VT: The study below is a very thin ‘cover’ for a biowarfare program, one of many we have documents on.  There is no imaginable reason for a test like this unless a bioweapon was being ‘honed in’ through modification much like….COVID 19.

STUDY SYNOPSIS

There is little information available about the prevalence of arthropod-borne and zoonotic infections such as Crimean-Congo Hemorrhagic Fever (CCHF), Hemorrhagic Fever with Renal Syndrome (HFRS), tickborne encephalitis (TBE), West Nile Fever virus (WNV) infection, brucellosis, leptospirosis, tularemia, anthrax, rickettsial infections, and Q fever, as well as the prevalence of infections caused by Bartonella species, Borrellia species, Ehrlichia species, and Salmonella typhi. In addition, many of these infections have non-specific clinical presentations making diagnosis difficult in the absence of reliable diagnostic testing. In Georgia, the population seroprevalence study has never been conducted on these diseases. We propose a single-center seroprevalence study to characterize the epidemiology of these infections among Georgian military recruits. In this study, infection is defined as prior exposure to the infectious agent reflected by a measurable pathogen-specific antibody response.

The objectives of the study are to:

1 . Determine the antibody prevalence of fourteen arthropod-borne and zoonotic infections prior to recruitment of military personnel.

2. Determine epidemiological risk factors associated with prior exposure to these infections.
3. Utilize the envisioned military disease surveillance system for scientific research on especially dangerous pathogens (EDPs).
4. Establish strategic research collaboration among the Central Military Hospital, NCDC, and the U.S. Army Medical Research Unit-Georgia (USMRU-G) in Georgia to target EDPs.

Blood samples will be obtained from 1000 military recruits at the time of their military registration physical exam. Serum samples will be tested for antibodies against the following fourteen pathogens: Bacillus anthracis, Brucella, CCHF virus, Coxiella burnetii, Francise/la tularensis, Hantavirus, Rickettsia species, TBE virus, Battonel/a species, Borrelia species, Ehrlichia species, Leptospira species, Salmonella typhi, and WNV. A questionnaire will also be administered to collect participants’ demographic information, history of clinical symptoms, and exposure factors to these infections. Samples will be tested serologically and stored for possible future testing. The results of this study will establish baseline information about the prevalence of prior exposures to these infections among Georgian military recruits as evidenced by a pathogen-specific antibody response. Findings from this study can be used by the Georgian military to guide future force health protection efforts, to have a better understanding about the health status of the population of military recruits, and to inform the public health sector as to the presence and frequency of exposure of the infections under study in Georgia, with a caveat that the military population is a specific population with specific risk attributes and thus the study results cannot be directly extrapolated to make inferences about the whole population of Georgia.

ABBREVIATIONS

1.0           INTRODUCTION

Investigation of the prevalence of prior exposure to infectious agents in a population provides substantial insight into the epidemiology and possible control of these infections in the population under study. Knowledge of the burden and circulating pathogens in the population that is entering the military system will provide valuable information for force health protection (19). In addition, it will be useful for general public health system in the country. Therefore, we propose to conduct a seroprevalence study among military recruits from different regions of Georgia as they undergo pre-enlistment medical and health assessment at the Central Military Hospital in Gori, the military hospital of the Georgian armed forces. The study participants will be serologically tested for prior exposure to selected arthropod-borne and zoonotic infections.

Crimean-Congo hemorrhagic fever (CCHF) is an acute, highly-contagious viral zoonosis transmitted to humans not only by ticks of the genus Hyalomma but also through direct contact with blood or tissues of viremic hosts. In humans, CCHF typically presents with high fever of sudden onset, malaise, severe headache, and gastrointestinal symptoms. During the last decade, this zoonotic disease has emerged and re-emerged in several Balkan countries, Turkey, southwestern regions of the Russian Federation, and in the Ukraine, with high case fatality rates (1). In the 21st century, outbreaks have become more frequent in Turkey (2), Iran (3), and the country formerly known as Yugoslavia. It has been suggested that CrimeanCongo hemorrhagic fever virus (CCHFv) is a migrating pathogen, but it is not clear to what extent. The analysis of the migration pattern of CCHFv has shown that Turkey may be a donor in Europe, towards both the east and the west (4). Georgian public health professionals and infectious diseases physicians have always suspected the possibility of undetected cases of CCHF in Georgia. In August 2009, the first laboratory confirmed case of CCHF was reported in Georgia (5).

