[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]



                                     

                         [H.A.S.C. No. 111-182]

 
FIGHTING SUPERBUGS: DOD'S RESPONSE TO MULTIDRUG-RESISTANT INFECTIONS IN 
                     MILITARY TREATMENT FACILITIES

                               __________

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                           SEPTEMBER 29, 2010

                                     
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              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                     VIC SNYDER, Arkansas, Chairman
JOHN SPRATT, South Carolina          ROB WITTMAN, Virginia
SUSAN A. DAVIS, California           WALTER B. JONES, North Carolina
JIM COOPER, Tennessee                MIKE ROGERS, Alabama
JOE SESTAK, Pennsylvania             TRENT FRANKS, Arizona
GLENN NYE, Virginia                  CATHY McMORRIS RODGERS, Washington
CHELLIE PINGREE, Maine               DOUG LAMBORN, Colorado
NIKI TSONGAS, Massachusetts          TODD RUSSELL PLATTS, Pennsylvania
               John Oppenheim, Professional Staff Member
                Thomas Hawley, Professional Staff Member
                      Famid Sinha, Staff Assistant


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2010

                                                                   Page

Hearing:

Wednesday, September 29, 2010, Fighting Superbugs: DOD's Response 
  to Multidrug-Resistant Infections in Military Treatment 
  Facilities.....................................................     1

Appendix:

Wednesday, September 29, 2010....................................    25
                              ----------                              

                     WEDNESDAY, SEPTEMBER 29, 2010
FIGHTING SUPERBUGS: DOD'S RESPONSE TO MULTIDRUG-RESISTANT INFECTIONS IN 
                     MILITARY TREATMENT FACILITIES
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Snyder, Hon. Vic, a Representative from Arkansas, Chairman, 
  Subcommittee on Oversight and Investigations...................     1
Wittman, Hon. Rob, a Representative from Virginia, Ranking 
  Member, Subcommittee on Oversight and Investigations...........     3

                               WITNESSES

Collier, Col. James D., USAF, M.D., Assistant Surgeon General, 
  Health Care Operations, Office of the Surgeon General..........     9
Hospenthal, Col. Duane, USA, M.D., Office of the Surgeon General, 
  Infectious Diseases Consultant.................................     6
Martin, Capt. Gregory, USN, M.D., Program Director, Infectious 
  Disease Clinical Research Program..............................     7
Smith, Dr. Jack, Acting Deputy Assistant Secretary for Clinical 
  and Program Policy, Office of the Assistant Secretary of 
  Defense for Health Affairs.....................................     4

                                APPENDIX

Prepared Statements:

    Collier, Col. James D., joint with Lt. Col. Michael Forgione.    63
    Hospenthal, Col. Duane, joint with Col. Jonathan Jaffin......    45
    Martin, Capt. Gregory, joint with Judith F. English..........    52
    Slaughter, Hon. Louise McIntosh, a Representative from New 
      York, Committee on Rules...................................    31
    Smith, Dr. Jack..............................................    34
    Wittman, Hon. Rob............................................    29

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    [There were no Questions submitted during the hearing.]

Questions Submitted by Members Post Hearing:

    Dr. Snyder...................................................    77
FIGHTING SUPERBUGS: DOD'S RESPONSE TO MULTIDRUG-RESISTANT INFECTIONS IN 
                     MILITARY TREATMENT FACILITIES

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
              Subcommittee on Oversight and Investigations,
                     Washington, DC, Wednesday, September 29, 2010.
    The subcommittee met, pursuant to call, at 1:30 p.m., in 
room 2118, Rayburn House Office Building, Hon. Vic Snyder 
(chairman of the subcommittee) presiding.

  OPENING STATEMENT OF HON. VIC SNYDER, A REPRESENTATIVE FROM 
       ARKANSAS, CHAIRMAN, SUBCOMMITTEE ON OVERSIGHT AND 
                         INVESTIGATIONS

    Dr. Snyder. Good afternoon, and welcome to the Subcommittee 
on Oversight and Investigations' hearing on the Defense 
Department's efforts to monitor and control outbreaks of 
multidrug-resistant infections that have occurred in military 
hospitals over the past several years.
    While the U.S. military has provided high-quality 
healthcare for servicemembers wounded in Iraq and Afghanistan, 
infection outbreaks caused by multidrug-resistant bacteria 
emerged as a problem early on during military operations. One 
of the pathogens with the most notoriety is Acinetobacter 
baumannii--incidentally, any pronunciations are my own and any 
resemblance to accurate pronunciations is clearly coincidental, 
so--Acinetobacter baumannii, a group of opportunistic bacteria 
which can accumulate antibiotic resistance relatively quickly. 
The only treatments available to fight the infections, in some 
cases, are highly toxic, older drugs that can cause harm to a 
patient's health.
    According to the DOD [Department of Defense], over 3,300 
servicemembers developed Acinetobacter infections from 2004 to 
2009. While the bacteria are found in the natural environment, 
evidence suggests that the source of infections was in the 
military hospitals. Contamination in these hospitals placed 
other patients at risk. Outbreaks of multidrug-resistant 
infections have created management challenges for the military.
    Initially, the source of infections was difficult to 
identify because wounded personnel are evacuated to several 
treatment facilities before reaching a medical center in the 
United States. Also, determining the nature and extent of the 
problem took time because infections did not show up in 
patients until days after injury, and screening and 
surveillance capabilities were limited.
    Moreover, implementing infection control and prevention 
measures in combat hospitals are challenging given the physical 
conditions and limited infrastructure available. The lack of 
infection control expertise at these facilities, as well as 
limited experience in treating multidrug-resistant infections 
compounded efforts to manage outbreaks.
    In the past few years, the number of infections in military 
hospitals has decreased significantly, in part because the 
total number of combat casualties has gone down, but also 
because DOD and the services have implemented measures to 
strengthen infection screening, control, and prevention in the 
military healthcare system. Steps have been taken to promote 
awareness of basic infection control practices such as using 
new gloves and gowns with each patient. Guidelines for 
isolating patients with suspected multidrug-resistant 
infections and more targeted use of antibiotics were 
implemented. Additional infection control training is now 
available to deploying medical personnel. Furthermore, 
standardized screening for multidrug-resistant bacteria has 
been instituted at the major military medical centers.
    Lastly, research has been conducted, which has led to a 
better understanding of the risks and treatments associated 
with multidrug-resistant infections.
    While considerable progress has been made in controlling 
infections, the problem has not been solved and new outbreaks 
will be a continuing challenge. According to some service 
officials, there is a need for (1) a more comprehensive 
surveillance system to monitor infections; (2) enhanced 
training and expertise in infection control; (3) a coordinated 
and sustained approach in research and development; and (4) 
perhaps an infection control consultant in each combat theater.
    The incidence of drug-resistant infections is a national 
and global problem in both the civilian and military world that 
has grown dramatically over the past decade in civilian 
hospitals. According to the Centers for Disease Control and 
Prevention, almost 100,000 Americans are killed each year by 
hospital-acquired infections. Health experts warn that the 
problem could get worse in the next several years because there 
are few new antibiotic treatments expected from the drug 
research pipeline. Because patients with severe injuries are 
most susceptible to these infections, DOD and the services must 
remain vigilant in their efforts to monitor and prevent them.
    The purpose of this hearing is to examine how the 
Department of Defense has responded to outbreaks of multidrug-
resistant infections over the past several years and whether 
effective surveillance, prevention, and research programs are 
in place to manage this challenge in the future, and what 
Congress can do to help.
    That concludes my opening statement.
    Congresswoman Louise Slaughter has had an interest in this 
issue of multidrug-resistance for some years now. I would ask 
unanimous consent to include as an addendum to my opening 
statement, a statement from Representative Slaughter.
    [The prepared statement of Ms. Slaughter can be found in 
the Appendix on page 31.]
    Dr. Snyder. And I will now recognize Mr. Wittman for any 
comments he would like to make.

   STATEMENT OF ROB WITTMAN, A REPRESENTATIVE FROM VIRGINIA, 
  RANKING MEMBER, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

    Mr. Wittman. Well, thank you, Chairman Snyder. And good 
afternoon to our witnesses. Thank you so much for joining us 
today and thank you for your service to our country.
    You know, it is easy to start a debate or to find a 
contrary view on almost every issue that arises here in 
Washington. The good news is that the subject of today's 
hearing is that rare exception to the rule. You know, there is 
no political party, no healthcare provider and certainly no 
patient that wants any part of infection, much less the 
virulent infections that are the subject of today's hearing.
    Multidrug-resistant organisms, or MDROs, are a serious 
matter for both our military and civilian healthcare providers 
and are with us to stay, I fear.
    I understand that infection control demands constant 
vigilance in medical facilities, requiring careful training and 
strict adherence to proper procedures within all areas of 
military treatment facilities. Infection control is 
particularly difficult in an austere deployed setting with 
limited supplies, limited access to fresh water, and the 
necessity of handling potentially large numbers of casualties 
who have been living in a field environment.
    I traveled last spring to Afghanistan and after a single 
day was covered in a significant layer of dust. So I can tell 
you after moving through Kandahar Province, I have a deep 
appreciation for what you all have to deal with downrange. And 
I can only imagine the condition of troops living in the field 
for months at a time, just based on my short experience there.
    So I know infection control under such circumstances must 
be daunting. And we are all glad to see that the growing 
problem of Gram-negative bacterial infections in military 
facilities was identified several years ago, and that 
considerable progress has been made in screening for and 
controlling these infections. In fact, the number of cases of 
the most virulent bacteria was cut by almost two-thirds of 
military facilities from the peak. My hat is off to you on 
that.
    Still, improvements can be made in enforcing infection 
control protocols and reporting mechanisms and in research for 
both the better treatment and better control procedures.
    We on the committee fully support your efforts in this 
area, and I look forward to hearing from you on how we can help 
to continue to make progress in combating infections of all 
types.
    I look forward to your testimony today. And again, thank 
you so much for what you have done. And thank you in the future 
for what you will do in addressing this daunting issue.
    And, Mr. Chairman, with that I yield back.
    [The prepared statement of Mr. Wittman can be found in the 
Appendix on page 29.]
    Dr. Snyder. Thank you, Mr. Wittman.
    Our witnesses today are Dr. Jack Smith, the Acting Deputy 
Assistant Secretary for Clinical and Program Policy, Office of 
the Assistant Secretary of Defense for Health Affairs; Colonel/
Dr. Jonathan Jaffin, Director, Health Policy and Services, 
Office of the Army Surgeon General; Colonel/Dr. Duane 
Hospenthal, Infectious Disease Consultant to the Army Surgeon 
General and Chief of Infectious Disease Service at Brooke Army 
Medical Center; Colonel/Dr. James D. Collier, Assistant Air 
Force Surgeon General for Health Care Operations; Lieutenant 
Colonel/Dr. Michael Forgione, Infectious Disease Consultant to 
the Air Force Surgeon General and Chief of Medicine at Keesler 
Air Force Medical Center; Captain/Dr. Gregory Martin, 
Infectious Disease Consultant to the Navy Surgeon General and 
Program Director of the Infectious Disease Clinical Research 
Program at the Uniformed Services University of the Health 
Sciences; and Ms. Judith English, Navy Bureau of Medicine and 
Surgery Infection Control Consultant.
    Thank you all for being here. We will--somewhere we have a 
clock that you can see. We will turn the clock on for five 
minutes. When the red light starts flashing, it means five 
minutes have gone by. If you have more things to say, let us 
know. Otherwise, we will get to our questions. We have seven 
witnesses but only four of you actually are doing opening 
statements. And we will begin with you, Dr. Smith.

