holistic idea that health is

a whole, which is based on a fluid, shared ecosystem

(ie, humans, animals, and their environments). In

2007, in recognition of the interdependency of human

and animal health, the American Medical Association

adopted a One Health resolution, and the American

Veterinary Medical Association convened a One

Health task force to examine the ways to promote the

concept between the two organizations.

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Military Veterinary Services

the early detection of significant disease trends and

activities that would otherwise not be readily visible

looking at only a portion of a single population.

The recent establishment of the Army Public Health

Center should further enhance detection capabilities

as this command extends the reporting and analysis

of human and animal disease activities from a single

installation to the entire military. These coordinated

surveillance activities are also conducted at the over-

seas research laboratories where military researchers

partner with local ministries of agriculture, health,

and defense to identify reservoirs and vectors and

determine disease prevalence and incidence in animal

and human populations. Additional information on

military veterinarians’ roles in conducting zoonotic

disease surveillance and control is presented in the

following sections, including how service member

animal practitioners become accredited.

NATIONAL VETERINARY ACCREDITATION AND THE MILITARY VETERINARIAN

Program Background, Mission, and Veterinary Ac-

complishments

The eradication of livestock and poultry diseases

such as contagious bovine pleuropneumonia, foot and

mouth disease, and screwworm has had a tremendous

impact on public health, livestock productivity, and,

thus, the United States economy.

The United States

is currently on the verge of eradicating brucellosis,

tuberculosis, and pseudorabies.

Military veterinarians

have played, and will continue to play, a pivotal role

in the eradication process via various means, including

becoming accredited practitioners who partner with

other veterinarians to promote animal health.

The United States Department of Agriculture

(USDA) established a national veterinary accredita-

tion program in 1921 so that accredited veterinarians

could assist federal veterinarians in executing the

mission of controlling animal diseases and facilitat-

ing the movement of healthy animals. According to

a USDA publication, “[t]he mission of the National

Veterinary Accreditation Program [NVAP] is to en-

sure the health of the [n]ation’s livestock and animal

population and to protect the public health and well-

being,”; more specifically, “[a]ccredited veterinarians

work cooperatively with USDA’s Animal and Plant

Health Inspection Service (APHIS) and [s]tate animal

health officials to protect and improve the health, qual-

ity, productivity, and marketability of US animals by

preventing, controlling, and eradicating” both endemic

and foreign animal diseases.

Because of their unique missions worldwide,

military veterinarians must be familiar with disease

prevention, control, and eradication, and regulations

governing interstate, intrastate, and international ship-

ment of animals. Each year military veterinarians also

evaluate and facilitate the exportation and importation

of hundreds, if not thousands, of domestic animals

worldwide, giving these veterinarians the opportunity

not only to encounter foreign animal diseases, but also

to prevent diseased animals from entering or exiting

the United States. During the past decade, veterinary

practitioners, particularly military veterinarians, per-

formed key roles in the detection and eradication of

several diseases not previously found in the United

States: (a) contagious equine metritis, (b) exotic New-

castle disease, (c) West Nile virus, (d) screwworm, (e)

monkey pox, and (f) H1N1 influenza virus.

Accreditation Process, Requirements, and Creden-

tialing

Currently, qualified veterinarians can earn accredi-

tation in two existing categories: Category I and Cat-

egory II. Category I includes all animals “except food

and fiber species, horses, birds, farm-raised aquatic

animals, all other livestock species, and zoo animals

that can transmit exotic animal diseases to livestock.”

Category II includes all animals; nothing is excluded.

Note that dogs and cats are included within Category

I, whereas all bird species fall only into Category II.

Category II accreditation may be most beneficial for

military veterinarians because they are frequently

required to examine dogs, cats, and birds and issue

health certificates for interstate and international travel

during deployments and permanent change of station

reassignments.