Tick-borne encephalitis virus (TBEv) is a virus in the family Flaviviridae. It causes Tick-borne encephalitis (T BE). This viral infection causes substantial morbidity in Europe (mostly middle to Eastern Europe), where the prevalence has increased by almost 400% in the last 30 years. Other regions or countries affected by TBE are the Ukraine, the Baltic States, the Russian Federation, and East Asia (6). TBE is commonly transmitted by tick bites from infected ticks, but can also be transmitted from ingestion of unpasteurized dairy products from infected animals such as sheep, cows, and goats. In endemic regions, 70-90% of human infections are either sub-clinical or asymptomatic (7). Some patients progress to meningitis or meningoencephalitis with a high rate of permanent neurologic sequelae following central nervous system (CNS) infection. The infection tends to induce a long-term antibody response. Georgian scientists suspect that sporadic TBE cases can occur throughout the country because the virus has been isolated from ticks. However, these data are unpublished and were accumulated approximately 20-30 years ago.

Another cause of viral encephalitis is West Nile virus (WNV), which typically produces asymptomatic infections or a mild febrile illness often accompanied by myalgia, malaise, headache, and gastrointestinal distress (8). However, it can also cause a myriad of clinical symptoms usually related to encephalitis or other neurological effects. Long term sequelae such as fatigue, muscle weakness, and headache have been noted among patients whose initial infection was mild, and persistent movement disorders and cognitive impairment may occur in patients with neuroinvasive disease (9). Unlike TBE, WNV is transmitted by mosquito vectors, primarily of the Culex species. WNV has been reported in several countries near Georgia, including the Ukraine and Romania, as well as in the region of southern Russia (8).

Brucellosis is one of the most common zoonotic infections, with more than 500,000 new cases reported annually, worldwide. Brucellosis is caused by infection with Brucella species bacteria (10). Human infection can occur through consumption of contaminated, unpasteurized animal products, direct contact with infected animal parts, and through the inhalation of infected aerosols (1 1 Brucellosis is endemic in Georgia (12, 13). According to the National Center of Disease Control and Public Health of Georgia, approximately 300 brucellosis cases were reported in 2008-09 (14). However, the true number of cases might be higher because not all patients seek medical treatment and underreporting by the national public health system. Rodent-borne hantavirus infections cause hemorrhagic fever with renal syndrome (HFRS) and occur throughout most of Europe and Russia. The pathogenic hantaviruses detected in Europe and Russia include Puumala, Dobrava, Saaremaa, Tula, Amur, and Hantaan viruses (15, 16). Seroprevalence studies of this emerging pathogenic virus have shown rates as high as 6—9% in Sweden, Estonia, and European Russia. The clinical manifestations of hantavirus infection vary and depend largely on the strain of the infecting virus. Classic case presentation of HFRS is characterized by fever, acute renal failure, hypotension, hemorrhage, and vascular leakage (16). There is a lack of epidemiological information about hantaviruses in the Republic of Georgia. Although some reports from other neighboring countries suggest that this pathogen circulates in the Caucasus, but the burden of hantavirus disease is still unknown. To date, few confirmed hantavirus cases have been reported in Georgia (17).

