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Emerging Infectious Diseases and Antimicrobial Resistance

Infectious disease threats to military forces remain high due to deployment worldwide and ease of global transportation. Infections from novel respiratory pathogens (avian influenza strains, MERS-CoV, or SARS), infections from viral hemorrhagic fevers (HFRS, CCHS, Ebola, or Lassa) and infections of the central nervous system pose a high risk to individual military travelers, and can be a severe threat to introduce these infections into the United States. The EIDAR RA has established protocols to evaluate the etiology, epidemiology, clinical presentations and outcomes of such infections. The collaboration with DoD GEIS, the Centers for Disease Control and Prevention, the World Health Organization’s International Severe Acute Respiratory Infection Consortium (ISARIC) and DoD diagnostic laboratories allows a rapid identification and reporting of such infections. The collaboration with the USAMRIID enables the RA to evaluate the safety and impact of emergency investigational new drug treatment use of experimental agents.  

Antimicrobial resistance is also a serious health threat to the military population, both from acquisition while traveling or exposure to multi-drug resistant organisms (MDROs) domestically. New forms of antibiotic resistance have emerged over the past years and spread rapidly. Infections caused by multidrug-resistant organisms add substantial and avoidable costs to the healthcare systems due to prolonged and costlier treatments, longer hospital stays, and additional visits. Antibiotic use is a crucial factor leading to antibiotic resistance, and use of antibiotics for malaria prophylaxis may increase the risk of MDRO acquisition during travel . Half of all antibiotics prescribed are not needed or are not effective as prescribed increasing the risk of bacteria becoming resistant to those antibiotics. In response to the launch of the 2014 Executive Order for Combating Antimicrobial Resistant Bacteria (CARB), data from several established IDCRP protocols have been used to assess the epidemiology of MDR gonococci and in MRSA skin and soft tissue infections in military populations, and the characterize the MRDOs isolated in traumatic wounds. In addition in collaboration with WRAIR MRSN, WRAIR and NMRC Wound Infection Departments and USAISR a retrospective study was initiated to evaluate the clinical outcomes of MDR pathogens from combat-related trauma. Data from these studies are crucial for the development of new treatment and diagnostic procedures, to improve combat wound care and infection prevention, inform physicians on the optimal use of antimicrobial agents.

In the 2015 National Security Strategy, President Obama specifically mentions the need to enhance pandemic preparedness at home and address the threat arising from new drug-resistant microbes and biological agents among the Homeland Security and Global Health Security Objectives.  Emerging infections and antimicrobial resistance may be either an emerging endemic threat (such as West Nile Virus or MRSA), an international threat with potential to spread to the United States (such as Chikungunya or Dengue virus, or MDR Neisseria gonorrhoeae), or a cluster or outbreak which by its nature is unpredictable (such as Ebola virus or MDR Acinetobacter).

Likewise, clinical events related to prevention and treatment of potential agents of bioterrorism are rare and unpredictable in the continental US. IDCRP has established capacity to collect clinically meaningful data on outcomes from outbreaks, but also gain experience with endemic disease caused by such agents through collaborations with the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) and Navy Medical Research Command–Frederick (NMRC-F).  Where collaborative multi-center research protocols can be conducted in emerging diseases, rather than widespread use of emergency INDs (eINDs), IDCRP will support those studies for the Military Health System.

Emerging antimicrobial resistance among hospital pathogens has typically become endemic, but clustered outbreaks certain occur.  Detailed microbial descriptions and pathogen epidemiology by reference laboratories, such as the WRAIR’s Multi-Drug Organism Resistance and Surveillance Network (MRSN), are well established.  2014 also marked the initiation of the President’s Combating Antimicrobial Resistant Bacteria (CARB) initiative , and March 2015 marked the release of the National Action Plan for Combating Antimicrobial Resistant Bacteria from the White House.  While efforts will cross section populations within America, little is known about clinical outcomes or the cost burden from these pathogens within military populations, nor are risk factors for MDRO acquisition in military populations well defined.

While this is a new area of research for IDCRP, several new projects have been approved for FY15 and new projects will be proposed for FY16.  More importantly, collaborations with WRNMMC, SAMMC, NIAID, NIH Clinical Center, USAMRIID, WRAIR, USAISR and NMRC are in place and new collaborative projects are expected to be added.

AFHSC provides integrated biosurveillance summaries of West Africa Ebola and Caribbean Chikungunya.