Veterinarians applying for accreditation under the

NVAP must fulfill the following four requirements: (1)

possess a current and valid license and otherwise be

legally able to practice in the state for which accredi-

tation is desired; (2) complete the web-based initial

accreditation training with a passing score of 80% or

higher (website access can be obtained from the APHIS

Veterinary Services Area Office in the state for which

accreditation is desired); (3) complete the core orien-

tation to include state-specific training in the state for

which accreditation is desired; and (4) complete the

NVAP application (VS Form 1-36A).

Each veterinarian’s accreditation is not valid until

written approval is obtained from APHIS, and initial

APHIS accreditation is good for 3 years. After 3 years,

APHIS-approved supplemental training is required

for accreditation renewal, and this mandatory training

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Global Zoonotic Disease Surveillance and Control

is available online at no charge. As of this chapter’s

publication, three units of supplemental training

per renewal period are required for Category I vet-

erinarians and six units for Category II veterinarians.

Supplemental training options can be found at www.

aphis.usda.gov/nvap.

Veterinary accreditation is usually not required for

interstate shipment of cats and dogs. However, several

states and territories do require health certificates be

counter-signed by a USDA-accredited veterinarian

(eg, Connecticut, Delaware, Indiana, Louisiana, New

Hampshire, and the US Virgin Islands). Similarly, the

shipment of dogs and cats internationally does not

normally require signature by a USDA-accredited

veterinarian; however, some countries do require

accredited veterinary endorsement on the official cer-

tificate of veterinary inspection. Given the lack of stan-

dardization among states, territories, and countries,

all military veterinarians must maintain knowledge

of both interstate and international animal shipping

requirements.

The current Army Public Health Center definition

of a military veterinarian encompasses both commis-

sioned officers and general schedule veterinarians em-

ployed by the Army Public Health Center.

Because

the current definition includes these two groups of

veterinarians, the US military has developed relation-

ships with countries where many military and family

members and accompanying pets reside (eg, Japan,

Korea, and the European Union) that permit a military

veterinarian to sign and stamp the health certificate in

lieu of the required USDA endorsement. In this capac-

ity the military veterinarian serves and is recognized

as an US government official veterinarian.

In addition to accreditation, many military veteri-

narians become credentialed as foreign animal disease

diagnosticians by attending the Foreign Animal Disease

Diagnostic School at the Plum Island Animal Disease

Center in Orient Point, New York. By so doing, the

military adds to the number of credentialed US veteri-

narians capable of supporting a USDA response to for-

eign animal disease introductions to the United States.

VETERINARY ELECTRONIC HEALTH RECORDS AND HEALTH EXAMS

Humans have been using animals as sentinels of

zoonotic diseases since ancient times. It only stands

to reason that if one is looking for an outbreak of a

zoonosis, the occurrence of such a disease should

appear in the local animal population first. By study-

ing this group, informed decisions can later be made

regarding the preservation of health in the similarly

exposed human population. When the population of

domestic animals is routinely presented for veterinary

care, health records are created that can be analyzed for

the presence of zoonoses or effects of environmental

exposures, which is crucial to the decision-making

process. Traditionally, this zoonotic surveillance has

been conducted using paper records or, more recently,

locally maintained electronic records.

Unfortunately, both paper and local electronic

records present numerous obstacles to real-time zoo-

noses surveillance. Neither form is accessible globally

without the use of some means of transmission to a

centralized surveillance center, thus increasing time

to analysis. Paper records are also often difficult to

read, must be abstracted to provide data for analysis,

are easily lost, and are not usually standardized in

terminology or format. These drawbacks predispose

any analysis to errors based on the skill of the ab-

stractionist and the interpretations of the investigator.

Additionally, abstraction is manpower intensive and

time consuming, adding increased cost and rendering

most analyses retrospective in nature (much abstrac-

tion work is completed long after the occurrence of the

zoonosis or exposure of interest). Abstracted surveil-

lance data is even less useful on the battlefield, where

more immediate decision support is required.

