Johns et al. BMC Public Health 2011, 11(Suppl 2):S3 http://www.biomedcentral.com/1471-2458/11/S2/S3 children <15 years and 61 percent from female patients. WARUN in Nepal and AFRIMS in Thailand analyzed the samples using real-time PCR and culture. Eighty-two of the outbreak samples were positive for Vibrio cholerae (01/0139) by PCR. Many of the PCR positive samples sub- sequently grew V. cholerae serogroup 01 serotype Ogawa in culture. Antibiotic sensitivity analysis of the V. cholera isolates showed universal resistance to nalidixic acid, colistin, streptomycin, sulfisoxazole, and trimethoprim/ sulfamethoxazole but sensitivity to the commonly recom- mended antibiotics azithromycin, ciprofloxacin, ampicillin and tetracycline. The National Public Health Laboratory performed the initial culture on these stool samples, and the WARUN and AFRIMS laboratories eventually verified and confirmed the cause of the outbreak. The effort enabled local health authorities to institute appropriate treatment and prevention measures in a timely manner. Department of Defense resources have also been directed toward the investigation or characterization of other phenomena that may threaten public health other than the disease incidence. For example, AFRIMS and NAMRU-2 investigators were among the first worldwide to recognize that increases in Plasmodium falciparum treatment failures to the powerful artemisinin combina- tion therapies signaled the onset of resistance to the last remaining class of malaria treatments in widespread deployment today. As a result of these findings, world- wide efforts are under way to contain spread of drug- resistant forms of the parasite from what is hoped to be a relatively constrained area in Southeast Asia along the Thai-Cambodian border [19]. Although many methods may be used to detect out- breaks, most often an astute clinician or laboratory worker identifies an unusual occurrence or an increased frequency. However, syndromic or electronic surveil- lance may serve as another method to augment, but not replace, traditional disease surveillance efforts [8]. AFHSC-GEIS partners at NMRCD have implemented a near real-time electronic disease surveillance system based on highly cost-effective and sustainable strategies affordable in resource-constrained, developing countries. This system is called Alerta and was first implemented in the Peruvian Navy population in 2002, the Peruvian Army three years later and more recently the Peruvian Air Force. Currently, Alerta covers 98 percent, 99 per- cent and 95 percent of the Peruvian Navy, Army and Air Force population, respectively, and receives over 200 notifications per week. The system has been useful in outbreak detection, identifying over 20 outbreaks in the last year, six of which were for influenza. Eighty-six reporting units operate nationwide, including border units, hospitals, infirmaries and ships incorporated in the Peruvian Navy surveillance system. Due to this pre- vious experience, the Peruvian Army’s expansion has Page 8 of 9 been faster, currently receiving reports from 120 units throughout the country. Within the one-year period of review, the 76 outbreaks identified by the AFHSC-GEIS network spanned the clinical disease spectrum and involved efforts of interna- tional significance. The U.S. DoD has established a robust and flexible global response framework through open collaborations with long-standing host country partners, other global health institutions and agencies such as the WHO, the CDC and Institute Pasteur. In doing so, AFHSC-GEIS, through its global network of partners, is addressing the specific milestones for build- ing sustained capacity for early detection and rapid response as prescribed by the IHR (2005). Conclusions The Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response Sys- tem continues to expand internationally to effectively iden- tify and respond to threats from a wide range of disease agents and geography. The growth and enhancement of this surveillance system in anticipation of pandemic/avian influenza allowed the DoD to identify the current influenza pandemic [20,21] and a number of other infectious disease outbreaks in communities throughout the globe. A multi- purpose system with defined goals and pillars of focus, the AFHSC-GEIS network has evolved to become a true model for emerging infectious surveillance platforms at the local, regional and international level. By utilizing this established global system, the DoD is able to provide a common and systematic approach to disease surveillance and a frame- work for effective response. As emerging and re-emerging threats develop in areas where partners work collabora- tively with host countries and global health institutions, the AFHSC-GEIS network stands ready to respond. Acknowledgements #AFHSC-GEIS Outbreak Response Writing Group: Sonam Wangchuk2, Tandin Dorji2, Robert Gibbons2, Sopon Iamsirithaworn2, Jason Richardson2, Rome Buathong2, Richard Jarman2, In-Kyu Yoon2, Geeta Shakya3, Victor Ofula4, Rodney Coldren4, Wallace Bulimo4, Rosemary Sang4, Duke Omariba4, Beryl Obura4, Dennis Mwala4, Matthew Kasper5, Gary Brice5, Maya Williams5, Chad Yasuda5, Robert V Barthel6, Guillermo Pimentel6, Chris Meyers8, Peter Kammerer8, Darcie E. Baynes8, David Metzgar8, Anthony Hawksworth8, Patrick Blair8, Melody Ellorin8, Robert Coon8, Victor Macintosh9, Kristen Burwell9, Elizabeth Macias9, Thomas Palys10, Kurt Jerke10 The authors wish to thank the numerous individuals who perform surveillance as part of the AFHSC-GEIS global network, including all individuals in the Ministries of Health and Ministries of Defense of our partner nations whose efforts have contributed to the success of the network. Disclaimer The opinions stated in this paper are those of the authors and do not represent the official position of the U.S. Department of Defense, local country Ministries of Health or Defense, or other contributing network partners. This article has been published as part of BMC Public Health Volume 11 Supplement 1, 2011: Department of Defense Global Emerging Infections