STATEMENT OF DR. JACK SMITH, ACTING DEPUTY ASSISTANT SECRETARY 
   FOR CLINICAL AND PROGRAM POLICY, OFFICE OF THE ASSISTANT 
            SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

    Dr. Smith. Thank you, sir. Chairman Snyder, Ranking Member 
Wittman, members of the committee, thank you for the 
opportunity to discuss Department of Defense efforts to address 
the growing challenge of healthcare-associated infections, 
particularly those from multidrug-resistant organisms, or 
MDROs.
    We greatly appreciate the committee's interest in this 
important issue and its continued strong support for the 
dedicated men and women of America's Armed Forces.
    Mr. Chairman, as the committee so well understands, 
healthcare-associated infections, including those from MDROs, 
are a serious problem for the military but also represent a 
growing problem in healthcare facilities across the Nation. 
These pathogenic organisms, which are predominantly bacteria, 
have not only increased the length of hospital stays but also 
mortality rates. So the problem is quite serious and one that 
we must continue to address.
    The sources of these bacteria and infections are 
multifactorial with both environment and facility-related 
factors. In hospital settings, they are most likely to 
contaminate environmental surfaces, equipment such as 
ventilators and dialysis machines, the hands of healthcare 
workers, visitors and family members, and the respiratory, 
urinary, skin, and gastrointestinal tracks and wounds of 
hospitalized patients.
    Accumulated data have shown that transmission of MDRO 
infections in combat-wounded servicemembers who have returned 
to the U.S. does not appear to have a single source or involve 
a single strain of bacteria but, rather, are derived from 
multiple sources and must be addressed as system issues.
    DOD has been actively engaged in measures to screen, 
surveil, prevent, and control infections in military treatment 
facilities at home and on the battlefield. The military health 
system maintains a quality assurance program implemented in all 
military treatment facilities that establishes policies and 
procedures and requires training of our personnel to minimize 
the risk of infection to patients and staff, control the spread 
of infection, assess patient care, review healthcare records, 
and manage health resources and risk.
    We have also established an Infection Prevention and 
Control Panel with service subject matter experts as a 
subcommittee of our Military Health System Quality Forum. The 
Global Emerging Infection Surveillance and Response System, a 
division of the Armed Forces Health Surveillance Center, is a 
central hub that leverages the surveillance and response assets 
of the services and oversees military medical research units 
and is paving the way for laboratory standardization for 
microbes of military interest.
    The Multidrug-Resistant Organisms Repository and 
Surveillance Network System, established by the Medical 
Research and Materiel Command, is working to rapidly 
characterize emerging drug-resistant threats, track and monitor 
MDRO patients, and reduce the risk of healthcare-associated 
infections, which will aid in the development of a daily alert 
surveillance system for MDROs of significant importance.
    Since December of 2008, the military health system has been 
participating in the Centers for Disease Control's national 
healthcare safety network. Currently, 33 of our military 
treatment facilities are participating. We are also 
participating in the American College of Surgeons National 
Surgical Quality Improvement Program, or NSQIP, which is 
focusing on, among other issues, the occurrence of surgical-
site infections which could involve MDROs. And the Joint 
Theater Trauma Registry is adding an infectious disease module 
to study and better understand the risks, interventions, and 
outcomes associated with combat trauma.
    Standard infection prevention and control practices and 
standard clinical practice guidelines have been established and 
implemented in both garrison military treatment facilities and 
deployed areas.
    Admission MDRO colonization screening is performed at the 
four major receiving military medical centers for OEF 
[Operation Enduring Freedom] and OIF [Operation Iraqi Freedom] 
wounded: Landstuhl Regional Medical Center, Walter Reed Army 
Medical Center, National Naval Medical Center, and Brooke Army 
Medical Center. Patients are not released from contact 
precautions or isolation until they screen negative. And 
screening results are collected, reviewed, and reported.
    And DOD partnerships have been established with the VA 
[Veterans Administration] and the CDC [Centers for Disease 
Control] to address the challenges presented by MDRO and other 
infections. In addition to screenings, surveillance, 
prevention, and control, DOD has numerous studies underway to 
further our understanding of MDRO and other infections to 
enhance the prevention and control of infections and develop 
new treatments and therapeutics. Several DOD research 
laboratories receive funding to conduct research on MDROs, 
including Walter Reed Army Institute of Research, U.S. Naval 
Research Laboratory, U.S. Navy Medical Research Center, the 
Institute of Surgical Research, the Armed Forces Institute of 
Pathology, and the four major medical centers already 
mentioned.
    Mr. Chairman, the Department shares the committee's 
concerns about the threat of multidrug-resistant organisms and 
we are working to improve our preventive measures, treatment, 
surveillance, and research as we respond to outbreaks of MDRO 
and other infections in military personnel and facilities.
    We appreciate the committee's interest in this important 
issue and I will be happy to respond to any questions you may 
have.
    [The prepared statement of Dr. Smith can be found in the 
Appendix on page 34.]
    Dr. Snyder. Thank you, Mr. Secretary.
    Colonel Hospenthal, I think you are next. You are 
recognized.

 STATEMENT OF COL. DUANE HOSPENTHAL, USA, M.D., OFFICE OF THE 
        SURGEON GENERAL, INFECTIOUS DISEASES CONSULTANT

    Colonel Hospenthal. Chairman Snyder, Representative 
Wittman, members of the committee, thank you for this 
opportunity to discuss how the U.S. Army operates to prevent 
and treat multidrug-resistant organism infections.
    As you have already pointed out, multidrug-resistant 
organisms have increasingly become a healthcare threat in the 
U.S. and throughout the world. Focus in the U.S. and abroad to 
control these infections has included attempts to prevent 
transmission within our hospitals and other healthcare 
settings. These efforts have been championed by the Joint 
Commission through patient safety goals, and by the Centers for 
Disease Control and Prevention through guidelines and the 
prevention of MDROs.
    Since the onset of Operations Iraqi Freedom and Enduring 
Freedom, infections and colonizations with MDROs, especially 
MDR Acinetobacter and the extended spectrum beta-lactamase 
producing E. coli and Klebsiella, have complicated the care of 
our injured U.S. military personnel. The source of these 
bacteria in returning combat-injured personnel has not been 
fully elucidated, but it appears that most likely these 
bacteria are spread nosocomially, both in the combat theater, 
along the journey back to, and within, military medical centers 
in the United States.
    In addition to routine practices and participation and U.S. 
civilian healthcare standards, which I have mentioned, the 
military healthcare system has responded to the problem with 
specific efforts focusing on ameliorating the problem in 
returning injured personnel. And these efforts include the 
admission MDRO screening, which Dr. Smith has discussed; 
development of specific guidelines to prevent infections in the 
combat injured; efforts to improve infection prevention and 
control in the combat theaters; establishment of an MDRO 
repository and surveillance network; and enhanced research 
efforts.
    Admission MDRO colonization screening is performed, as 
mentioned, in the four major receiving medical centers. 
Patients are not released from contact isolation until they 
screen negative. This provides near real-time monitoring in the 
rates of this colonization and potential infections in 
evacuated personnel to feed back to the combat theater.
    Clinical practice guidelines, developed by a consensus 
conference including the Army, Air Force, Navy, and civilian 
personnel have been produced and promoted. These guidelines for 
the prevention of infection after combat-related injuries have 
focused on limiting antibiotic overuse and basic infection 
control interventions in theater.
    Critical review of infection control practices and 
challenges in the combat theater hospitals was conducted by 
myself and Colonel Helen Crouch in 2008 and 2009. These reviews 
produced multiple interventions to improve our infection 
control in a deployed setting. And this includes a renewed 
emphasis and focus on basic infection control methodologies and 
practices; development of electronic resources and Web pages; 
deployment of clinical microbiology and antibiotic control; as 
well as the establishment at the Army Medical Department Center 
and School, a short five-day course for identified infection 
control officers for deployed Level III hospitals.
    Also a standardized infection control policy was produced 
and is being staffed currently in the Afghanistan theater.
    The repository established to collect and study MDROs was 
established in June of 2009. The MDRO Repository and 
Surveillance Network, the MRSN, was established to collect and 
characterize bacterial isolates and provide epidemiological 
data to manage this problem. In conjunction with clinical and 
transportation data, the MRSN could help localize sources of 
MDROs to enhance and focus infection control methods. And data 
from the Joint Theater Trauma Registry will be essential to 
this effort.
    Over the past several years, the DOD has enhanced and 
expanded research in the prevention and treatment of MDROs. The 
Army is committed to aggressive efforts to prevent and treat 
MDRO infections. This includes a commitment to continue 
research aimed at understanding, preventing, and treating these 
infections. Additional efforts are underway to prevent 
transmission of MDROs within our military hospitals. We join 
civilians and other Federal agencies in our commitment to 
combat the spread of MDRO infections.
    Thank you again for this opportunity to address the Army's 
efforts. And thank you for your continued support to our 
Nation's soldiers.
    [The prepared statement of Colonel Hospenthal and Colonel 
Jaffin can be found in the Appendix on page 45.]
    Dr. Snyder. Thank you. Captain Martin.

STATEMENT OF CAPT. GREGORY MARTIN, USN, M.D., PROGRAM DIRECTOR, 
          INFECTIOUS DISEASE CLINICAL RESEARCH PROGRAM

    Captain Martin. Chairman Snyder, Congressman Wittman, 
distinguished members of the subcommittee, I am pleased to have 
the opportunity to update you on Navy Medicine's response to 
the problem of multidrug-resistant organisms.
    As the Navy Surgeon General specialty leader for infectious 
diseases and a practicing infectious disease physician at 
Bethesda Naval Hospital, I can assure you this issue is vitally 
important to the Vice Admiral Adam Robinson and to all of Navy 
medicine.
    One only has to listen to NPR [National Public Radio] or 
watch the evening news to understand that the threat from 
multidrug-resistant organisms has really become a global issue. 
The Infectious Disease Society of America, the Institute of 
Medicine, and the World Health Organization have all identified 
resistant infectious agents as major public health threats for 
which a coordinated global effort is urgently needed.
    The DOD has been a national leader in identifying and 
addressing the MDRO challenge. While focused on the combat 
injured, many of whom have survived overwhelming blast injuries 
with burns and amputations, the reality of treating these 
infections has been sobering. In some cases, MDRO infections 
have been responsible for persistent infections, leading to 
delayed healing, amputations, or sepsis.
    MDRO infections in our combat injured were first identified 
in 2003 on the hospital ship Comfort and at Bethesda. The Naval 
Hospital began screening of OEF/OIF patients for MDROs and 
instituted infection control measures to prevent their 
acquisition and transmission among patients and staff. Bethesda 
screening was then adopted in each of the major casualty 
screening centers in the U.S. and in Landstuhl.
    Our Army colleagues deployed an expert team to treatment 
facilities in theater to assess infection control measures and 
ensure that standard precautions were being adhered to, even in 
forward treatment areas. Their efforts led to changes in 
practice in all three services with cohorting of long-term 
patients separately from the acutely injured patients who were 
unlikely to harbor MDROs and were typically being MedEvac'd 
back to Landstuhl and CONUS [continental United States] Army 
and Navy facilities.
    Furthermore, infection control training needs were 
identified and a predeployment infection control course made 
available to each of the services.
    The establishment of the MDRO repository and surveillance 
network to collect isolates will enable a more definitive 
molecular analysis of the relationships among the MDROs, as 
well as common sources for their acquisition. As our patients 
transfer between hospitals of the different services, all DOD 
MTFs [Military Treatment Facilities] will benefit from the 
repository system.
    Most importantly, our patients, their families, and our 
clinicians would like to know what can be done to limit the 
harm these infections inflict on our wounded warriors. In this 
regard, Navy BUMED [Bureau of Medicine] has funded the Trauma 
Infectious Disease Outcome Study, or TIDOS, to combine 
surveillance, laboratory, and clinical data from combat-injured 
patients and follow them through their subsequent care in VA 
hospitals.
    The DOD is uniquely capable to develop a program like TIDOS 
that can monitor a large group of patients and develop 
evidence-based recommendations that will be utilized not only 
in the care of an injured marine from Afghanistan but also the 
high school student with an infection after a car accident.
    In the last few weeks, the TIDOS project has expanded to 
include the VA hospitals, and is now one of the first medical 
programs to bridge the military to the VA transition. We are 
enthusiastic that TIDOS will provide the data to assess our 
treatment of combat-related infections and effect changes in 
practice that will improve future outcomes.
    Overall, I feel the response of the DOD infectious diseases 
and infectious control communities to the worldwide threat of 
MDROs is something we should be proud of. Careful surveillance, 
coordinated interventions, and increased research efforts are 
helping the Navy and the DOD to remain at the forefront in the 
response to MDROs.
    I appreciate the opportunity to have updated you on our 
efforts and look forward to your questions. Thank you.
    [The prepared statement of Captain Martin and Ms. English 
can be found in the Appendix on page 52.]
    Dr. Snyder. Thank you, Captain Martin. Colonel Collier.