The global electronic health record (EHR) is de-

signed to negate the aforementioned surveillance ob-

stacles. Because the EHR is web-based, the individual

record is updated immediately upon completion of a

patient encounter, providing the ability to trend his-

torical medical diagnoses and results. Operating over

the internet also allows the updated data to be available

anywhere and at any time, permitting simultaneous

access to multiple users worldwide. Further, the data

is stored in a secure, redundant, and mineable database

that reduces the risk of data loss.

The EHR is particularly useful for tracking military

working dog (MWD) health in a more timely and

connected manner. The MWD undergoes a complete

physical exam every 6 months, resulting in a lifelong

longitudinal health history that is used in epidemio-

logical studies to investigate potential exposures and

theorized effects on health outcomes.

11–17

Like other

abstraction work, early studies of the MWDs tended

to be time consuming, manpower intensive, and tardy

(most being completed years after an exposure or

zoonotic disease occurred). However, by using the

EHR, animal location, environment, and complete

health history is centrally located and available for

multiple analyses. The EHR also provides the capa-

bility to follow a cohort of animals prospectively to

an anticipated medical outcome, or lack thereof, with

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Military Veterinary Services

the data from all aspects of the epidemiological triad

available for analysis, rapid reporting, and informed

decision-making.

To be of optimum use, the EHR first must conform

to recognized standards. Coding systems that support

morphology, topography, and diagnostic terminol-

ogy standardization need to be incorporated into the

EHR application. The three most recognized coding

systems in human medicine are (1) the International

Statistical Classification of Diseases and Related Health

Problems,

(2) the Diagnostic and Statistical Manual

of Mental Disorders,

and (3) the Systematized No-

menclature of Medicine-Clinical Terms.

In conjunction with the American Animal Hospital

Association, starting in 2002, the veterinary community

began the onerous task of developing a standard termi-

nology for an animal coding system that is tied to the

Systematized Nomenclature of Medicine-Clinical Terms

coding system.

This system is now maintained for the

veterinary community by the Veterinary Terminology

Services Laboratory located at the Virginia Maryland

Regional College of Veterinary Medicine, Virginia Tech,

Blacksburg, Virginia.

The ability to code to a standard

set of terms allows the greatest flexibility in data analysis

because cases are not erroneously included or excluded in

the case definition based on disparate terminology. Stan-

dardized coding also dramatically improves the value

of large, web-based databases for zoonotic surveillance.

Another critical element that affects EHR usability

is network connectivity. The EHR is hosted on a server

platform accessible to both military and commercial

networks, enabling the capture of animal health en-

counters from any environment where the warrior

animal may be found. Ideally, the application should

be accessible through a multitude of devices and means

(eg, laptop, tablet, handheld, and desktop end-user

devices) by local area network or wireless network con-

nections. This redundancy of data collection decreases

the risk of data loss through misplaced or damaged

paper records.

Security of data, both at rest and during transit,

is vital to the security of the entire internet and also

to the usefulness of the EHR system. The record

system must be compliant with all current Depart-

ment of Defense (DoD) security and information

assurance directives and needs to be stored within

a secure enclave. Common Access Card authentica-

tion is required for all users, and access is limited by

role-based permissions. Such restrictions ensure all

users are operating the application within the scope

of their duties and credentials, preserving the medi-

colegal requirement of the EHR. A full audit trail is

maintained for any transaction within a record with

a date and time stamp as well as identification of the

authenticated user.

The EHR system also contributes to a leader’s global

zoonotic disease surveillance and control decision-

making capabilities in multiple ways. For example, the

system provides a centrally managed large enterprise

veterinary practice, such as the military, with visibility

at all levels of military veterinary care. Reportable

disease triggers can be incorporated that will allow

real-time data transfer of zoonotic outbreaks, not only

to veterinary service command personnel, but also

to DoD public health officials throughout the area of

interest. Collection and reporting of this data in real

time can result in improved decision support and

employment of appropriate preventive measures by

commanders.

