Doctor discusses Navy's role in detecting H1N1


By Gerry J. Gilmore

 WASHINGTON (AFPS) -The
Navy played a key role last spring in
the discovery of the H1N1 influen-
za's presence in the United States,
according to a senior Navy medical
officer.
 In April, technicians at the San
Diego-based Naval Health Research
Center (NHRC) encountered a puz-
zling influenza specimen provided
by a 10-year-old military family
member, said Navy Capt. (Dr.)
Tanis Batsel Stewart, director of
emergency preparedness and con-
tingency support at the Navy
Bureau of Medicine and Surgery.
 The specimen contained the "A"
type of influenza virus that can
cause pandemics, Batsel Stewart
said, but it couldn't be sub-typed.
 "It's very unusual not to be able
to sub-type an influenza virus," she
said in a recent phone interview with
American Forces Press Service.
 The specimen, she said, was then
sent to the Centers for Disease
Control and Prevention in Atlanta
for more testing, where technicians
determined it was a new strain of
influenza virus.
 A second specimen from a 9-
year-old girl that arrived at the
NHRC soon afterward was found to
be identical to the one submitted by
the military family member, Batsel
Stewart said. That specimen, too,
was sent to the CDC, where it was
determined to be the novel influenza
A H 1N1 virus, commonly known at
the time as "swine flu."
 "That was a definite red flag -
that we have a new influenza strain
circulating that might very well
cause a pandemic, and obviously, it
has," she said.
 The CDC activated its emer-
gency operations center to better
coordinate the public-health
response to H1N1 April 22. The
U.S. government declared a public
health emergency April 26, and
began aggressively implementing
the nation's pandemic response


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plan.
 The World Health Organization
announced June 11 that the spread
of the H1N1 virus had reached pan-
demic proportions, with cases
reported in 70 countries at the time.
President Barack Obama issued a
national emergency declaration on
H1N1 last month.
 "By rapidly identifying the virus,
implementing public health meas-
ures, providing guidance for health
professionals and the general public
and developing an effective vaccine,
we have taken proactive steps to
reduce the impact of the pandemic
and protect the health of our citi-
zens," the president said in his dec-
laration.
 The Washington-based Navy
Bureau of Medicine and Surgery is
the headquarters and center for
Navy medicine, while the NHRC is
a leading research and development
laboratory for the Defense
Department. The NHRC manages
and executes medical research,
development and test and evaluation
programs for the Naval Medical


Research Command in Silver
Spring, Md.; the Navy Medicine
Support Command in Jacksonville,
Fla.; and the Navy Bureau of
Medicine and Surgery.
 The Naval Health Research
Center's respiratory diseases
research department conducts
active, laboratory-based surveil-
lance of infectious diseases that
affect military personnel and family
members, with an emphasis on res-
piratory illnesses. The department
also addresses the safety and effica-
cy of drgs and vaccines.
 The Navy has for years conduct-
ed influenza and other infectious-
disease surveillance programs in
conjunction with the other U.S. mil-
itary services in partnership with
foreign nations and public health
organizations, Batsel Stewart said.
 The U.S. military's infectious
disease research capability "is the
largest in the world," she said, not-
ing the U.S. maintains labs in Egypt,
Indonesia, Kenya, Peru and
Thailand that fall under the auspices
of the Department of Defense


Global Emerging Infections
Surveillance and Response System.
 More than 100 countries, "from
Afghanistan to Zimbabwe," partici-
pate in the surveillance program,
Batsel Stewart said.
 A presidential directive estab-
lished the response system, which
falls under the Armed Forces Health
Surveillance Center, in June 1996.
The directive expanded the Defense
Department's mission to include
support of global surveillance, train-
ing, research, and response to
emerging infectious disease threats.
 It also charged the department to
strengthen its global disease-reduc-
tion efforts through centralized
coordination, improved preventive
health programs and epidemiologi-
cal capabilities, and enhanced
involvement with military treatment
facilities.
 The Naval Health Research
Center's respiratory diseases
research department serves as the
Navy hub for the surveillance and
response system.
 "We don't anticipate, at this