   STATEMENT OF COL. JAMES D. COLLIER, USAF, M.D., ASSISTANT 
SURGEON GENERAL, HEALTH CARE OPERATIONS, OFFICE OF THE SURGEON 
                            GENERAL

    Colonel Collier. Chairman Snyder, Representative Wittman, 
good afternoon and thank you very much for this opportunity to 
discuss this critical issue with you today.
    The Air Force is working diligently with our sister 
services to control infectious diseases in theater and in our 
medical treatment facilities. As you are well aware, this 
problem continues to challenge the medical community in both 
the public and private sectors around the globe. And we 
appreciate your support in our endeavors to address it.
    As I am the last to speak, I will try not to be redundant 
to the previous witnesses, and have submitted my full statement 
for the record.
    In response to the challenge of treating and managing MDRO 
infections in our returning servicemembers, the DOD has 
instituted coordinated Tri-Service efforts in the areas of 
infection control and prevention, in surveillance, and in 
research and development.
    I will speak briefly about Air Force infection control 
initiatives. The Air Force is committed to infection control 
throughout our continuum of care. The most common patients in 
our Air Force theater hospitals to develop MDRO infections are 
those who remain in intensive care units for extended periods 
of time. Active Duty ICU patients are stabilized and sent to 
Landstuhl Regional Medical Center or CONUS hospitals as quickly 
as possible.
    In contrast, injured and ill host-nation patients have very 
limited resources for long-term medical care within their 
country; thus they tend to stay longer in our theater 
hospitals. This population is the one most susceptible to MDRO 
infection and colonization.
    Our theater hospitals have a physician and nurse as the 
infection control officer and representative to provide ongoing 
oversight and promote continuing awareness of infection control 
standards. They conduct surveillance, provide educational 
briefings on antibiotic-resistance issues and wound management, 
and emphasize basic infection control efforts to prevent spread 
between hospitalized patients throughout the deployment 
rotation.
    The Air Force also has a specific package, the 
expeditionary infectious disease team, which is available to 
provide dedicated infectious disease and infection control 
assets for the theater surgeon. As the primary source of 
patient transportation from theater hospitals to Landstuhl and 
back to and throughout CONUS, air medical evacuation [AE] is 
the linchpin of our healthcare continuum.
    Our AE crews are trained annually in infection control. In 
addition to the usual standard precautions, crews are trained 
to mitigate the risk of transmitting nosocomial infections in 
the operational environment. They are trained to disinfect 
equipment and have in-flight kits that contain both spill kits 
and personal protective equipment. Further, hand sanitizers are 
placed throughout the aircraft cabin. AE personnel are also 
educated about airflow in our different air frames and where 
best to position patients to avoid the spread of infection.
    The Air Force has formal infection control courses that are 
conducted at Sheppard Air Force Base in Texas. There are three 
levels of training provided: for those assigned to infection 
control positions, both officer and enlisted on the active duty 
side; for those assigned as the infection control function and 
committee chairperson; and training specific for our reserve 
component members.
    We also utilize equivalent civilian infection control 
courses. The new draft of our Air Force instruction, entitled 
``Infection Prevention and Control Program'' has added an 
optional element, which suggests that an active duty officer 
serve as an infection control assistant and rotate through the 
infection control office in those facilities that have a 
civilian infection preventionist assigned. This is designed to 
facilitate actual hands-on management of the infection control 
program in garrison for active duty officers so they may gain 
experience prior to deploying.
    While none of our Air Force MTFs consistently receive 
combat-injured U.S. personnel at this time, our medics do 
practice in all of the major MTFs responsible for the care of 
these patients, which include forward-based hospitals and, as I 
mentioned, in our air and medical evacuation system.
    An MDRO colonization screening process of OIF and OEF 
wounded, upon admission, is now in place; and, encouragingly, a 
recent review of this data has shown a significant decrease in 
the number and percentage of patients colonized with 
Acinetobacter upon arrival at Landstuhl and the three Level V 
CONUS facilities.
    While much remains to be done and understood to control or 
eliminate this complex medical dilemma, we continue to work 
with the world's foremost infectious disease experts to find 
the answers that will prevent future patients from contracting 
an infectious disease from others in the very environment 
designed to protect and heal them.
    Whether they are our military and family members here in 
CONUS or our wounded warriors in theater, we must find a 
solution to this constantly evolving challenge.
    We appreciate your support, Mr. Chairman, and that of the 
committee as we seek to achieve this daunting but critical 
goal. Thank you.
    [The prepared statement of Colonel Collier and Colonel 
Forgione can be found in the Appendix on page 63.]
    Dr. Snyder. Thank you all. I thank you all for being here.
    Colonel Collier, I think you were the only person brave 
enough to try your own pronunciation of Acinetobacter. So we 
applaud you for that. You know--well, Mr. Wittman, I will put 
ourselves on the 5-minute clock, whoever the timekeeper is 
here.
    When you think about what this means for families and 
individuals who have been wounded, moved to a military facility 
in country, moved to Landstuhl, come back to the United States, 
get put into one of our military hospitals, have family members 
probably down there by then, and then to develop one of the 
infections and have things go south very rapidly, it must be 
just heartbreaking not only for the family but also for the 
healthcare providers that are trying to take care of this 
person.
    And, Dr. Smith, I will ask you the question but then I will 
let you defer to whoever you want to. I would like a little 
tutorial, if I could get one, on IED [improvised explosive 
device] injuries, and if the fact of a blast effect, in 
addition to an open wound, how that--if that is a factor in 
these infections.
    Dr. Smith. Well, sir, I am certainly not an expert on IED 
injuries. But as we all know, they have become quite a problem 
for us in DOD during the course of this war. I believe we do 
have Colonel Hospenthal who could perhaps respond to that.
    Colonel Hospenthal. Sure. I mean, certainly the blast 
injuries from IEDs cause tremendous tissue damage and 
devascularization. Initially when we were looking for a source 
of these MDROs, we were concerned whether there are--some of 
the bacteria in the soil and organic debris were actually being 
lodged up in organic fragments and such. And so certainly it 
doesn't look like that is the main cause of these MDRO 
infections, but certainly the damage is. The damage that is 
caused there has to be carefully debrided while trying to save 
tissue, and so devitalized tissue may need the--the surgeons 
may need to go back multiple times to try to debride off the 
dead parts of the tissue, to allow the vascularized surviving 
tissues to survive, all during the while there is pressure 
from--or colonization with bacteria, like we have bacteria 
always on our bodies. And in the hospitalized environment, 
these bacteria are all off in these multidrug-resistant 
bacteria that then colonize these wounds and can cause the 
infections that we see.
    Dr. Smith. And, Colonel Jaffin, you have some comments 
concerning this.
    Colonel Jaffin. Sir, I guess I am the only surgeon at the 
table. But what we see, especially with the large blast 
injuries, is a lot of separation of tissue along the tissue 
planes, that there is disruption of the vascular supply leading 
to large amounts of tissue. And so in order to minimize 
deformity and dysfunction, we try and preserve as much of that 
tissue as we can.
    At the same time, we are caught trying to make sure that we 
remove all of the tissue that is not viable. That nonviable 
tissue is a great culture medium for any organism. And that is 
why the importance of the drug--of the infection control 
measures to prevent colonization with the multidrug-resistant 
organisms.
    Dr. Snyder. In terms of the availability of research 
dollars, you all have your own budgets, and we have a lot of 
activity going on with NIH [National Institutes of Health]. I 
don't have a sense of the adequacy of research dollars 
available to you all for looking at this issue. Is it adequate? 
Is it inadequate? It seems like it actually went down over the 
last couple of years. This is in the area where Congress can 
help. If we are not doing our job, you won't have adequate 
research dollars.
    Dr. Smith or anyone else want to comment?
    Dr. Smith. Yes, sir. I will begin with what is budgeted at 
the DOD level. We have currently in this fiscal year $13.68 
million allocated for studies related to multidrug-related 
organisms or multidrug-resistant organisms--I am sorry--$10.25 
of that in antimicrobial countermeasures and $3.43 of that in 
wound infection prevention and management. And the other--the 
services do allocate some research dollars I believe as well to 
MDROs and infectious-disease issues. And I will let the 
services speak to those.
    Dr. Snyder. I think that is your cue.
    Dr. Smith. Do you have figures for Army, MIDRP [Military 
Infectious Diseases Research Program] or----
    Colonel Jaffin. I can probably take that, sir. For MIDRP, 
there is about $430,000. For the specific on wound infections, 
there is $895,000. U.S. Navy wound infection research also gets 
money. I don't have the exact number right here. USUHS 
[Uniformed Services University of the Health Sciences] has a 
little over $4 million. For congressional special interest 
projects on wound infection, there is almost $12 million. SBIR 
[Small Business Innovation Research] project is about $3.7 
million.
    Dr. Smith spoke about the Defense health programs and then 
war supplemental intermural projects, there is about another 
$2.5 million, sir.
    Dr. Snyder. Anyone else have any comment?
    Dr. Smith, I thought that the upcoming year--you said out 
of the current fiscal year--I thought the upcoming estimate is 
actually going to be a drop of several million dollars, from 
almost $14 million; is that correct?
    Dr. Smith. Sir, I don't have figures for fiscal year 2011 
or beyond at this point. It is my understanding that money has 
been programmed for this area of research. And in addition to 
that, there is incremental funding of programs in the outyears. 
So that if there is promising research that has been identified 
and is ongoing, then that is often funded in the year of 
execution.
    Dr. Snyder. In your opening statement, you described that, 
Dr. Smith, as vigorous research funding. It doesn't seem 
incredibly robust to me. Am I wrong? I mean, it seems like this 
is a huge problem; it is a huge national and international 
problem. You have got major facilities around the world. It 
seems like that money would be stretched out pretty thinly, 
pretty rapidly. Is that a fair statement?
    Dr. Smith. I am not sure that I used the ``vigorous 
funding,'' sir, when--in my statement.
    Dr. Snyder. I think you said ``vigorous research.''
    Dr. Smith. We certainly do have funding allocated for 
research. And this is very definitely an important, a vital 
area of interest for the military. But as you pointed out, it 
is also a national problem and we are collaborating with, 
coordinating with the National Institutes of Health and other 
organizations that are devoting research dollars to this. We do 
have to balance our research funding in this area with other 
areas of military research interest. So it is in a competitive 
process. But as I say, we have $13.6 million for this year.
    Dr. Snyder. I think your opening statement on page six says 
the DOD has a vigorous research program. And around here when 
we hear ``vigorous,'' we automatically think of funding, I 
guess.
    Mr. Wittman, I went over my time. Mr. Wittman.
    Mr. Wittman. Thank you, Mr. Chairman. I will begin with Dr. 
Smith, and I would like to get the perspective, too, of the 
other folks here from the different service branches. I want to 
focus on the element of training and the element of deployed 
infection control officers downrange.
    First of all, I would like for you to give us an overview 
about the scope and breadth of training that our infection 
control officers receive and our infection control personnel 
receive and our medical care personnel receive. Both in a 
deployed situation and back stateside; and then also to 
determine how are those individuals deployed downrange? What 
mixture of personnel do we have there? Is there a specifically 
assigned officer in charge of infection control at these 
medical care facilities downrange? Who are those personnel? I 
understand in the past that there were nurses that were 
assigned as infection control officers. Is that still the case?
    If you could tell us a little bit about the extent of 
training and then how those individuals are deployed in our 
medical care facilities.
    Dr. Smith. Yes, sir. Well, I will begin with the policy 
level and work down probably as far as the stateside 
facilities, and then pass it to my service colleagues to speak 
a little bit more about the deployed environment.
    But, of course, infection control is an element of the 
training of all medical professionals now. So our physicians, 
our nurses, our corpsmen, our technicians, are all being 
trained in their basic professional training about infection 
control.
    There also is Joint Commission accreditation of our 
inpatient facilities and we have ambulatory accreditation of 
our outpatient clinics which have initiatives focused on 
infection control. Infection control programs are a requirement 
for accreditation in those. And along with that goes 
appropriate training and orientation of staff in the facility-
level infection control programs.
    I do know that in the predeployment setting, DOD is also 
providing some additional training for personnel, but would 
urge that we keep in mind that the people who are deploying 
into the operational setting are the same people who have been 
providing the care back in the medical treatment facilities.
    So certainly the professional, fundamental training, the 
infection control specific training that they are getting and 
utilizing every day in our military treatment facilities is 
useful as they deploy to that operational environment. And 
there has been pointed out in some of the testimony some of the 
challenges of practicing good infection control procedures and 
prevention in that austere environment. That is very definitely 
a critical factor.
    But let me pass to my left and ask whether the services 
would like to comment on the deployed environment.
    Colonel Hospenthal. I would agree with everything Dr. Smith 
has just stated. Certainly as medical healthcare professionals, 
we all receive nearly continuous training in infection control 
because it has become such a big issue throughout the world.
    In the deployed setting, certainly all the medical 
personnel have been working in hospitals and do have the basic 
training. Our mission in 2008 to review infection control 
practices and challenges revealed that there really weren't 
well-trained, dedicated infection control officers in charge of 
the program at the Level III facilities. It wasn't that the 
personnel weren't doing infection control or weren't doing a 
pretty good job, but the infection control officers that we 
have seen downrange really had not had more training and 
additional training. And often they were nurses, and often they 
really didn't have dedicated time to do their infection control 
officer duties.
    And that is really the challenge that we identified and 
focused on over the last several years: developing the kind of 
just-in-time five-day infection control officer course and in 
getting policy changed on the Army side to stress infection 
control.
    Recently there was an EXORD [executive order], actually 
this week, that went through that makes it a requirement that 
as the CSH is--as the Combat Support Hospital breaks into 
separate pieces, rather than operate as one single unit, that 
each one of those pieces or slices as we call them that have 
inpatients have an infection control officer who has been 