Finally, EHRs provide the means to determine

outcome-based best practices that result in improved

health and treatment of zoonotic diseases. Secondary

benefits can also be received from administrative and

operational reporting capabilities, allowing for more

efficient manpower distribution, better inventory man-

agement, and streamlined corporate practice manage-

ment. All these capabilities lead to healthier animals

and, ultimately, service member wellness.

The multiple benefits of the EHR system aside, the

most important factor for its effective use is a will-

ingness of the veterinary community to accept the

system. The best-built application cannot function as

designed if the user is allowed to resist conversion to

it. Command emphasis from all levels is critical to the

successful implementation of any EHR and practice

management system.

DEPLOYMENT SURVEILLANCE AND DISEASE CONTROL

Vector-borne diseases (VBDs), many of which are

considered enzootic, have long been studied in various

parts of the world to aid in the development of new

vector-control strategies for US military deployments.

However, in Afghanistan, tick analyses, other indig-

enous animal seroprevalence, and molecular studies

are lacking; the unavailability of such information is

likely due to the austere state of Afghanistan’s infra-

structure. Since VBD information is considered a vital

component of a more complete and informative medi-

cal threat brief to medical and veterinary caregivers

serving in Afghanistan, an effort to identify the VBD

risk in Afghanistan was initiated in the spring of 2010.

Similar surveys have proven to be useful in com-

paring risk of disease for MWDs with the feral canine

population in Iraq.

One objective of this survey

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Global Zoonotic Disease Surveillance and Control

effort was to determine the prevalence of the follow-

ing VBDs in the tick and feral dog population within

various regions across Afghanistan: Ehrlichia canis,

Babesia canis/gibsoni, Rickettsia spp., Leishmania infan-

tum, Bartonella spp., and Anaplasma phagocytophilum.

The survey, which was not completed, was supposed

to obtain samples from a minimum of 150 feral dogs

being euthanized in accordance with vector control

policies. Blood (serum and ethylenediamine tetraace-

tic acid-preserved whole blood) and tick samples

were to be collected for analysis. Analysis was to

consist of (1) tick species identification, (2) indirect

fluorescent antibody serology, and (3) molecular

polymerase chain reaction analysis on all serologi-

cally positive samples—as well as tick samples—to

assess for correlation between infection and exposure

and actual presence of pathogen deoxyribonucleic

acid (LTC Andrew McGraw, chapter author, unpub-

lished data, June 2012).

Unfortunately, although sampling materials and

instructions were distributed to no less than six sites

spread across Regional Command-South and Regional

Command-East in Afghanistan, the follow-on and re-

placement veterinary and preventive medicine units

within each Command elected not to participate in

this survey. Furthermore, an inadequate number of

specimens were collected to provide sufficient data

to interpret any valuable results. If it were more com-

plete, this survey’s conclusions and clinical relevance

could have provided veterinary health care providers

and handlers with vital medical threat information

about which relevant VBD are present in this area of

operations. Additionally, because some of these or-

ganisms possess zoonotic potential, this survey may

have served as vital public health information for hu-

man health care providers and preventive medicine

personnel (LTC Andrew McGraw, chapter author,

unpublished data, June 2012).

Lessons learned from this unfinished study rein-

force the precept that any disease surveillance initiative

in a given theater of operations needs to be mandated

in a “top down” fashion from the theater veterinarian

to prevent these initiatives from being dropped before

they are fully implemented or completed. Without

buy-in from follow-on personnel, the enduring poten-

tial for new surveillance programs is weak.

THE ARMED FORCES HEALTH SURVEILLANCE CENTER AND

DEPARTMENT OF DEFENSE LABORATORY NETWORK

Background and Overview

In 1996, President Bill Clinton issued the Presiden-

tial Decision Directive National Science and Technolo-

gy Council-7 on Emerging Infectious Diseases,

which

guided the establishment of the DoD Global Emerging

Infectious Surveillance and Response System (GEIS).

