Johns et al. BMC Public Health 2011, 11(Suppl 2):S3 http://www.biomedcentral.com/1471-2458/11/S2/S3 Collaborating Center, in compliance with IHR (2005). With the onset of this influenza A/H1N1 pandemic in April 2009, substantial efforts were made by AFHSC-GEIS network partners to assist the global health community in responding to this threat. Fifty-one (67 percent) of the 76 outbreaks responses involved respiratory diseases, 41 (80 percent) of which were due to novel influenza A/H1N1. Beginning in April 2009, with the onset of the influ- enza pandemic, disease surveillance and investigative support activities were dominated by novel influenza A/H1N1-related responses. As with other investigations, the activities for novel influenza A/H1N1 were wide- ranging and involved different populations and situations. The AFHSC-GEIS network supported the diagnostic confirmation (directly in DoD lab or through support of host-country laboratories) of the first cases in 14 coun- tries (Bhutan, Cambodia, Colombia, Djibouti, Ecuador, Egypt, Kenya, Kuwait, Lao People’s Democratic Republic, Lebanon, Nepal, Peru, Republic of the Seychelles and the United States), again demonstrating direct support for increasing compliance with IHR (2005). The non-U.S. activities were a result of the respective AFHSC-GEIS partner laboratory’s roles as regional reference testing centers and the bilateral collaborations with host-country Ministries of Health. These bilateral relationships resulted in support of 17 large-scale outbreaks among civilians in 13 countries. U.S. service members and beneficiaries were affected by the pandemic from the beginning. In the first wave (April through August 2009), AFHSC-GEIS network partners actively investigated 18 different outbreaks on U.S. military installations and among previously defined high-risk groups [11]. These high-risk groups included deployed or deploying personnel, shipboard personnel, new accessions (basic and advanced military trainees and service academy students), health care workers, children and staff in daycare centers, and pregnant women. Stressful military environments, highly mobile missions and complex troop dynamics helped to propa- gate pandemics in the past and have drawn the atten- tion of the military’s operational leadership and leaders of civilian sectors within host countries. These investi- gations involved from a few dozen cases to more than 1,000 cases tested. Shipboard investigations involved a number of responding units and included ships at sea in the Atlantic and Pacific Oceans, and the Persian Gulf, as well as vessels in port in major cities around the world. Shipboard investigations have benefitted from the ongoing surveillance of respiratory disease on large U.S. Navy ships [12]. Patients meeting the case definition of febrile respiratory illness (FRI), temperature > 100.4°F and cough or sore throat, undergo throat swabs and the Page 4 of 9 specimens are stored in liquid nitrogen or -80°C freezers. This surveillance, conducted by NHRC, has facilitated timely specimen collection and pathogen identification in a number of shipboard respiratory outbreaks in recent years. The surveillance system detects a wide variety of circulating influenza types as these ships make numerous worldwide port stops over a short time period. In general, the specimens are saved and processed at the end of a ship’s deployment, which usually lasts six months. How- ever, in the case of an outbreak, febrile respiratory illness (FRI) specimens from immediately before the outbreak onward can be processed onboard the ship with specific polymerase chain reaction (PCR) testing or shipped over- night to NHRC for 12- to 24-hour turnaround molecular testing and culture. Shipboard investigations ranged from simple identifi- cation of the novel influenza A/H1N1 virus to detailed epidemiologic investigation and testing [13]. NMRCD, in partnership with the Peruvian Navy, investigated a shipboard outbreak in June through July 2009 aboard a 355-crew Peruvian Navy ship at sea in the Pacific Ocean. During the four-week investigation, team mem- bers confirmed 78 of 85 (92 percent) febrile acute respiratory illness cases as novel influenza A/H1N1. The attack rate aboard the ship during the time of the out- break was 22 percent. Early detection, through an active shipboard surveillance system modeled on the NHRC program, played an important role in the rapid detection and subsequent control of the outbreak [14]. The USS Boxer (LHD 4), with a complement of more than 2,200 U.S. Sailors and Marines, was docked at Phuket, Thailand, from June 23 through 29, 2009. On June 30, four of 14 patients with ILI tested positive for influenza A by PCR. By July 9, 102 individuals had pro- vided respiratory specimens (throat swabs in viral trans- port media) that were sent to NHRC, where 69 were confirmed as novel influenza A/H1N1. Overall, more than 200 cases were identified in a five-week period and 177 personnel were isolated with FRI for an average duration of 3.6 days (Figure 2) [15]. As part of the deployment process, troops usually transition through pre-deployment training at what the U.S. Army refers to as power projection platforms (PPP). These are usually large installations with thou- sands of individuals transferring to the deployed setting each year [16]. The first wave of novel influenza A/H1N1 included outbreaks among deploying service members from nine of the 15 PPPs and subsequently resulted in two large-scale outbreaks in the operational theatre (Iraq and Kuwait). The most notable PPP out- breaks were at Fort Riley, Kansas (n=33), Fort Hood, Texas (n=44), Fort Lewis, Washington (n=144), and Fort Bliss, Texas (n=188). Response activities at each of the PPPs varied based on the reality on the ground