Leptospirosis, the most widespread zoonosis, is emerging as a major public health problem worldwide. The clinical manifestations of human leptospirosis are diverse, ranging from mild, flu-like illness to a severe disease form known as Weil’s syndrome, characterized by jaundice, acute renal and hepatic failure, pulmonary distress and hemorrhage, which can lead to death (18). Leptospirosis is caused by spirochetes belonging to the genus Leptospira, which comprises both saprophytic and pathogenic species. Leptospirosis has a broad geographical distribution, occurring in both rural and urban areas of tropical, subtropical and temperate regions. In most endemic areas, the majority of infections are mild or not clinically apparent (19). The epidemiology of this disease is not well described in Georgia. The ongoing hospital based surveillance of acute febrile illness in Georgia, which covers several major hospitals in Tbilisi, has detected up to 20 confirmed cases of leptospirosis using the microagglutination test.

Francisella tularensis spp. holarctica (type B) has been identified throughout the northern hemisphere and is the predominant type found in Europe (20). Type B is less virulent than type A. Human transmission of tularemia can occur through multiple routes including arthropod bites, contact with infected animals or animal products, aerosol droplets, and contact with contaminated water or mud. The clinical presentation of tularemia is variable and can be divided into discrete clinical forms depending on the site of exposure; ulceroglandular, glandular, oculoglandular, oropharyngeal, and respiratory tularemia (21). The ulceroglandular form is the most common and presents as an indolent skin ulcer at the site of inoculation together with swelling of the regional lymph nodes. In November 2006, an outbreak of waterborne tularemia occurred in the eastern region in the Republic of Georgia. Outbreak investigation revealed 26 tularemia cases. Of these, 21 were oropharyngeal cases, and 5 were glandular cases (22).

The prevalence and incidence of rickettsial infections (including Q fever) are unknown in Georgia. Rickettsioses can be classified into two major categories based on genetic similarity and clinical presentation: a spotted fever group and a typhus group. Most rickettsial infections are transmitted by arthropods (23). The combination of a typically mild, non-specific clinical presentation, a presumed near worldwide distribution, along with the lack of diagnostic testing suggest that infections with Q fever may be present in Georgia. Up to 60% of people infected with Coxiella burnetii are asymptomatic. The acute form of the disease is characterized by flu-like symptoms, pneumonia, or hepatitis, and chronic manifestations including endocarditis, hepatitis, and chronic fatigue syndrome (24). A better understanding of the extent and burden of this infection provides useful information for decisions regarding disease control measures and comprehensive diagnostic programs in Georgia.

1. anthracis is a gram-positive, rod-shaped bacterium that exists in the environment as a spore and can remain viable in the soil for decades (25). The relative ease with which large amounts of B. anthracis can be grown under laboratory conditions and the spore’s resistance to killing and ease of dissemination facilitates the potential use of the microbe for bioterrorism (26). Anthrax has been classified into one of three syndromes based on the primary site of infection: cutaneous, gastrointestinal, or inhalational. In Georgia, anthrax is an endemic disease. In 2011, there were 81 registered cases of anthrax. In 2012, 142 cases were detected. All of them were cutaneous anthrax cases (14). Seroprevalence studies in healthy population can provide a further insight into this important disease in Georgia.

Salmonella enterica serotype Typhi (S.typhi) is a gram-negative bacterium causing typhoid fever. This organism is an important cause of febrile illness in crowded and impoverished populations with inadequate sanitation and also poses a risk to travelers visiting countries of endemicity (27). Typhoid fever continues to be a global public health problem with over 21.6 million cases and at least 250,000 deaths occurring annually. In developing countries such as India, the disease occurs with an incidence ranging from 102 to 2,219 per 100,000 of the population (28). In Georgia, the typhoid fever is a reportable disease. 17 cases have been described in the southern Georgia in 2002. Since then no big outbreak has been described (29). There are no scientific publications from Georgia about this disease. This study will help to describe the exposure to the S. typhi in Georgia.

There is very little or no epidemiological information about the three pathogens discussed below. This study will be the first attempt at looking into the seroprevalence of these diseases. These diseases should be considered in the differential diagnosis of fever, for example. The data obtained from this study and the Acute Febrile Illness study will establish a baseline of epidemiological data of these emerging zoonotic diseases for further clinical studies in Georgia.