Under the GEIS umbrella, the DoD’s overseas and

primary Military Health System research laboratories

perform infectious disease surveillance, including

the study of zoonotic infections within five infectious

disease categories: (1) respiratory infections, (2) febrile

and vector-borne infections, (3) gastrointestinal infec-

tions, (4) antimicrobial infections, and (5) sexually

transmitted infections.

24,25

Prior to GEIS (and beginning in 1985), the US

Army Medical Surveillance Activity (AMSA) devel-

oped and managed the Defense Medical Surveillance

System, a longitudinal database that included the

outpatient and inpatient healthcare information of

all active duty military members and some benefi-

ciary information. AMSA also housed and managed

the DoD’s serum repository, which is comprised of

serum contributions from human immunodeficiency

virus screenings and pre- and post-deployment do-

nations conducted or collected throughout service

members’ careers.

In 2008, GEIS and AMSA were consolidated into the

Armed Forces Health Surveillance Center (AFHSC),

providing a centralized location for more rounded

disease surveillance activities and a more integrated

gateway to public health for civilian and military ben-

eficiaries at home and abroad. By using the AFHSC’s

combined resources, stronger epidemiological studies

of disease occurrence among the military population,

including deployed US military personnel, can be

pursued. For example, by tapping into the surveil-

lance and monetary resources within the AFHSC, the

DoD infectious disease research laboratories can also

study diseases of global military importance, includ-

ing zoonoses.

In 2015, the AFHSC was realigned under the De-

fense Health Agency as a branch within the Public

Health Division. The AFHSC maintains its key roles

in disease surveillance, epidemiology, and biosurveil-

lance activities.

Zoonotic Disease Surveillance and the Military

Veterinarian

Military veterinarians serve critical roles within the

DoD’s global infectious disease research laboratories.

Because veterinary officers are responsible for surveil-

lance project funding and providing oversight of an

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Military Veterinary Services

infectious disease steering committee, they signifi-

cantly influence the research products and programs

performed in these DoD laboratories.

The oversight of global surveillance programs that

survey both human and animal disease profits from the

inclusion of a veterinary perspective, especially with

regards to the One Health concept. Since all tracked

infectious disease categories—except for the human

sexually transmitted infections programs—have a zoo-

notic or animal health component, veterinary preven-

tive medicine proficiency and public health expertise

are very beneficial management tools. Veterinarians

are also integral to developing innovative solutions

and programs to respond to outbreaks and emerging

threats, and interfacing, collaborating, and consulting

with senior representatives from the DoD, Centers

for Disease Control and Prevention, Department of

Homeland Security, Department of State, and other

government and civilian agencies.

Zoonotic disease surveillance efforts that have

capitalized on, and demonstrated the broad utility of,

military veterinarians include development of diagnos-

tic assays; epidemiologic studies defining reservoirs,

disease prevalence, and transmission factors; disease

surveillance within high-risk populations; and sur-

veillance at the human-animal interface.

Military

veterinarians have also played key roles in disease

discovery,

outbreak response,

29-31

epidemiologic de-

scriptions,

32,33

vaccine evaluation and development,

and pandemic prevention and response.

(See also

Chapter 11, Zoonotic and Animal Diseases of Military

Importance, and Chapter 15, Veterinary Pathology.)

Using deployed military veterinarians to develop

and strengthen a host nation’s surveillance programs

and laboratory capacity is critical to global zoonotic

disease surveillance and control. Nation-building vet-

erinary missions are discussed in more detail in other

chapters of this volume. (See also Chapter 17, Veteri-

nary Support in the Irregular Warfare Environment)

As previously noted, the comparative knowledge and

expertise about animals and humans is the strength of

the veterinary medical officer. The veterinarian sees

the military and medical environment from a different

perspective: this officer brings a more encompassing

view to public health and preventive medicine, a spe-

cialized perspective that leads to considering different

approaches to disease surveillance, epidemiology, out-

break response, and prevention at home and abroad.