trained in either our five-day just-in-time course, or who has 
experience.
    And I believe this problem has really developed because of 
the operational tempo. We have a lot of hospitals downrange. We 
have been there a long time, and these hospitals are not 
operating as a single CSH. They are broken into multiple 
segments. And because of that, we just did not have enough 
infection control officers trained throughout this.
    Captain Martin. I really have to defer to my two previous 
colleagues because I think most of what they said really refers 
to all of us. Since all of these in-theater hospitals are 
really Tri-Service, we talk constantly. I mean, I am on a 
constant first-name basis with all of these guys; and we know 
what is going on, who is going where, and we have a pretty good 
handle on the issues.
    I think, as Colonel Hospenthal just brought up, earlier on 
in the war things were a little less organized as far as what 
we knew was going on. And now the focus on infection control is 
much more evident at all of these facilities, both in CONUS and 
OCONUS [outside the continental U.S.]. So I think that we are 
really--have a much better handle on ensuring that infection 
control practices--standard practices are being met, even at a 
much more forward setting than we had previously.
    I also have with me Ms. Judy English, who is your Navy 
infection control leader consultant. And any comments about 
specific things that you would want to bring up from--she is an 
infection control nurse, and I think she is one of the only 
nurses we have in here. And it has been an important thing for 
Judy to be at BUMED because I think it emphasizes just how 
important infection control is to the Navy both in CONUS and 
OCONUS.
    Ms. English. Thank you. Thank you, sir.
    The Navy infection prevention and control arena has been 
trying in CONUS to civilianize. So that at this point in time, 
68 percent of our infection preventionists are civilians. And I 
have a monthly video teleconference and digital conference 
online that is two times in the day, so people all over the 
world can sign on. And this is for management and education 
purposes. And we do this continuously, as well as the usual 
getting together.
    We are also working with the Army and the Air Force as 
members of the TMA [TRICARE Management Activity] Infection 
Prevention and Control Panel. And we are now going over the 
data that Army, Navy, Air Force are all entering into the CDC's 
National Health Care Safety Network relevant to central line-
associated bloodstream infections and ventilator-associated 
pneumonias in babies through the elderly in critical care.
    And now the Navy is working with the Navy-Marine Corps and 
Public Health Center with beta testing sites to document all 
MDROs that are in CHCS [the Composite Health Care System], so 
that as soon as the Centers for Disease Control can accept HL7 
[Health Level 7] download of these data, the entire Navy MTFs 
[medical treatment facilities] and DTFs [dental treatment 
facilities] will immediately go into downloading all of the 
MDROs, working with DOD and CDC. And this will be another 
benchmark data that is not as high as the pulsed-field gel 
electrophoresis that is going on. But this is the best that we 
can do without higher technology. This will be a 21st-century 
technology download as soon as CDC can accept these data.
    Colonel Collier. Thank you. I think in the Air Force we 
mirror our sister services in our in-garrison performance, 
although, because of the small size of most of our facilities, 
it is a dual-hatted position. Downrange, we also dual-hat it, 
but those personnel have to have passed the training level 
required of an infection disease preventionist to get that 
position in our downrange hospitals.
    The only additional place where we carry out additional 
training then is our air medical evacuation business. And the 
air medical evacuation crews do receive additional training in 
order to understand how that works on an otherwise dirty 
airplane.
    So, yes, sir, thank you.
    Dr. Snyder. Thank you, Mr. Wittman.
    Maybe I will start with you, Colonel Collier, and go the 
other way, or maybe you can speak for the whole group. But in 
terms of the development of new drugs--I mean, those are 
expensive research projects to try to come up with a new drug. 
How much are--is the military or military patients involved in 
research looking for the next generation or a new kind of drug 
to deal with these infections?
    Colonel Collier. Sir, I am not able to answer that 
question, but I would ask my colleague if he has some input.
    Colonel Forgione. Thank you. As far as the Air Force's 
position in that, we do participate in clinical trials through 
the Infectious Disease Clinical Research Program that is stood 
up at USUHS and is NIH-collaborative as well. And so we do 
occasionally have patients that will participate in large 
multicenter trials. As far as a direct research initiative in 
the Air Force looking for new drugs, we do not have that 
service at this time.
    Captain Martin. This is kind of a difficult question 
because the DOD is not really set up well to develop new 
antimicrobial agents. That is really probably such an expensive 
and difficult undertaking that ``Big Pharma'' is really the 
only ones with pockets deep enough and with the ability to 
develop a lot of new antimicrobial agents. Whereas the DOD, 
especially the Army, has developed all the anti-malarials we 
have, and we have a pretty good system for looking at that.
    It would really not be in our best interest for the DOD to 
start looking at the very basic science needed to do a lot of 
the regular antimicrobials. So what we have done, I think, is 
focus more on some of the things that we can work on. And that 
is the clinical side of it.
    So we are doing some testing on some agents that are not 
approved in the United States now that have been funded, some 
Japanese products, and some other drugs that are really second- 
and third-line drugs we are using for some of these. We are 
looking at doing some studies with those clinically.
    I think the more important thing is that we are able to 
collect a lot of these different isolates. We are allowed to. 
With our repository services and whatnot, able to molecularly 
characterize these. And then when other universities that have 
the ability to do this ask for isolates, we are able to send 
them out. We are able to send a lot of multidrug-resistant 
Acinetobacter isolates out because we have a large collection 
of them, because we have been able to hold them. And these are 
clinical isolates that they actually need.
    So we partner with a lot of our civilian organizations. Dr. 
Smith talked about a lot of the funding. A lot of that funding 
actually goes out to civilian universities to do studies that 
we are really not equipped to be able to do. We are trying to 
focus more on the clinical end of things and directly with 
patients.
    Colonel Jaffin. Mr. Chairman, one of the things that we try 
and do in DOD medical research is we try and target those areas 
that the civilian sector is not targeting. There is an 
extensive, and has been mentioned, an extremely expensive 
program in Big Pharma to look for new antimicrobials. We have a 
few agents that we are looking at, some polypeptides and things 
like that.
    But the main focus is to partner--to try to expand the 
indications for the new agents that a pharmaceutical company 
may be working with to try and target the specifically 
difficult organisms or organisms that are not seen commonly in 
civilian practice. And again, as Captain Martin mentioned, it 
is that partnership and the working with Big Pharma and other 
universities to enable to leverage our research dollars and our 
research interests with theirs.
    Dr. Smith. Yes, sir. And if I may comment, I agree with 
what has been said by my colleagues to my left. There are a few 
specific areas of research that DOD is pursuing that may have 
some particular military usefulness with human albumin and 
plastic coatings of orthopedic implants, predatory bacteria 
microbial biofilms for the treatment of burns and wound 
infections, and a look at Staph aureus [Staphylococcus aureus] 
toxoids.
    So I think what we do have is a need for collaboration, 
coordination across many sectors, with DOD focusing on those 
areas of particular military interests, sir.
    Dr. Snyder. Do you think that the--you mentioned--I guess, 
you, Colonel Jaffin, mentioned Big Pharma dealing with this 
issue. Are you convinced that there is adequate research going 
on in the private sector on resistant organisms? I mean, when 
you start looking at a specific Gram-negative bacteria that has 
resistance, the number of cases--it can be devastating to a 
person, devastating to a hospital to have to deal with it.
    Are the economics there to make it worthwhile for a company 
to invest in that kind of research, not being sure you are 
going to find a solution?
    Dr. Smith. Sir, I am unable to comment on what Pharma may 
be investing in.
    Dr. Snyder. Well, we are talking about--you talked about 
you thought you had a specific niche, implying that the rest of 
it is over in the private sector. I am not convinced that there 
is adequate research going on in this area, looking for the 
next generation.
    Colonel Hospenthal, do you have a comment?
    Colonel Hospenthal. I mean, from the non-DOD side, 
certainly the Infectious Disease Society of America which we 
are--the three consultants are members of--have identified this 
as a problem in getting new drugs, as has a similar counterpart 
in the EU [European Union]. There isn't that many drugs in the 
pipeline. I think----
    Dr. Snyder. If I can interrupt. That is actually what led 
to this hearing today, it was because, I don't know, sometime 
in the last couple of years I became convinced that this is an 
example where the military is inheriting a problem, whether it 
is lack of foreign language skills or whatever it is, and you 
are having to try to figure out how to solve it, but this is 
going to be a tough one to solve.
    The reason there is not adequate dollars in the civilian 
side, is because it is going to take a huge amount of money to 
find a new drug, or two or three, for a relatively small number 
of cases, without much financial payoff. So then the question 
becomes, well, should we actually be beefing it up, should that 
perhaps be a role that we could play?
    So I am interrupting you, but that is what led to this 
discussion. Because I don't see them in the pipeline either.
    Colonel Hospenthal. Well, because of the cost and because 
of the Big Pharma story, we have chosen to focus really the DOD 
research dollars on the wound, the colonization itself, the 
biofilms that are in the wound that allow these bacteria to, 
you know, survive and develop resistance.
    So it isn't that we are not doing research on 
antimicrobials. We mostly have focused on topical 
antimicrobials in the wound, immune response in wounds, and how 
can we make that--and a wound has to have bacteria in it. We 
have bacteria all over our body. So how can we keep the numbers 
of the bacteria down and not produce superbugs in those wounds? 
That has been the focus that we have chosen with the research 
dollars over the last several years.
    Captain Martin. You know, I just want to add to that, as 
you suggest, any microbial pipeline is really pretty empty. I 
mean, we don't have many new things coming down the line that 
look very promising for these really bad bugs. And as Colonel 
Hospenthal said, we are able to look at some other things, 
other than antimicrobials to treat these. And I think vaccines 
have been a portion of it.
    So we have a major problem with Staph aureus infections in 
the military, especially in recruit settings, just because they 
are common skin flora. And MRSA [Methicillin-resistant 
Staphylococcus aureus], widely known all over, is a big problem 
for us as well. So we are partnering with Pharma and looking at 
Staph aureus vaccines and doing those trials actually in troops 
in boot-camp type settings to see does this actually work in 
our setting. What we need in DOD, not what we need in end-stage 
renal disease patients in an ICU [incentive care unit] 
somewhere, but what we need in DOD.
    So there are other vaccine-type candidates. We have to look 
at--something was mentioned a little bit about phage, where 
viruses that will attack bacteria have been looked at. All of 
these are important other avenues besides antimicrobials that 
we are trying to pursue. And, again, looking at the clinical 
end, where the science meets the patient; because that is what 
we are having to deal with as the clinicians involved in caring 
for these patients.
    Ms. English. And this whole lack of medication. People 
can't take a pill or have an IV [intravenous line] to kill the 
bug that they have, that we got so used to over the last few 
decades has brought us back to bedside care and scrupulous 
adherence to standard precautions. And if anybody shows any 
symptoms of something that might be contagious, we put a 
barrier between the healthcare provider and those moist body 
substances from the time they come back from overseas. And we 
use a long-acting chlorhexidine gluconate that stays on the 
skin for bathing these wounded warriors when they come back.
    And we find out as soon as we can that they are colonized 
or infected, so that we go back to basics to keep them as 
healthy as possible and not to share their bugs among 
themselves. It is real hard to keep marine buddies away from 
each other when one of them is isolated and their buddy is in 
an ICU and is not isolated. But you know, in special 
circumstances, we have dressed up a marine dad so he could go 
in to see his baby born when he had Acinetobacter, when he had 
to do it on a video screen, and he and mom were able to know 
that they were there for each other.
    Dr. Snyder. Mr. Wittman.
    Mr. Wittman. Thank you, Mr. Chairman. I think all these 
different pieces of the issue are very interesting in how they 
fit together and how we make sure that we are successful in the 
end.
    One of the critical elements, I believe, is the system of 
surveillance; how do we look at reporting and tracking these 
multidrug-resistant organisms; how do we do that in our medical 
facilities?
    And let me ask this. Can you all talk--and we will begin 
with Dr. Smith--talk a little bit about the current 
surveillance system? Is it adequate? What is it focused on? Has 
it developed through the years?
    I know that the Army, I believe, has a system of tracking 
infections. I wanted to know a little bit about is that maybe a 
model that should be used across all of our medical facilities? 
And this is both downrange and deployed facilities and 
nondeployed facilities back here stateside.
    So just a little bit about that in looking at the Army's 
multidrug-resistant organism repository and surveillance 
network to see if that is maybe a paradigm that could be used 
or what are the other services using as far as that effort to 
track and keep up with these organisms and the infections that 
go along with them?
    Dr. Smith, I will begin with you and then I would like to 
get the other panel members.
    Dr. Smith. Yes, sir. Thank you.
    I think we have--I would have to say we have a developing 
system of surveillance. It certainly has gotten better and 
better over time. And I mentioned a number of the elements of 
that network of surveillance.
    We are utilizing our Armed Forces Health Surveillance 
Network. The Global Emerging Infections System is out there 
gathering information from our overseas labs. We are 
participating now in NSQIP, the National Surgical Quality 
Improvement Program, which has a focus on infectious 
complications of surgery. We are participating in the National 
Health Care Safety Network through the CDC, which gives us part 
of the picture. So we have a great deal of information that is 
beginning to be available to us. And the NHSN [National 
Healthcare Safety Network] and the NSQIP are relatively new for 
us. We are still looking at how we utilize those data.
    The services, as you have heard, do have some other parts 
of that picture. But before I turn it over to them, let me say 
that they participate in our quality forum, which is run across 
service lines at the OSD [Office of the Secretary of Defense] 
level. So we do have our Infection Prevention Control Panel 
with the subject matter experts coming together to look at what 
can we see, what do we identify as problems, and what do we 
need to do about them in terms of both treatment, prevention, 
further surveillance, and also the research picture?
    So let me turn it over then to service representatives to 
address their specifics.
    Colonel Hospenthal. Well, this is certainly a huge problem. 