Bartonellosis comprises infections caused by newly emerging pathogens in the genus Bartonella. At least a dozen species belong to the genus Battonella. Three Bartonella species are currently considered important causes of human disease, but other significant human pathogens in this genus were found to cause disease in humans occasionally. B. quintana is found worldwide and causes febrile outbreaks. Poor sanitation and lack of personal hygiene strongly correlate with transmission by the body louse Pedicu/us humanus. B quintana is emerging as a recognized cause of disease among homeless persons and persons with AIDS. Trench fever syndrome is found among people with alcoholism and those who are homeless. Currently, Battonel/a species cause several clinical syndromes, including catscratch disease (with enlarged nodes and other organ involvement), bacteremia, endocarditis, bacillary angiomatosis, peliosis hepatis, Oroya fever, and verruga peruana (30, 31).

Lyme disease is a multi-organ animal-borne disease, caused by spirochetes of Borrelia burgdofferi (Bb), which typically affect the skin, nervous system, musculoskeletal system and heart. A history of confirmed exposure to tick bites, typical signs and symptoms of Lyme borreliosis and positive tests for anti-Bb antibodies, are the basis of a diagnosis. A two-step diagnosis is necessary: the first step is based on a high sensitivity ELISA test with positive results confirmed by a more specific Western blot assay. Antibiotic therapy is curative in most cases, but some patients develop chronic symptoms, which do not respond to antibiotics (32).

Human monocytic ehrlichiosis is a tick-borne infectious disease transmitted by several tick species, especially Amblyomma spp. caused by Ehrlichia chaffeensis. E. chaffeensis is an obligatory intracellular, tick-transmitted bacterium that is maintained in nature in a cycle involving at least one and perhaps several vertebrate reservoir hosts. Human ehrlichiosis is a zoonotic disease, caused by a rickettsia that infects leukocytes. It was described for the first time in the United States of America in 1986. The most common symptoms include headache, muscle aches, and fatigue. A rash may occur, but is uncommon. Most of the symptoms of ehrlichiosis can likely be ascribed to the immune dysregulation that it causes (33).

The main objectives of this study are to describe the antibody prevalence of select arthropod-borne and zoonotic infections and determine risk factors associated with them among Georgian military recruits. For all of the pathogens under study, initial infection will result in long lasting protection to subsequent exposure to the same pathogen, making re-infection an extremely rare event. The limitation of this study for the use of general public health system is that the study population predominantly consists of young males. As long as this specificity of the study population is taken into account, data from this observational study will provide useful and vital information to the national public health system in Georgia. This epidemiological information can be used by the Georgian armed forces to guide and develop force health protection efforts, as well as to inform military physicians with regard to the extent of exposure to these pathogens among military recruits.

2.0          INVESTIGATIONAL PLAN

2.1         Objectives

The objectives of this study are to:

1. Determine the antibody prevalence of fourteen arthropod-borne and zoonotic infections prior to recruitment of military personnel.
2. Determine epidemiological risk factors associated with prior exposure to these infections.
3. Utilize the envisioned military disease surveillance system for scientific research on especially dangerous pathogens (EDPs).
4. Establish strategic research collaboration among the Central Military Hospital, NCDC, and the U.S. Army Medical Research Unit-Georgia (USMRU-G) to target EDPs.

2.2         Overall Study Design

This protocol is written in compliance with provisions of Title 32, Part 219, Section 1 10 of the Code of Federal Regulations (32 CFR 219.1 10). This protocol describes a seroprevalence study of military recruits in Georgia. Volunteers will be enrolled in the study at the time of the physical exam routinely conducted during registration of new military recruits.

• Study site

The Military Hospital of the Ministry of Defense of Georgia located in Gori (hereafter referred to as the Military Hospital) is the study site. Military recruits from all regions undergo medical and comprehensive health evaluations at the Military Hospital.

• Selection of the Study Population

At the age of 18, individuals are considered adults in Georgia. The literacy level of new military recruits is reportedly high; the vast majority (95%) of the population over 15 years of age is literate.