US NORTHERN COMMAND CIVIL SUPPORT AND THE ONE HEALTH CONFERENCE

In 2009, a novel human influenza virus, capable of

causing serious disease to which the human popula-

tion had no immunity, emerged in North America

and swept the globe. Influenza A, H1N1, a virus that

contained swine, avian, and human influenza virus

gene segments, first caused human illness in Mexico in

March 2009.

Shortly thereafter, on April 21, 2009, the

Centers for Disease Control and Prevention reported

the first cases of emerging H1N1 influenza A infection

in the United States.

The virus rapidly spread to all 50

states and across the Northern Hemisphere, and in June

2009, the World Health Organization (WHO) declared

the new strain of H1N1 a pandemic. By August 10, 2010,

the date this iteration of the influenza pandemic was

declared over by the WHO, more than 214 countries

had been affected and 18,000 deaths had occurred.

The global threat of pandemic influenza led federal

authorities to seek civil support from the DoD. Explod-

ing patient workload, coupled with high healthcare

worker absenteeism, overwhelmed regional and na-

tional medical infrastructures. The pandemic influenza

also had a major effect on the world economy and

politics by impacting international trade, markets,

travel, and investments.

However, care must be taken whenever the DoD

provides civil support for pandemics. For example,

as a group, DoD personnel are particularly vulnerable

to respiratory viral infections based on their exposure

to many different populations across the world, their

frequent mobility, and their close contact in personal

training environments and large-group work settings.

DoD mission assurance can be compromised during

a pandemic if entire military units or key personnel

become ill. The DoD could be affected in other ways

as well, including medical readiness, operational ca-

pabilities, and freedom of movement.

To mitigate the impact on mission assurance and

to prepare to support civil authorities, US Northern

Command (USNORTHCOM) operationalized pan-

demic influenza concept plans 3551—Concept Plan to

Synchronize DOD Pandemic Influenza Planning

and

3591—USNORTHCOM Response to Pandemic Influ-

enza.

USNORTHCOM’s Command Veterinarian

Lieutenant Colonel Martin LaGodna monitored and

analyzed biosurveillance information streams, collabo-

rated to develop influenza mitigation and response

plans, wrote force health protection guidance and

instructions, and advised the command as a subject

matter expert on infectious disease, animal health,

food safety, and preventive medicine.

The experience of recognizing and responding to a

human influenza virus of animal origin demonstrated

the relevance of the One World-One Health concept

(ie, effective public health is multidisciplinary and

multifaceted). Global leaders must understand the

inter-relationships between human, animal, and

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environmental health, and public health challenges

and solutions need to be synchronized among medi-

cal, animal, food, agriculture, and environmental

stakeholders. Since infectious diseases do not respect

national boundaries, communication and cooperation

is also essential across the international public health

community.

To foster a shared vision of the One Health concept

among the NORTHCOM Surgeon’s joint, interagen-

cy, and international partners, Lieutenant Colonel

Martin LaGodna obtained a grant from the Armed

Forces Health Surveillance Center to sponsor the first

NORTHCOM Surgeon’s One Health Conference, June

14 through 15, 2011, in Colorado Springs, Colorado.

This strategic health meeting brought together more

than 100 senior civilian and military public health,

food, agriculture, wildlife, and environmental health

professionals from Canada, Mexico, the Bahamas,

and the United States to discuss biosurveillance,

the human-animal-environmental health triad, and

emerging One Health infectious disease threats af-

fecting North America and the Caribbean. A second

One Health Conference was held the following year

(June 12–14, 2012).