And the biggest issue that I see that is difficult to actually 
fix here is that if we had a single thing to track and follow 
around this would be a whole lot easier. We could make it a 
reportable thing, call it brucellosis, and things would be much 
easier.
    Even the CDC doesn't see this as something that is easy to 
put your arms around, because there are dozens of genus of 
these Gram-negative rods, there is probably 200 species of 
these Gram-negative rods, and there are literally probably 
thousands of different genetic elements that cause these 
resistance patterns.
    So if you put all of those combinations together, they are 
hard to even decide what we are tracking and what we are 
looking to track with surveillance methodologies. And so even 
to pick out what we want to look for is difficult.
    Certainly the Marine and Navy Public Health Center is 
working this through the CHCS data, but it is very difficult. 
CDC guidelines, because of this, really are to identify issues 
at your own facility and individualize your response and 
whether you conduct surveillance by doing cultures or by doing 
syndromic versus diagnostic results.
    Certainly because of this and because of the fact that a 
lot of these don't even track by ICD-9 [International 
Classification of Diseases, 9th revision] codes, there is not 
an ICD-9 code for Acinetobacter, is one of the reasons that we 
actually put together the standardized screening at Landstuhl, 
National Naval, Walter Reed, and BAMC [Brooke Army Medical 
Center] is just so we could have an idea of how many of these 
Acinetobacters and how many of these other MDROs are coming 
through the door from the combat theater, from Landstuhl as 
they transfer into the U.S.
    So with the MRSN [Multidrug-resistant Organism Repository 
and Surveillance Network], the hope would be that this will 
help provide some answers with some tracking data from the JTTS 
[Joint Theater Trauma System] and JTTR [Joint Theater Trauma 
Registry]. The MRSN is housed as an Army program currently, but 
it has always been thought of as being a DOD program over the 
long term. And certainly my Navy and Air Force colleagues were 
involved and still are involved in running that program. That 
program is based at the Walter Reed Army Institute of Research, 
but it certainly gets National Naval Medical Center isolates, 
Landstuhl isolates, et cetera.
    Captain Martin. Just to add on to what Colonel Hospenthal 
said, I think that this is also an issue of trying to track 
these things where you don't know if a patient is colonized or 
infected. We get asked how many of these you have. Well, do you 
count the one that the same patient has had multiple times in 
the lab over a long period of time? It becomes really difficult 
to track.
    We have been able to, and it was just alluded to through 
the Navy and Marine Corps Public Health Center looking at the 
CHCS computer system that is used DOD-wide, now able to really 
look at the--they are trying to get all the hospitals to report 
resistance the same way so they can look at this.
    But this whole question about the recent superbug coming 
out of India, NDM-1, we are asked how much of this are we 
seeing in the Navy and Marine Corps? We are very quickly able 
to go through and say, we are not seeing any of this; we 
haven't seen any isolates of this. We could go through and look 
at all of the stuff in the repository and say, there is not any 
of this.
    The study I talked about, TIDOS, the Trauma Infectious 
Diseases Outcomes Study, is really collecting all of these 
specimens from everybody, Army, Navy, Air Force. Even though it 
has a Navy-funded program, most of the work is actually done at 
Army hospitals. All of those isolates are collected, we are 
able to save them and see what is going on, and have a pretty 
good handle now, which we really didn't have five or six years 
ago on what is going on with MDROs.
    Ms. English. Infection control-wise, in the Navy and Army 
for patients who have MDROs or some other epidemiologically 
important pathogen, since the BRAC [Base Realignment and 
Closure] is coming soon, Walter Reed and National Naval Medical 
Center have become closer and closer, and we have devised 
identical protocols. And we put, for bed management, if a 
patient has ever had an MDRO, we have them listed. We note that 
in AHLTA and/or CHCS [the patient electronic health record] so 
the bed manager will note when they come back to the clinic or 
as an inpatient and puts them on appropriate transmission-based 
precautions. And this is communicated among the different 
services, and as people are sent to San Antonio to go back 
closer to home. But inside the Beltway is where this started.
    We also devised a clearance culture protocol using the 
Infectious Diseases and Infection Prevention people from Walter 
Reed and National Naval Medical Center in congruence with the 
Centers for Disease Control, because it is so hard to keep 
people on isolation precautions when they feel better, they are 
not dripping anymore. Do we have to stay here? Can't I go visit 
my buddy? And we devised a protocol so that there are three 
screenings, at least 72 hours apart, when the person has been 
off all antimicrobial therapy for the bug for at least 72 
hours. And this was agreeable to all three places. And that was 
a first, to get people off isolation without having to wait 
weeks or months.
    Colonel Forgione. I think, as all the folks up here have 
expressed, that this is really a process in evolution. And I 
think we have some very good basic surveillance going and some 
platforms that are going to help us to answer a lot of these 
questions.
    With these MDROs, it is a little different than some of our 
tried-and-true reportable diseases, like tuberculosis, where we 
have a very long history of managing this, very good guidelines 
of how we do it, and it is all reported. I think we are still 
defining what an MDRO infection is in some places and what 
colonization versus true infection means.
    And as the network that I think we have set up across the 
services continues to evolve, we will be able to provide better 
answers and then provide maybe guidelines out there that would 
then better define exactly what these entities are and how to 
address them.
    Captain Martin. Sir, can I add one thing? Also not to toot 
our own horns, but I think in infectious disease, infection 
control communities in the DOD are probably one of the more 
united groups of anywhere in medicine in the DOD. We cross-
train at Bethesda and Walter Reed. We are Army and Navy. In San 
Antonio we are Army and Air Force. We swap staff around 
frequently. We have a very good idea of what is going on.
    And so when we talked about this before, it was hard for us 
to separate out what we would do in each service, because we 
really do this very much in a unified fashion, which I think is 
the best way for our patients and the best way overall for the 
way we want to go with this.
    Dr. Snyder. And for the sake of our transcriptionist, that 
``staff'' was with a double F, and not with a P-H kind of 
thing.
    I wanted to ask Ms. English, you talked very eloquently 
about really getting in the prevention aspects of it. Have you 
seen a difference over time, over the last several years, once 
an infection has been diagnosed in terms of how well patients 
have done as you have tracked that over the last six or seven 
years, once they are diagnosed with an infection?
    Apparently not a dramatic improvement.
    Captain Martin. I think that is a tough question and I 
think it is a very good question. I think that we are much more 
sensitive to the fact that we have to be ready to treat an MDRO 
right up front much more quickly. So we tend to collect our 
samples and maybe more broadly treat with antimicrobial 
therapies up front than we would have before, which may give us 
a day or two jump on this before material comes back from the 
lab.
    And we also have a pretty robust discussion among ourselves 
about how do you want to tackle this one. You know, this 
patient has renal failure, and on top of it has this MDRO and 
these other issues going on. Because these are tough, tough 
clinical cases to handle very frequently.
    So I think we are a little faster to be able to get that 
together than maybe we were at first when we were a little more 
shocked by these. I don't know if you have any comments to add, 
Colonel Forgione, or----
    Colonel Hospenthal. I would agree with that. We have also 
made ourselves and our surgical colleagues aware that just 
looking for bacteria because it might be there is not always 
the best idea. So we do not swab wounds like we used to when we 
first started thinking about Acinetobacter and just treating 
the colonization. So we really have become more sophisticated 
into only treating folks who clearly have infections. That way 
we are not exposing our folks to some of these older and more 
toxic agents.
    Overall, I think patients are doing better. But that is my 
anecdotal--my opinion. The TIDOS study certainly will give us 
that data on how folks were treated, what works best. The 
orthopedic groups in the military and across the civilian are 
doing some larger studies for prevention with irrigation 
pressures, irrigation fluids, irrigation additives for most of 
these.
    Most of these are traumatic extremity injuries. So there is 
major funding for that research that is being done multicenter 
and internationally. And I certainly think that data will help 
us as well. We have developed prevention guidelines that talk 
about peri-injury antibiotics, debridement, irrigation, et 
cetera. That is a DOD, Army, Air Force, Navy program. We are 
actually in the middle of revising those guidelines and doing 
an update for prevention.
    And I guess one side note, during all of this we noticed 
that minocycline was actually an effective old drug for at 
least the Acinetobacters. And we did work with the company that 
actually owned the license for intravenous minocycline to get 
it back on the market. It was never--it is still approved. It 
is now available again.
    Dr. Snyder. Colonel Hospenthal, I want to make sure I 
understand what you are saying about the irrigation. On the 
studies on the irrigation, are you saying that sometimes there 
is inadequate irrigation in terms of cleansing, or you can 
fire-hose it away to where you devitalize some tissue?
    Colonel Hospenthal. Right. Probably the latter is more 
important. I mean no one really knows how much irrigation fluid 
to use. But is that really important? If you need to use it, 
how much you need to get all the visible junk out of there.
    More important is the pressure. There is a division among 
surgeons, and in the literature, both basic research and animal 
research and clinical trials, that high pressure is better 
because these explosive IED blasts push things up in there and 
we need to get them out so they don't become a nidus of 
infection, versus high pressure is really only used to chisel 
away at bones and take out bone marrow, and you shouldn't be 
using high pressure and causing more tissue damage that then 
might get infected. So trying to sort out which of those 
actually is the better approach is being funded as a clinical 
trial.
    And then there is the debate, you know, naturally you are 
thinking if I am pushing fluid up in there, wouldn't it be 
better to have some antimicrobial or antiseptic compound in 
that fluid? Well, the research on that is all over the board as 
well. A lot of the things that we would put in fluid to 
irrigate actually kills bacteria, but it also kills growing and 
granulating tissue. And so it may cause delayed healing that 
then does get infected. So there are research projects into 
looking at additives for irrigation fluid as well.
    Dr. Snyder. I can't let you all get out of here today 
without at least having you respond to the following question. 
I had a discussion this morning with somebody who works on the 
Hill, expressing their disappointment about going to the doctor 
yesterday with about a day and a half of a cold, and the doctor 
just flat-out refused to give them antibiotics. And this person 
was incensed that that was the case, and probably was doctor 
shopping.
    Any one of you want to comment on the issue of the proper 
use and overuse of antibiotics and its relationship to these 
challenges you all are talking about today?
    Colonel Jaffin. Sir, I think you have hit the--one of the 
big problems around the world is that the expectation that 
anything that you go to a doctor for needs antibiotics to cure. 
We have aggressively taught that to all our healthcare 
providers, all our healthcare team, that you only use 
antibiotics when clinically indicated, and you use the most 
specific antibiotic for that particular organism to prevent the 
growth of drug resistance.
    Captain Martin. I think it is a very, very interesting 
question. And I have found kind of a dichotomy. That here in 
the U.S., because people now have heard about the overuse of 
antibiotics, in some people it has been easier to tell them you 
don't need an antibiotic for this.
    I think, as the Colonel just mentioned, the problem is in a 
lot of the rest of the world--and I have lived and worked 
overseas before in Latin America, and we are seeing this now 
with the bugs coming out of India. A lot of the other world, 
the rest of the world, you can just go and buy antibiotics. And 
people frequently do, and take a day or two, or a dose or two 
of all kinds of antibiotics.
    So we see some of the most resistant bugs coming out of the 
developing world, where you wouldn't expect that they would 
have ready access to some of these, but they do. So we see 
whether it is multidrug-resistant Salmonella infections out of 
Southeast Asia or sexually transmitted infections. Big problems 
with this. And a lot of it is inappropriate use of antibiotics. 
I think we have a lot of inappropriate use in the U.S. still, 
not nearly what we had before.
    And the example you brought up is I think the most common 
one. I mean, busy physicians who have six and a half minutes to 
see a patient, sometimes it is easier to pull out the 
prescription pad and give them what they want than it is to 
talk them through the fact that they have a viral infection.
    Ms. English. Excuse me. But on the other hand, this weekend 
starts the 2010-11 flu season. And if your colleague had a 
fever above 100.4 and upper respiratory symptoms, he would be 
wise to consult with his primary care provider to receive 
oseltamivir if he hasn't received his flu shot by now.
    Mr. Wittman. Just one additional question. This is a little 
bit in the weeds. But I noticed, Ms. English, you made 
reference to pulsed field as one of the treatments. I know I 
was intrigued by some of the research that is going on out 
there with actually accelerating wound healing with that 
technology. And I know that in my previous life in working in 
public health, there was a lot of research there as far as food 
safety, and having it as an antimicrobial agent in food 
preparation.
    But I would be interested to hear a little bit more from 
you about the future of that technology and the applicability 
there as far as infection control.
    Captain Martin. I think there was a little confusion. What 
she was talking about was pulsed-field gel electrophoresis 
characterizing organisms, which is a different thing than what 
you are talking about, which is also being looked at.
    And in fact in the new hospital, the new Bethesda that we 
are building, they are looking a lot at using some pulses of 
ultraviolet and whatnot to knock down contamination in 
operating rooms and in other rooms. So that is another moving 
area that is really important, especially when you are talking 
about organisms that are even becoming resistant to some of the 
topical antimicrobials that we use. So that is ongoing research 
as well.
    Dr. Snyder. Thank you all for your time today, and thank 
you for the work that you do. I will leave it as an open-ended 
question for the record. If any of you have anything additional 
you would like to add, please send it to the staff here in the 
next week or so, and we will get it to the Members and also 
include it as part of the record of this hearing.
    I hope as time goes by, as you all continue your thinking 
about these issues, if you see a further congressional role in 
this, I hope you will let us know, because we would be very 
receptive to doing what we can. If it is a funding need or 
whatever it is, we would certainly be glad to look at it if you 
see some additional needs there that are not being met that 
Congress can play a role in.
    Thank you all very much. The hearing is adjourned.
    [Whereupon, at 2:51 p.m., the subcommittee was adjourned.]
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                            A P P E N D I X