In Georgia, men and women who are joining the army undergo routine medical checkup. This same group of people will constitute the sampling frame in the selection of the study population. A non-probability random sampling technique will be used to sample or enroll study participants (military recruits). Potential participants will receive information about the study at the information session conducted by a study team member at the Military Hospital. The detailed description of the selection and enrollment process is provided below in section 2.3.1

• Sample size

A maximum of 1000 adult military recruits will be enrolled in this study. This sample size will detect a seroprevalence of at least 2.5% with an absolute precision of ± 1% at the 95% confidence interval. This sample size also allows detecting an expected odds ratio of 2 with a power of least 80% for risk factor analysis. Sample size calculation was not adjusted for multiple outcome (pathogens) measures.

2.3         Study Methodologies

2.9. Volunteer enrollment

All the military recruits who are going to serve in Georgian Army undergo their pre-recruitment medical assessment at the Military Hospital. The recruitment takes place several times a year; the exact time and the number of recruits is decided by the Ministry of Defense of Georgia. New recruits at the time of their routine medical and physical assessment will be invited to attend a group information session concerning this study. The group information session at which recruits will be introduced to the study will take place during the routine activities of the military health screening and will take advantage of the normal grouping of recruits at that time. The group session will take place in a private room at the Military Hospital. High ranking military officers and direct supervisors of the new recruits will not be present during the group session, and they will not participate in any activity related to this study.

A study team member will conduct the session and will cover the following: 1) explanation of the study objectives, 2) study participation is voluntary, 3) responses will be kept confidential, 4) time to study participation, 5) laboratory procedures and results, and 6) what institutions are conducting the study. All recruits will be given the informed consent document (ICD) and along with a study team member will review the ICD. No other recruitment approach will be used for study enrollment. During their medical examination at the doctor’s office, recruits will then be given the opportunity to ask questions and enroll or refuse in private after the ICD has been reviewed with them in detail.

All recruits, regardless of whether they agreed to participate, will carry a volunteer folder through their health screening activities in order to obscure enrollment status from other recruits and people not involved in the study. Each volunteer will read, sign, and date the ICD (Appendix A) before any study procedure is initiated. The ICD and any other study documentation used for enrollment will be translated into the Georgian language. The procedures for accurate translation are outlined in Section 6.3.2.

2.3.2 Eligibility criteria

Inclusion Criteria

Volunteer must be military recruits undergoing routine medical assessment at the military hospital in Gori. Volunteer must sign ICD

Exclusion Criteria

Volunteer age <18 years old.

The exclusion criteria are by self-report only; age will not be verified.

2.3.3 Questionnaire

Participants will be asked to complete a standardized questionnaire (Appendix B). The questionnaire will be administered in a private office by a study team member trained in research ethics. This questionnaire collects demographic data, history of clinical symptoms related to the pathogens under study, epidemiologic risk factors, and health seeking behavior. The face-to-face interview will take approximately 20 minutes.

2.3.4 Blood samples

A trained phlebotomist will collect approximately 10 milliliters (mL) of blood. The blood draw will take place in a private setting on enrollment. The clinical samples will be initially processed at the Military Hospital and NCDC. Samples will be serologically screened for the presence of antibodies to the pathogens under study. The remaining samples will be stored at -20 ⁰ C and then transferred to the USMRU-G or NCDC for confirmatory laboratory testing and subsequent storage. If the participant consents for storage and future use of samples, the stored specimen may be sent to WRAIR or another laboratory for advanced laboratory analysis such as pyrosequencing in order to identify any organisms that escaped serological detection. Otherwise, any remaining specimen will be destroyed at the completion of this study. All samples will be labeled only with the volunteer identification number (VIN) and date Of collection.