VETERINARY CORPS PARTICIPATION IN INTERAGENCY AND EMERGENCY RESPONSE

In addition to supporting global missions, the US

Army veterinarian has played an integral role in respond-

ing to domestic emergencies. Some of the capability

requested as part of the military response effort includes

providing veterinary medical expertise and furnishing

trained animal and food technicians and equipment to

protect public health, domestic and wild animals, and

the nation’s food supply. During domestic emergencies,

these US military personnel primarily use their allocated

resources and specialized training to accomplish the

following critical tasks: (a) assisting efforts to prevent

contamination of food; (b) preventing disease through

vaccination programs; (c) supporting disease eradication

programs; (d) establishing temporary animal shelters

and hospitals; and (e) performing food inspections.

Today’s interagency relationship between the US

Army Veterinary Corps (VC), the US Department of

Agriculture (USDA) Animal Plant Health Inspection

Service (APHIS), and the Federal Emergency Man-

agement Agency can be traced back to 1972 with the

creation of APHIS and the Defense Civil Prepared-

ness Agency (DCPA). In 1977, DCPA evolved into the

Federal Emergency Management Agency (FEMA).

Since its creation in 1916, the Veterinary Corps’

duties to respond to national emergencies has trans-

formed from “ad hoc” response units to the more mod-

ern and sophisticated Medical Detachment Veterinary

Service Support units. Every year, one Medical Detach-

ment Veterinary Service Support unit is designated to

remain on alert and trains continuously to respond to

any national or state emergency.

The US Army VC senior leadership works closely

with the USDA and other federal agencies in times of

natural disasters. Two historical emergency response

events in which the VC provided significant con-

tributions to protect the nation from disease, food,

and animal loss are highlighted below. (In addition

to Chapter 17, Veterinary Support in the Irregular

Warfare Environment, already cross-referenced in

this chapter, see also Chapter 1, Military Veterinary

Support Before and After 1916, and Chapter 9, Food

Safety and Food Defense, for more information about

other US veterinary efforts to aid military and civilian

populations across the globe.)

Venezuelan Equine Encephalomyelitis Outbreak,

Texas, 1971

The USDA and US Army began monitoring Ven-

ezuelan equine encephalomyelitis (VEE) outbreaks

in Central and South American horses and humans

since the viral disease was first identified in Venezuela

in 1938. VEE contributed to the death of hundreds of

thousands of horses in South America, and during

the 1960s, a VEE epidemic slowly advanced from up-

per South America through Central America and into

Mexico, threatening each country’s human and equine

populations and the US horse industry.

The governments of Colombia, Ecuador, Guate-

mala, El Salvador, Honduras, Nicaragua, Costa Rica,

and Mexico requested US assistance to halt this deadly

emerging disease. US Army laboratories that had

been studying and investigating the disease since its

discovery evaluated VEE’s capabilities as a bioweapon

and developed a live attenuated human vaccine called

TC-83 to protect those scientists who studied the virus.

In 1968, TC-83 was used in Colombia in horses, and

the vaccine provided good immunity against VEE.

Overall, more than two million horses in Central and

South America were immunized with the TC-83 vac-

cine from 1967 to 1970. Horse deaths ended 7 to 10 days

after vaccination, and the vaccine protected 90 percent

of equine populations. Furthermore, following the vac-

cination of the majority of horses in rural communities,

human cases ceased to occur.

Despite such results,

during this time, TC-83 was still considered experimental

and was not approved for use in horses by the USDA.

In mid- to late June, VEE cases were identified

among horses and humans in Mexico just south of

the US border in Brownsville, Texas.

On June 19,

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1971, a task force was assembled in Harlingen, Texas,

to prevent the spread of VEE using vaccination as a

primary mitigation measure. The objective was to

protect horses and humans from VEE, and in the event

of its appearance in the United States, to implement

additional control measures such as aerial spraying

and quarantines to halt the spread of the disease. The

task force consisted of multidisciplinary specialists,

including representatives from USDA, US Public

Health Service, DoD (ie, US Army veterinarians,

preventive medicine officers, and Air Force officers),

Texas Animal Health Commission, and Texas State

Department of Health. On June 25, 1971, vaccination

in horses was started.