                           September 29, 2010

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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                           September 29, 2010

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                   QUESTIONS SUBMITTED BY DR. SNYDER

    Dr. Snyder. What does the Department of Defense need in order to 
have sufficient surveillance capabilities to identify and monitor 
multidrug-resistant infections throughout the military healthcare 
system? Should the Army's Multidrug-resistant Organism Repository and 
Surveillance Network (MRSN) be expanded to become a department-wide 
capability? If so, what policy and resources are needed to make this 
happen?
    Dr. Smith. The Department of Defense currently has sufficient 
surveillance capabilities to identify and monitor multidrug-resistant 
infections throughout the military healthcare system. We do not believe 
it's necessary to expand Army's Multidrug-resistant Organism Repository 
and Surveillance Network to become a department-wide capability. When 
necessary, we will consult Congress on the need for additional 
resources and authority.
    Dr. Snyder. Shouldn't MDROs be made reportable medical events in 
DOD and service surveillance systems such as the Global Emerging 
Infections Surveillance and Response System (GEIS)? Why aren't they?
    Dr. Smith. Although including selected Multidrug-Resistant 
Organisms as reportable events could have helped quantify the size of 
the issue, TRICARE Management Activity's Infection Prevention and 
Control Panel, which includes Service representatives and infectious 
disease experts, felt that in most circumstances tracking the 
infections was unlikely to affect the treatment and outcome for 
individual patients because patterns are monitored and acted upon by 
infectious disease and infection control practitioners among others at 
the local level. The panel also felt that electronic systems would soon 
be available (e.g., Multidrug-resistant Organism Repository and 
Surveillance Network System) that can be mined to help answer questions 
related to the size of the issue. The Department of Defense (DOD) 
determines which medical events are included in the DOD Tri-Service 
Reportable Events Guidelines only after reviewing recommendations from 
the Centers for Disease Control and Prevention, the Council of State 
and Territorial Epidemiologists, other public health organizations, 
International Health Regulations from the World Health Organization, 
and after soliciting advice from Infectious Disease experts throughout 
the Department.
    Dr. Snyder. What resources and policy are needed to provide 
military treatment facilities, particularly those in deployed areas, 
adequate standardized laboratory testing capabilities to identify and 
characterize MDROs?
    Dr. Smith. At this time, the Department of Defense does not need 
additional resources and policies to standardize laboratory testing 
capabilities to identify and characterize Multidrug-Resistant Organisms 
(MDROs). We will consult and work with Congress if resources and policy 
changes are necessary.
    Dr. Snyder. Over the past several years military research and 
development related to MDROs has been funded through several different 
Department, service, and congressional programs and initiatives. Why 
hasn't there been a long-term, stable funding source for MDRO-related 
research? Is there a need for a more coordinated and sustained research 
and development program (i.e., a program of record) focused on MDROs? 
If so, who should be responsible for it?
    Dr. Smith. There has not been long-term, stable funding for 
Multidrug-Resistant Organisms (MDRO)-related research because in the 
years immediately preceding Operation Iraqi Freedom/Operation Enduring 
Freedom, there was no military medical research in the area of MDROs. 
Military personnel who suffer combat-related injuries are at 
significant risk of developing acute and chronic infectious 
complications. Prior to 2008 and preceding Operation Iraqi Freedom/
Operation Enduring Freedom, there was no military medical research in 
the area of MDROs.
    In view of the fact that more in-depth research was required on 
MDROs, DOD established an intramural program of research on wound 
infections. In 2010 and subsequent years, the Defense Health Program 
(DHP) has increased funding for medical research to address wounded 
warrior focus areas to include wound infections. Research and 
development activities sponsored under the DHP represent a long-term 
sustainable program for preventing or inhibiting infection with MDROs.
    Moving forward, the Department will ensure there is a coordinated 
and sustained biomedical research and development program. To address 
this, DOD has established the Armed Services Biomedical Research 
Evaluation and Management (ASBREM) Committee. The ASBREM Committee 
serves to facilitate coordination and prevent unnecessary duplication 
of effort within DOD. The ASBREM is chaired by the Director of Defense 
Research and Engineering and co-chaired by the Assistant Secretary of 
Defense for Health Affairs. The ASBREM Committee includes Senior 
Executive representatives from the Services, and acquisition 
executives. Given the establishment of ASBREM, in future, it may serve 
as an oversight committee for managing the research and development 
focused on MDROs.
    Dr. Snyder. What are the principal knowledge gaps and priorities 
for military research and development related to MDRO infections?
    Dr. Smith. The principle knowledge gaps and priorities for military 
research and development related to Multidrug-Resistant Organism 
infections include the following Defense Health Program-sponsored 
activities in basic and applied research:

        Basic research in wound infection prevention and management is 
        focused on the following knowledge gaps and priorities:

        --  Identification and characterization of host immune response 
        biomarkers, particularly those predictive of infection, to aid 
        in clinical decisionmaking (e.g., optimal wound closure time);

        --  Development of capabilities for early detection of 
        antimicrobial resistance and characterization of antimicrobial 
        resistance patterns in wound-colonizing and infecting 
        organisms;

        --  Development of tools to detect and identify nosocomial 
        pathogens; and

        --  Discovery of novel environmental treatments to prevent and/
        or eliminate pathogen contamination from military medical 
        settings.

        Basic research in antimicrobial countermeasures is focused on 
        the following knowledge gaps and priorities:

        --  Identification and characterization of microbial virulence 
        factors and other potential therapeutic targets of metabolic or 
        signaling pathways associated with wound infection and biofilm 
        processes;

        --  Identification of novel therapeutics (e.g., drugs) to 
        mitigate wound infection and biofilm processes; and

        --  Discoveries applicable to polymicrobial infections and 
        topical treatment approaches.

        Applied research in wound infection prevention and management 
        is focused on the following knowledge gaps and priorities:

        --  Development of an in vivo model for polytrauma/blast wound 
        infection;

        --  Identification and characterization of host immune response 
        biomarkers, particularly those predictive of infection, to 
        support clinical wound-management decisions (e.g., optimal 
        wound closure time);

        --  Development of tools for early detection of antimicrobial 
        resistance and characterization of antimicrobial resistance 
        patterns in wound-colonizing and infecting organisms;

        --  Development of tools to detect and identify nosocomial 
        pathogens; and

        --  Development of novel environmental treatments to prevent 
        and/or eliminate pathogen contamination from military medical 
        settings.

        Applied research in antimicrobial countermeasures is focused on 
        the following knowledge gaps and priorities:

        --  Development of strategies to mitigate the action of 
        microbial virulence factors and other potential therapeutic 
        targets of metabolic or signaling pathways associated with 
        wound infection and biofilm processes;

        --  Development of novel therapeutics (e.g., drugs) targeting 
        microbial virulence factors and/or other pathway components to 
        mitigate wound infection and biofilm processes;

        --  Preference is for topical treatment therapies applicable to 
        polymicrobial infections, although novel treatment approaches 
        are also encouraged (e.g., chelators, antibody, phage, 
        antimicrobial peptides, quorum-sensing inhibitors, lysine, and 
        host immunoaugmentation including antibody); and

        --  Preference is for projects with facile applicability for 
        advanced development leading to Food and Drug Administration-
        approved products.