2.3.5 Laboratory diagnostics

Samples will be tested serologically for antibody response to the following pathogens: Bacillus anthracis, Brucella, CCHFv, Coxiella burnetii, Francisella tularensis, Hantavirus, Rickettsia species, TBEV, Bartonella species, Borrelia species, Ehrlichia species, Leptospira species, Salmonella typhi, and WNV. lgG positive Coxiella burnetii and Borrelia burgdofferi test results as well as 10% of negative samples will be sent to the NCDC or USMRU-G for confirmatory testing. Most of the assays used in this study are not licensed by the U.S. Food and Drug Administration; therefore, the test results will be for research purposes only. Genetic testing of human DNA will not be conducted on the samples collected in this study.

Table 1: ELISA and IFA tests for the Military Seroprevalence study

2.3.6. Sample transponation

Batched serum samples will be transferred at regular intervals from the Military Hospital to the NCDC and/or

USMRU-G

2.3.7 Data management

All data analyses will be carried out using STATA Version 1 1 (Stata Corporation, College Station, TX) and Epilnfo ^TM version 7.0 (CDC, Atlanta) or other similar statistical programs. An Epilnfo ^TM data entry screen will be created that will mirror the questionnaires and will serve as an electronic case report form (CRF). Double-data entry will be performed by the USMRIID/WRAIR CRU team, and the original paper questionnaire will be used to correct any discrepancies in the datasets. Subsequently, about five percent of the paper questionnaires will be compared to the dataset for internal quality control. The paper questionnaires, consent forms, and enrollment logs will be stored in a locked cabinet at the Military Hospital and will only be accessible to study investigators. The electronic CRF will not contain personal identifiers and will be password protected. Only study investigators and data entry personnel will have access to the

electronic study database.

Testing for this protocol will be for research purposes only and will not be provided to the individual volunteer.

2.3.8 Data Analysis Plan

Overall prevalence of antibody seropositivity along with 95% confidence interval will be calculated using the exact mid-p binomial formula for each infection under investigation (Bacillus anthracis, Brucella, CCHFv, Coxiella burnetii, Francisella tularensis, Hantavirus, Rickettsia species, TBEv, Bartonella species, Borrelia species, Ehrlichia species, Leptospira species, Salmonella typhi, and WNV). Likewise, the prevalence of exposures of interest will be calculated. Exposures of interest are shown on the questionnaire and include contact with animals and animal products, contact with potential disease vectors, contact with water, and contact with ill people. General health status and treatment seeking behaviors will be described including hospitalizations, health care provider visits, and presence of mild and severe illness. The health status and treatment seeking behaviors will be examined for associations with antibody positivity. Descriptive and univariate analyses will be conducted for all variables of interest. The and Fisher exact tests will be used to evaluate heterogeneity of infection and exposure prevalence. Univariate and multiple logistic regression analysis will be used to examine the association (odds ratios) of exposures of interest with antibody positivity at the 95% confidence level.

2.4         Withdrawal of Volunteers

A volunteer may be withdrawn from the study for any one of the following reasons:

• Volunteer wishes to withdraw from the study (withdraws consent).
• Investigator deems it is in the best interest of the volunteer’s welfare to withdraw.
• Volunteer is found to have entered the study in violation of Inclusion/Exclusion Criteria.
• Volunteer fails to comply with the procedures outlined in the Informed Consent Document.
• Study is terminated by the U.S. Department of Defense or other U.S. government regulatory group or any regulatory authority in Georgia.

Once the questionnaire is filled out and the blood sample is taken, the volunteer’s participation in the study is completed. The volunteer can withdraw from the study at any time. In the event that a volunteer is withdrawn from the study, already collected information and test results will be kept and used for data analysis but no further information will be collected and no additional tests will be done. This is a study with one time blood draw with no follow up visits. It is not anticipated that a significant number of volunteers will withdraw from the study. For this reason, there will not be a plan in place to replace withdrawn volunteers.