42,43

Despite vaccination, VEE virus was isolated from

a horse on June 30, 1971. During the first week in

July, equine encephalitis fatalities were identified,

and on July 5, 1971, the first confirmed human case

was diagnosed (in a man). The Texas outbreak was

the first documented VEE outbreak in the United

States.

The US Air Force began aerial spraying on July

10, 1971. Six days later, the Secretary of Agriculture

Clifford M. Hardin declared Texas under a state of

emergency. New Mexico, Oklahoma, Arkansas, and

Louisiana were placed under quarantine to ensure

VEE would be contained and not spread to other states.

The USDA also obtained TC-83 from the military to

vaccinate all horses in Texas, New Mexico, Oklahoma,

Arkansas, and Louisiana.

The disease peaked among Texas horses during the

third week in July, but cases continued presenting until

November 7, 1971. The role of the military veterinar-

ian during this crisis included detection of equine

cases, vaccination of horses, working cooperatively

with county extension agents, and contributing to the

newly established equine surveillance system. Prior to

the outbreak, military veterinarians were instrumental

in the study of VEE and development of the vaccine

used to protect both humans and horses.

H5N2 Highly Pathogenic Avian Influenza Out-

break, 1983

On April 22, 1983, the first cases of low pathogenic

avian influenza H5N2 were diagnosed among layer

flocks near Lancaster, Pennsylvania. Clinical signs

included mild to moderate loss of production and

mortality at less than 10 percent. This pattern of

disease continued until October 1983 when the low

pathogenic form became a highly pathogenic form

and the state requested federal assistance. Poultry

mortality reached high levels (ie, up to 90 percent) in

Pennsylvania, and within a month, the disease spread

to New Jersey, Maryland, and Virginia.

Each state

determined its own quarantine areas and, with some

federal assistance, enforced control measures to reduce

the movement of infected animals or contaminated

vehicles, equipment, and product.

44,45

Depopulation, which focused only on flocks that

resided within the quarantined areas, was determined

to be the best control measure. This control was first

implemented in Virginia and Maryland, followed by

Pennsylvania and New Jersey. Over 17 million birds

were euthanized from 448 flocks that were affected.

Quarantine areas in New Jersey were released by state

and federal quarantine authorities in March 1984 and

in Virginia and Pennsylvania in September and Octo-

ber 1984, respectively; surveillance programs were set

up thereafter and continued several months past the

quarantine release.

44,45

In order to accomplish the surveillance and control

measures, the US Veterinary Corps provided over

40 veterinarians to assist in the areas of diagnostics,

pathology, and epidemiology among the 200-plus

DoD soldiers and civilian employees who deployed

to the quarantined areas. The military also provided

equipment for communications, transportation, and

laboratory analysis and supplemented the control ef-

forts to overcome the logistical challenges faced in this

extensive animal disease outbreak.

SUMMARY

Military veterinarians understand the One Health

concept and promote this modern initiative’s imple-

mentation in various global and domestic endeavors:

(a) they work collaboratively within the military health

system and contribute to the health and well-being of

the military member and their families; (b) they are ex-

tensively trained and can be accredited and credentialed

in the specialized roles of disease surveillance and con-

trol, at home and internationally, as they provide care

for animals, food safety, and security; (c) they proffer

insights for zoonotic disease surveillance, epidemiology,

prevention, and outbreak response at home and abroad;

and (d) they track diseases of military importance and

contribute to the health of military members using

new technologies and data management that assist

in surveillance. As coordinating participants within

the US interagency, the US Army VCs contribute key

subject matter expertise, experience, and capability to

emergency response measures that keep the United

States safe and secure from diseases that affect the

economy, security, and health of animal and humans.

Military veterinarians will continue to serve as valuable

team members of the military health care team, helping

to keep all service members fit and healthy to fight.

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