    Dr. Snyder. According to the Navy's statement, coordination of 
surveillance, treatment, and research efforts regarding infections in 
combat injured has taken years to develop and is only in the last year 
coming to fruition. Why did it take so long to achieve this level of 
coordination? What ``lessons-learned'' are being implemented to prevent 
future delay in similar situations?
    Dr. Smith. The question is referring to the development of TIDOS 
(Trauma Infectious Diseases Outcome Study) that has been developed at 
the Uniformed Services University's Infectious Diseases Clinical 
Research Program (IDCRP).
    While we understand the congressional concern, the delay between 
recognizing the problem and initiating a new program was not a failure 
to achieve coordination among the Services. With the establishment of 
the IDCRP in 2006, seed money from the National Institute of Allergy 
and Infectious Diseases became available to initiate TIDOS. Shortly 
thereafter, IDCRP investigators were able to demonstrate the critical 
data that TIDOS would provide clinicians treating the war injured. Navy 
Medicine provided funding for TIDOS in 2009 after the program's value 
was properly assessed for its ability to generate evidenced based data 
to improve how we deliver care. Adequate funding for TIDOS has been 
planned through 2011.
    We will continually review our efforts to fund clinical research 
programs to best respond to emerging needs across the enterprise.
    Dr. Snyder. DOD recently established a new research program--the 
Wound Infection Research Program--which was funded at about $14 million 
in 2010. Why is the Department only requesting about $2 million dollars 
for this program in 2011?
    Dr. Smith, Colonel Jaffin, Captain Martin, Ms. English, Colonel 
Collier, and Colonel Forgione. When DOD established the Wound Infection 
Research program in FY 2010, we did not have the multiyear funding 
option to spread the cost over multiple years. Therefore, the upfront 
cost in FY 2010 included two to three years' worth of medical research. 
The FY 2011 cost reflects smaller adjustments we need to achieve long-
term research planning.
    There has not been long-term, stable funding for Multidrug-
Resistant Organisms (MDRO)-related research because in the years 
immediately preceding Operation Iraqi Freedom/Operation Enduring 
Freedom, there was no military medical research in the area of MDROs. 
Military personnel who suffer combat-related injuries are at 
significant risk of developing acute and chronic infectious 
complications. Prior to 2008 and preceding Operation Iraqi Freedom/
Operation Enduring Freedom, there was no military medical research in 
the area of MDROs.
    In view of the fact that more in-depth research was required on 
MDROs, DOD established an intramural program of research on wound 
infections. In 2010 and subsequent years, the Defense Health Program 
(DHP) has increased funding for medical research to address wounded 
warrior focus areas to include wound infections. Research and 
development activities sponsored under the DHP represent a long-term 
sustainable program for preventing or inhibiting infection with MDROs.
    Moving forward, the Department will ensure there is a coordinated 
and sustained biomedical research and development program. To address 
this, DOD has established the Armed Services Biomedical Research 
Evaluation and Management (ASBREM) Committee. The ASBREM Committee 
serves to facilitate coordination and prevent unnecessary duplication 
of effort within DOD. The ASBREM is chaired by the Director of Defense 
Research and Engineering and co-chaired by the Assistant Secretary of 
Defense for Health Affairs. The ASBREM Committee includes Senior 
Executive representatives from the Services, and acquisition 
executives. Given the establishment of ASBREM, in future, it may serve 
as an oversight committee for managing the research and development 
focused on MDROs.
    Dr. Snyder. To what extent does the Department of Defense formally 
coordinate and share information with the Department of Veterans 
Affairs on the surveillance, prevention, and treatment of MDRO 
infections? How is this done?
    Dr. Smith. Currently, there are no formal coordination efforts 
between the DOD and VA on the surveillance, prevention, and treatment 
of MDRO infections. However, there are collaborative efforts underway 
between the Department of Defense (DOD) and Department of Veterans 
Affairs (VA) under the National Institute of Allergy and Infectious 
Diseases/Uniformed Services University Infectious Diseases Clinic 
Research Program which have established a long-term research protocol, 
entitled ``Trauma Infectious Diseases Outcomes Study,'' to study 
interventions and outcomes in our combat wounded who develop multidrug-
resistant organism (MDRO) infections. Patient recruitment for this 
protocol began in June 2009.
    Dr. Snyder. What does the Department of Defense need in order to 
have sufficient surveillance capabilities to identify and monitor 
multidrug-resistant infections throughout the military healthcare 
system? Should the Army's Multidrug-resistant Organism Repository and 
Surveillance Network (MRSN) be expanded to become a department-wide 
capability? If so, what policy and resources are needed to make this 
happen?
    Colonel Hospenthal and Colonel Jaffin. The Department of Defense 
should continue to maintain and strengthen established infection 
prevention and control policy and practice at the local military 
treatment facility (MTF), Service, and Department levels. Staffing and 
support resources along with implementing policy are needed in order to 
effect adequate identification and surveillance of MDRO infections 
throughout the military healthcare system. The Army's MRSN could be 
expanded throughout the Department to better coordinate and enhance 
MDRO surveillance, characterization, and response.
    Dr. Snyder. Shouldn't MDROs be made reportable medical events in 
DOD and service surveillance systems such as the Global Emerging 
Infections Surveillance and Response System (GEIS)? Why aren't they?
    Colonel Hospenthal and Colonel Jaffin. MDRO infections are 
currently tracked at the individual medical treatment facility level as 
suggested by the Centers for Disease Control and Prevention (CDC) and 
other professional organizations. As opposed to other reportable 
diseases (e.g., cholera or measles), MDROs are an ill-defined group of 
organisms. If MDROs were reportable the definition of an MDRO and the 
diagnostic procedures would have to be constantly updated. The term 
MDRO is chiefly used to discuss multidrug-resistant (MDR) Gram-negative 
bacteria even though current CDC definitions include Gram-positive 
organisms (e.g., methicillin-resistant Staphylococcus aureus (MRSA), 
vancomycin-resistant Enterococcus (VRE)). MDROs potentially include 
hundreds of individual species and resistance genes. Many of the 
resistance mechanisms can only be identified by specialized laboratory 
testing such as gene sequencing. Due to new resistance mechanisms and 
predominant bacterial species continuing to emerge, Gram-negative MDRO 
infections are not currently reportable events in U.S. civilian or 
military sectors.
    Dr. Snyder. What resources and policy are needed to provide 
military treatment facilities, particularly those in deployed areas, 
adequate standardized laboratory testing capabilities to identify and 
characterize MDROs?
    Colonel Hospenthal and Colonel Jaffin. Most military medical 
treatment facilities (MTF) outside of the combat zones have adequate 
capabilities to identify and characterize MDROs. The larger deployed 
MTFs have been provided clinical microbiology assets and equipment.
    Dr. Snyder. Since the outbreak of MDRO infections, what additional 
infection control and prevention training and education do medical 
personnel in deployed military treatment facilities receive? Please 
describe the nature and extent of the training, what personnel are 
required to take it, and where and how often it is provided. Are there 
plans to expand infection control training and education?
    Colonel Hospenthal and Colonel Jaffin. Additional infection control 
training was added to the Joint Forces Combat Trauma Management Course 
at Fort Sam Houston, Texas. This training is provided to personnel 
staffing level III deployed medical treatment facilities such as the 
Army's Combat Support Hospitals (CSHs). Additionally, a 5-day short 
course was established to train Infection Control Officers who are 
responsible for infection control programs within these hospitals. 
Because a single CSH may split to operate in multiple locations, a 
September 2010 Army Execute Order requires the CSH to assign an 
Infection Control Officer at each location that provides inpatient 
care.
    Dr. Snyder. Do all deployed military treatment facilities have 
trained and qualified infection control officers? If not, why? What 
policy or resources are needed to ensure there is not a shortage of 
military healthcare personnel trained and experienced in infection 
control?
    Colonel Hospenthal and Colonel Jaffin. Reviews of the combat 
theater hospitals in 2008 and 2009 found that not all had trained and 
qualified infection control officers (ICO). There is a shortage of 
personnel trained and qualified to serve as ICOs at all deployed 
medical treatment facilities (MTF). To remedy the shortage of qualified 
ICOs, a 5-day short course was established to train personnel who are 
responsible for infection control programs and have been identified to 
serve as Infection Control Officers at the CSH. Because a single CSH 
may split to operate in multiple locations, a September 2010 Army 
Execute Order requires the CSH to assign an Infection Control Officer 
at each location that provides inpatient care. Department of Defense 
staffing policy should be revised to require trained and qualified ICOs 
at all level III deployed MTFs (i.e., deployed hospitals).
    Dr. Snyder. According to the Army's statement, critical reviews of 
infection control practices and challenges in combat theater hospitals 
were conducted in 2008 and 2009, which led to improved infection 
control efforts. Are there plans to conduct such reviews on a regular 
basis in the future? If so, who will conduct these reviews, how often 
will they be conducted, and where will the results be reported to? If 
not, what policy and resources are needed to establish this process?
    Colonel Hospenthal and Colonel Jaffin. These reviews have been and 
continue to be planned and conducted ad hoc by the Infectious Disease 
and Infection Control Consultants to the U.S. Army Surgeon General with 
the support of the U.S. Central Command (CENTCOM) Surgeon. The informal 
plan is to continue these reviews on an annual basis with results 
communicated to the CENTCOM Surgeon, the three Services Surgeons 
General offices, and through presentations and publications to 
deploying healthcare providers. These reviews will be conducted on a 
routine and regular basis, ideally in conjunction with standardized 
theater infection control practices and establishment of an infection 
control theater consultant.
    Dr. Snyder. What are the principal knowledge gaps and priorities 
for military research and development related to MDRO infections?
    Colonel Hospenthal and Colonel Jaffin. For military research and 
development related to MDRO infections, principal knowledge gaps 
existed in diagnostic and treatment products and programs have been 
established to mitigate these gaps. Principal research priorities focus 
on addressing knowledge gaps in addition to research on prevention 
strategies and technologies. Programs established to address these 
knowledge gaps and priorities include the Military Infectious Diseases 
Research Program--Wound (MIDRP-W) and the Infections Diseases Clinical 
Research Program (IDCRP). The MIDRP-W focuses on wound infection 
research. The IDCRP, a joint program between Department of Defense 
(DOD) and National Institutes of Health, focuses on the design, conduct 
and publishing of collaborative clinical infectious disease research of 
importance to the DOD and the National Institutes of Allergy and 
Infectious Diseases through an effective research network that rapidly 
responds to evolving infectious disease threats.
    Dr. Snyder. According to the Navy's statement, coordination of 
surveillance, treatment, and research efforts regarding infections in 
combat injured has taken years to develop and is only in the last year 
coming to fruition. Why did it take so long to achieve this level of 
coordination? What ``lessons-learned'' are being implemented to prevent 
future delay in similar situations?
    Colonel Hospenthal and Colonel Jaffin. Since multidrug-resistant 
Acinetobacter were first discovered as infecting patients on the United 
States Naval Ship Comfort at the start of Operation Iraqi Freedom, 
several ad hoc groups have helped to coordinate the Department of 
Defense response to MDROs. This initial discovery and identification 
did not include all MDROs, only Acinetobacter. The work and 
coordination of these ad hoc groups have grown over the subsequent 
years to what exists today. Implemented lessons learned include the 
rapid identification and assessment of the class of infection along 
with rapid dissemination of findings to other services and Department 
of Defense infectious disease oversight organizations.
    Dr. Snyder. What does the Department of Defense need in order to 
have sufficient surveillance capabilities to identify and monitor 
multidrug-resistant infections throughout the military healthcare 
system? Should the Army's Multidrug-resistant Organism Repository and 
Surveillance Network (MRSN) be expanded to become a department-wide 
capability? If so, what policy and resources are needed to make this 
happen?
    Captain Martin and Ms. English. The collection of Multidrug-
resistant Organisms (MDROs) specimens from the National Naval Medical 
Center Bethesda for the MRSN is already occurring and could be expanded 
to other Navy military treatment facilities (MTFs). Most Navy MTFs have 
an MDRO identification and surveillance capability and the Navy and 
Marine Corps Public Health Center (NMCPHC) is expanding the central 
monitoring of CHCS (Composite Health Care System) laboratory input to 
eventually include all Navy MTFs.
    Dr. Snyder. Shouldn't MDROs be made reportable medical events in 
DOD and service surveillance systems such as the Global Emerging 
Infections Surveillance and Response System (GEIS)? Why aren't they?
    Captain Martin and Ms. English. No, the Centers for Disease Control 
and Prevention (CDC) have not recommended tracking MDROs in this 
manner. Diseases that are reportable are connected to individual 
patients whereas MDRO isolates may be from clinical specimens, 
colonization surveillance, environmental samples.
    Data regarding the resistance profiles of bacteria are best 
gathered in an antibiogram (spreadsheet describing the antibiotic 
susceptibility of bacteria from a facility's microbiology lab that is 
updated periodically). Collection and review of the data from Navy MTFs 
on a regular basis allows for MDROs to be tracked more effectively. The 
Navy and Marine Corps Public Health Center (NMCPHC) is tracking the 
resistance profiles of bacteria at Navy hospitals electronically by 
collecting data from the laboratory computer input into CHCS (Composite 
Health Care System).
    Dr. Snyder. What resources and policy are needed to provide 
military treatment facilities, particularly those in deployed areas, 
adequate standardized laboratory testing capabilities to identify and 
characterize MDROs?
    Captain Martin and Ms. English. Much of the initial identification 
of MDROs can be performed with standard microbiology techniques (with 
the addition of some commercially available test strips) and does not 
require high-tech capacity. The ability to provide reliable data 
regarding MDROs in the deployed areas requires a basic microbiology 
laboratory, not only with the basic capabilities currently in place, 
but also a trained microbiologist/micro lab tech to interpret the 
laboratory data and guide further testing.
    The provision of even a basic microbiology in a far forward-
deployed setting is often not possible. In these cases, identification 
of MDROs could also be achieved by shipping the MDRO suspect isolates 
on to Landstuhl Regional Medical Center or CONUS facilities where these 
organisms can be more reliably evaluated.
    Fully characterizing MDROs requires highly advanced laboratory 
abilities and could not be done in the deployed setting and is best 
performed at a centralized site such as that functioning with the 
Multidrug-resistant Organism Repository and Surveillance Network 
(MRSN).
    Dr. Snyder. Since the outbreak of MDRO infections, what additional 
infection control and prevention training and education do medical 
personnel in deployed military treatment facilities receive? Please 
describe the nature and extent of the training, what personnel are 
required to take it, and where and how often it is provided. Are there 
plans to expand infection control training and education?
    Captain Martin and Ms. English. Infection Control is a universal 
part of the training of all medical, dental and nurse corps officers as 
well as hospital corpsmen. The Navy does not require special training 
in infection control and has no specialized prevention training 
specifically for those deployed, but does have several programs to 
train Infection Preventionists (IPs). We have reemphasized basic 
infection control in the deployed military treatment facilities and 
requests for additional training, as needed, are strongly encouraged.
    IPs in charge of infection prevention and control programs must 
receive documented education in basic concepts of infection 
surveillance, prevention, and control from an accredited program 
providing continuing education credits. Navy Medicine holds monthly 
video teleconference/digital conference online (VTC/DCO) meetings 
hosted by the BUMED Infection Control Consultant. These sessions are 
offered to all medical treatment facility/dental treatment facility 
(MTF/DTF) IPs. They provide education on infection prevention/control 
topics as well as updates related to current literature and Joint 
Commission surveys.
    Additionally, each MTF/DTF is encouraged to send IPs to current, 
up-to-date courses. Examples include: EPI 101 (Fundamentals of 
Infection Surveillance, Prevention and Control) courses by Association 
for Professionals in Infection Control and Epidemiology (APIC); Courses 
in Healthcare Epidemiology cosponsored by the Society for Healthcare 
Epidemiology of America and the Centers for Disease Control and 
Prevention (SHEA/CDC); Annual Fellows Course in Hospital Epidemiology 
and Infection Control at the Johns Hopkins Hospital in Baltimore, 
Maryland; the Statewide Program for Infection Control and Epidemiology 
(SPICE) at the University of North Carolina at Chapel Hill.
    Dr. Snyder. Do all deployed military treatment facilities have 
trained and qualified infection control officers? If not, why? What 
policy or resources are needed to ensure there is not a shortage of 
military healthcare personnel trained and experienced in infection 
control?
    Captain Martin and Ms. English. All Medical, Dental, and Nurse 
Corps officers along with enlisted Hospital Corpsmen have training in 
infection control and infection control has been re-emphasized in all 
Navy facilities as the increase in Multi-Drug Resistance Organisms 
(MDROs) has occurred. There is not a specific designation for infection 
control officers in the Navy. Military treatment facilities in deployed 
settings assign a medical department officer to be responsible for 
infection control. The hospital ships USNS Comfort and USNS Mercy, each 
have assigned infectious diseases staff who are subject matter experts 
in infection control, and other ships with a large medical department 
may also deploy with an infectious diseases physician.
    The Navy has not experienced a shortage of military healthcare 
personnel trained and experienced in infection control.
    Dr. Snyder. According to the Army's statement, critical reviews of 
infection control practices and challenges in combat theater hospitals 
were conducted in 2008 and 2009, which led to improved infection 
control efforts. Are there plans to conduct such reviews on a regular 
basis in the future? If so, who will conduct these reviews, how often 
will they be conducted, and where will the results be reported to? If 
not, what policy and resources are needed to establish this process?
    Captain Martin and Ms. English. We are continually working to 
improve how we deliver healthcare in all our medical facilities. 
Continuously reviewing and revising how we do business helps us ensure 
we are evaluating and implementing best clinical practices. The Army's 
recent review of Infectious Disease and Infection Control was a good 
example of how we have learned and adapted to conditions in-theater. It 
was evident from the review that there was a need to reemphasize basic 
infection control practices. This approach has had a positive impact 
for not only our patients in-theater, but also for those in CONUS. In 
addition to our renewed emphasis on basic infection control, the Navy 
and Marine Corps Public Health Center (NMCPHC) is electronically 
tracking the resistance profiles of bacteria at Navy Military Treatment 
Facilities. Navy Medicine will continue to conduct additional reviews 
as appropriate and in collaboration with our partners in-theater.
    Dr. Snyder. What are the principal knowledge gaps and priorities 
for military research and development related to MDRO infections?
    Captain Martin and Ms. English. The principal gap in MDRO-related 
research is the lack of available drugs in the development pipeline to 
effectively treat these infections. This problem is not specific to the 
military as it affects civilian facilities worldwide. The need for an 
international focus on development of new drugs for these infections is 
outside the research capabilities in the U.S. military at this time. 
The military has chosen to focus its intramural research efforts on 
areas of specific concern for clinical care of the injured warfighter.
    The Navy has focused funding on the clinical aspects of MDRO 
infections in war injuries. The two focus areas are:

    1.   Developing enhanced surveillance and electronic reporting from 
Navy laboratories of MDROs to determine the source of these organisms 
and minimize their acquisition and spread among patients and staff.
    2.   Assessing what treatment and management strategies for wound 
infections with MDROs are associated with the best outcomes through the 
TIDOS (Trauma Infectious Disease Outcome Study).

    Dr. Snyder. According to the Navy's statement, coordination of 
surveillance, treatment, and research efforts regarding infections in 
combat injured has taken years to develop and is only in the last year 
coming to fruition. Why did it take so long to achieve this level of 
coordination? What ``lessons-learned'' are being implemented to prevent 
future delay in similar situations?
    Captain Martin and Ms. English. The question is referring to the 
development of TIDOS (Trauma Infectious Diseases Outcome Study) that 
has been developed at the Uniformed Services University's Infectious 
Diseases Clinical Research Program (IDCRP).
    With the establishment of the IDCRP in 2006, seed money from the 
National Institute of Allergy and Infectious Diseases (NIAID) became 
available to initiate TIDOS. Shortly thereafter, IDCRP investigators 
were able to demonstrate the critical data that TIDOS would provide 
clinicians treating the war injured. Navy Medicine provided funding for 
TIDOS in 2009 after the program's value was properly assessed for its 
ability to generate evidenced based data to improve how we deliver 
care. Adequate funding for TIDOS has been planned through 2011.
    The delay between recognizing the problem and initiating a new 
program was not a failure to achieve coordination among the Services. 
Navy Medicine has a strong working relationship with the Army and Air 
Force in the area of infection control. Our efforts to uncover the 
Multidrug-Resistant Organism problem were successful and subsequent 
efforts to fund clinical research programs have been addressed. Navy 
Medicine is currently funding TIDOS and is continuously reviewing 
priorities to best respond to emerging needs across the enterprise.
    Dr. Snyder. What does the Department of Defense need in order to 
have sufficient surveillance capabilities to identify and monitor 
multidrug-resistant infections throughout the military healthcare 
system? Should the Army's Multidrug-resistant Organism Repository and 
Surveillance Network (MRSN) be expanded to become a department-wide 
capability? If so, what policy and resources are needed to make this 
happen?
    Colonel Collier and Colonel Forgione. Expansion of the Army's MSRN 
to become a DOD-wide program would provide sufficient surveillance to 
identify and monitor these infections. We would work with the Army to 
determine what resources would be needed to make this a reality.
    Dr. Snyder. Shouldn't MDROs be made reportable medical events in 
DOD and service surveillance systems such as the Global Emerging 
Infections Surveillance and Response System (GEIS)? Why aren't they?
    Colonel Collier and Colonel Forgione. The CDC's National Healthcare 
Safety Network and The Joint Commission requires programs to track and 
control healthcare-associated infections (from catheters, ventilators, 
etc.) and has specific definitions for methicillin-resistant 
Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), 
Gram-positive infections. Certain MDROs are not reported due to their 
diverse species and broad range of resistance mechanisms; these make 
them complex to characterize. While mandatory reporting of Multidrug-
Resistant Organisms (MDROs) across the DOD would be challenging to 
establish and maintain, such a program would allow for coordinated 
surveillance and response. The first step will be to define which MDROs 
will be tracked.
    GEIS has supported the clinical laboratories that perform MDRO 
screening for our four major military medical centers who receive 
combat-wounded U.S. personnel using funds within the currently 
established current screening program. A DOD program as suggested in 
question one could potentially improve oversight in reporting MDROs 
across the DOD. GEIS focuses predominantly on emerging infections 
overseas.
    Dr. Snyder. What resources and policy are needed to provide 
military treatment facilities, particularly those in deployed areas, 
adequate standardized laboratory testing capabilities to identify and 
characterize MDROs?
    Colonel Collier and Colonel Forgione. USAF military medical 
treatment facilities (MTF) outside of the deployed areas are adequately 
equipped and staffed to perform bacterial identification and antibiotic 
sensitivities; emerging Multidrug-Resistant Organisms (MDROs) will be 
referred to designated DOD referral labs for advanced testing and 
characterization. Larger deployed MTFs should receive supplemental 
clinical microbiology assets and equipment. A DOD program policy to 
standardize deployed clinical microbiology assets would enhance 
surveillance and is essential to standardized analysis, interpretation 
and reporting of emerging MDROs.
    Dr. Snyder. Since the outbreak of MDRO infections, what additional 
infection control and prevention training and education do medical 
personnel in deployed military treatment facilities receive? Please 
describe the nature and extent of the training, what personnel are 
required to take it, and where and how often it is provided. Are there 
plans to expand infection control training and education?
    Colonel Collier and Colonel Forgione. All USAF medics receive 
annual training in infection control (IC) practices and principles as 
part of their normal duty assignment. Medics identified to deploy 
receive refresher IC training at various training courses (i.e. EMEDS, 
CCAT, etc). Individuals identified to deploy as the infection control 
officer are required to complete the 5-day Infection Control Course. 
Also there is a specific joint course available: ``Infection Control in 
the Deployed Setting,'' which deploying IC officers are required to 
take. There are no plans to expand these requirements.
    Dr. Snyder. Do all deployed military treatment facilities have 
trained and qualified infection control officers? If not, why? What 
policy or resources are needed to ensure there is not a shortage of 
military healthcare personnel trained and experienced in infection 
control?
    Colonel Collier and Colonel Forgione. Yes, the USAF provides an 
officer who has completed the infection control basic course to manage 
infection control at Expeditionary Medical Support (EMEDS) facilities.
    Dr. Snyder. According to the Army's statement, critical reviews of 
infection control practices and challenges in combat theater hospitals 
were conducted in 2008 and 2009, which led to improved infection 
control efforts. Are there plans to conduct such reviews on a regular 
basis in the future? If so, who will conduct these reviews, how often 
will they be conducted, and where will the results be reported to? If 
not, what policy and resources are needed to establish this process?
    Colonel Collier and Colonel Forgione. According to the Army 
Infectious Disease (ID) Consultant there are no formal plans for 
regular reviews of the infection control practices and challenges in 
deployed level III medical treatment facilities (MTF), but plans are 
currently underway for a review of the Afghan theater operations in 
winter of 2011 by the Army ID Consultant. The USAF has no plans to 
conduct a theater review in the coming year. We agree that there is a 
need to conduct routine and regular reviews, and support a joint team 
concept, using standardized theater infection control practices. The 
Air Force Surgeon General is working to have AFIA, our inspection 
agency, review infection control practices and outcomes at our 
hardened, sustained, MTFs in theater.
    Dr. Snyder. What are the principal knowledge gaps and priorities 
for military research and development related to MDRO infections?
    Colonel Collier and Colonel Forgione. The Joint Program Committee-2 
(JPC-2) used Fiscal Year 2010 Defense Health Program e-funds for 
approximately 32 Multidrug-Resistant Organisms (MDRO)-focused research 
projects in five DOD laboratories, in five civilian university 
laboratories, and in four companies in the commercial sector. The 
Military Infectious Diseases Research Program (MIDRP)/JPC2 current gaps 
for MDROs are:

    a.   Wound Infection Prevention & Management: Fundamental research 
to prevent infections and inform clinical wound management.
    b.   Antimicrobial Countermeasures: Fundamental research for 
discovery of tools to treat MDRO wound infections.
    c.   Wound Infection Prevention & Management: Applied research for 
development of tools to prevent wound infection and inform clinical 
wound management.

    Dr. Snyder. According to the Navy's statement, coordination of 
surveillance, treatment, and research efforts regarding infections in 
combat injured has taken years to develop and is only in the last year 
coming to fruition. Why did it take so long to achieve this level of 
coordination? What ``lessons-learned'' are being implemented to prevent 
future delay in similar situations?
    Colonel Collier and Colonel Forgione. There was coordination 
initially at the level of the infectious diseases specialists from the 
time the problem was identified initially on the USNS Comfort at the 
start of the Iraqi War in 2003 and the three services mobilized to 
tackle this challenging problem. Over the last seven years and despite 
the absence of a central coordinating body, the services created a 
relatively robust response to the issues despite the challenges 
outlined in these questions and our previous testimony. The 
infrastructure and research initiatives initiated to date laid the 
groundwork upon which we may build a more vigorous and improved DOD 
response in 2010 and beyond.
    The Air Force Medical Service has not been faced with many patients 
with Multidrug-Resistant Organism (MDRO) infections; so, as a service, 
the issue has not required significant resources. However, our 
significant participation in transporting wounded joint/coalition 
patients via the patient movement system (Air Evacuation and through 
our theater hospitals (Balad, Bagram)) and the guarantee that we will 
be similarly involved in future conflicts mean we must join the joint 
effort to address MDROs. To that end, we will continue to place 
competent and trained infection control officers at our Military 
Treatment Facilities and we support making the Army's Multidrug-
Resistant Organism Repository and Surveillance Network (MRSN) a DOD 
program and the use of the Global Emerging Infectious Surveillance and 
Response System (GEIS) as a database to track and analyze MDRO 
infections.

                                  
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