point, H1N1 becoming a severe
pandemic, causing a lot of deaths
and very severe illness," Batsel
Stewart said. "But, we've been
preparing for years within [the
Defense Department] and the Navy
and Navy medicine for something
along the lines of the pandemic of
the influenza of 1918, which was
horrendously severe."
 To help in preventing the spread
of influenza viruses, Batsel Stewart
recommended that people:
 Cough or sneeze into the crook
of their elbow, rather than into their
hand;
 Wash their hands frequently;
 Stay home if they feel ill;
 Keep sick children at home; and
 Distance themselves if they or
others are ill.
 Public health officials have urged
citizens to obtain both H1N1 and
regular seasonal flu vaccines.
Defense Department officials say
the department will have enough
H1N1 vaccine available for service-
members and their families.
 Meanwhile, the Pentagon's global
infectious disease surveillance net-
work watches for potential pandemics
as it also assists foreign partners.
 Batsel Stewart recalled a previ-
ous duty assignment in Lima, Peru,
where she and her colleagues assist-
ed Peruvian health authorities in
identifying new strains of dengue
fever virus.
 "Peru always thought that they
had one, maybe two strains of the
dengue fever virus circulating," said
Batsel Stewart, noting that the fever
has four strains. The U.S. medical
team discovered that Peru actually
has all four strains of dengue fever
virus. One of those strains, she
added, is dengue hemorrhagic fever,
causing victims to bleed internally
and sometimes externally.
 "So, the Peruvian government
and the Peruvian public health sys-
tem was better able to respond to
some of the cases they were saying
they would not have recognized pre-
viously," Batsel Stewart said.


Physicians discuss lessons learned from dealing with H1N1 virus


 WASHINGTON Senior medical officials who success-
fully slowed the spread of H1N1 flu virus at the U.S. Air Force
Academy in Colorado Springs, Colo., published what they
learned in an October article featured in the American Journal
of Preventive Medicine.
 Air Force Lt. Col. (Dr.) Catherine Witkop, a preventive
medicine physician from the 10th Medical Group, told partici-
pants in a "DoDLive" bloggers roundtable yesterday that med-
ical officials at the academy acted quickly to set up a team to
look at some of the virus's characteristics.
 "I was really pleased that we were able to capitalize on the
opportunity to actually learn more about the virus and provide
that information to the Centers for Disease Control, to the mil-
itary, [and] to the United States at large," she said.
 Witkop and Air Force Col. (Dr.) Kenneth K. Knight, 10th
Medical Group commander, discussed what other institutions
may be able to do to manage H1N 1's spread. Witkop noted that
some of the lessons learned from the summer outbreak can
apply at other training facilities, such as Lackland Air Force
Base, Texas.
 With a large population of trainees living in very close quar-
ters, Witkop said, controlling the virus's spread at Lackland and
limiting absenteeism from the six-week training period "is real-
ly crucial to completing that mission."
 "So we've done our best to share as much information as
possible, as quickly as possible," she said, "since this is such a


timely issue."
 During a four-week period in July, 11 percent of the Air
Force Academy's basic cadet population became ill. "There are
134 confirmed cases of H1N1 and 33 suspect cases, meaning
they had all the same symptoms, but were not tested," Witkop
said.
 Many challenges had to be considered quickly, Knight said,
such as how to treat patients, how to limit interactions with oth-
ers, when to hospitalize, and how to isolate the cadets.
 "It was a medical issue that had a huge implication to what
their job was about," he said. "We did lots of different
approaches as we were scrambling with the line leadership as
how to isolate, talking with CDC, (and) figuring out what the
appropriate treatment is," Knight said.
 "And it appears, then," he added, "with any epidemiologic
conclusion, (that) what we did was effective."
 Knight said the academy's medical group was careful to
share lessons learned through the outbreak's many phases.
 "When we were in the thick of things, we were daily shar-
ing what our experience was with the public health department
downtown, with all the other local military medical facilities,
with the other academies, comparing notes as to what their
experiences were with Lackland (and) with the line leader-
ship," Knight said. "Our line leadership here was pushing
information up to the chief of staff of the Air Force. So near-
term, we were essentially getting out real-time information as


to what was going on, to share that experience."
 Witkop spearheaded the article submission to the American
Journal of Peventive Medicine while sharing the lessons with
the CDC.
 "We've shared this information with the CDC well before it
got published, so that they would have the information to adjust
the guidelines that they were publishing," Knight explained.
 Isolation has proven to be a key factor in controlling the out-
break at the academy, Witkop said.
 "Our current approach is ... to isolate the cadets; however,
they are self-isolating per the CDC's guidelines," she said. "So
they would go back to their dorm rooms, continuing until they
are seven days from onset of symptoms and 24 hours after
being symptom-free."
 Both said public health education reminders are the key
ways academy officials are preventing another outbreak
among cadets, and that messages to wash hands, use sanitizers
and cover coughs are shared continuously.
 Meanwhile, Witkop said, academy medical officials contin-
ue to monitor the situation closely and continue their public
health efforts.
 "We're continuing to follow very closely ... the numbers of
cadets who are ill, to make sure that we're not approaching
another outbreak situation," she said. "We have daily reports
from all of our various clinics about the numbers of both cadets
and those in the community."


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November 25, 2009 GOSPORT