2.5        Protocol Deviation Procedures

The criteria for enrollment must be explicitly followed per protocol. If there is an inadvertent enrollment of individuals who do not meet enrollment criteria, these individuals will not donate samples for the study. The samples and data collected from such cases will be destroyed and all this information will be reported to the WRAIR and military hospital IRBs. A significant deviation occurs when there is nonadherence to the IRB approved protocol that has the potential to effect the rights and welfare of the research participant, to increase the risk to the research participant, to change the willingness of the research participant to continue participation, or to compromise the integrity of the study data in such a way that the study objectives cannot be achieved. Significant deviations must be reported promptly to the WRAIR IRB and the military hospital IRB, within 48 hours of becoming aware of the event, and recorded in the study deviation log.

Significant deviations should be promptly report (within 48 hours of the PI becoming aware of the deviation ) by telephone (301-319-9940), fax (301-319-9961) or email (USrmy.detrick.medcom-wrair.mbx.hspb) to the WRAIR IRB, through the WRAIR HSPB, and then must be followed-up in writing within 10 working days from awareness of the deviation.

Significant deviations should also be promptly report (within 48 hours of the PI becoming aware of the deviation ) by telephone (555-755-055) or email (hpagorimh@gmail.com) to the Military Hospital IRB, and then must be followed-up in writing within 10 working days from awareness of the deviation.

All other deviations (minor) will be recorded in the study deviation log and provided as part of the continuing review report.

Minor deviations will be reported at the time of continuing review and/or final report. However, any known major deviations or unexpected problems that may affect the health, safety, or welfare of volunteers will be reported promptly to the Military Hospital Institutional Review Board (IRB) and the WRAIR IRB. Minor deviations are defined as a change in the conduct of a protocol, intentional or unintentional, implemented without approval from the reviewing IRBs and implementation approval from the WRAIR Commander. Major deviations are defined as non-adherence to the IRB-approved protocol that has the potential to affect the rights and welfare of the research participant, to increase the risk to the research participant, to change the willingness of the volunteer to continue participation, or to compromise the integrity of the study data in such a way that the study objectives may not be achieved.

3.0       STUDY VISITS AND PROCEDURES

3.1 Enrollment and Screening.

A group information session will be held for new recruits at the time of their routine physical exam. A study team member will conduct this information session. Individually, in a private setting, volunteers will then be given the opportunity to ask questions and enroll or refuse in private. The rights and welfare of the military recruits will be safeguarded by excluding high ranking military officers or direct supervisors at both the group information session and informed consent process, providing privacy through the use of private rooms and uniform folders, and protecting confidentiality by using identification numbers, limiting access to personally identifying information, and storing information in secure cabinets.

Volunteers will be reminded that their participation in the study is completely voluntary and that their choice to participate or not will have no effect on their military service or current or future medical care. Informed consent will be obtained in private before any protocol activity is initiated. A signed copy of the completed ICD will be provided to the volunteer. Once it has been determined that the volunteer meets all the inclusion criteria and none of the exclusion criteria, he/she will be enrolled into the study. The results of the laboratory testing will not be provided to the volunteer.

3.2 Volunteer Identification and Compensation

Volunteers will be assigned a Volunteer Identification Number (VIN). The VIN will be the WRAIR-assigned protocol number followed by a unique four digit number starting at 0001. No volunteer will receive more than one VIN number. The link between the VIN number and the subject name will be the enrollment log. The enrollment log will be completed by the consenting investigator and kept in a locked file cabinet. The access to the study files, including the enrollment log, will be limited to the study personnel trained in ethical conduct of clinical studies.

Since volunteers will be minimally inconvenienced by participating in this study, they will not receive any financial or monetary compensation for study participation.

3.3 Blood Draw

The amount of blood drawn will be a maximum of 10 mL. Samples will be stored indefinitely at the NCDC or USMRU-G and aliquots might be sent to WRAIR headquarters for future research studies. Study team members at the Military Hospital, NCDC, USMRU-G, and at WRAIR involved in the laboratory aspects of the study will be responsible for the processing and storage of samples. Laboratory personnel will not have access to personal identifying information; all samples will only be labeled with the VIN and date of collection. Future testing will be limited to research broadly related to the present research objectives and will require IRB approvals prior to use. Only those samples from volunteers who give permission for future use can be used. Samples of volunteers who do not consent to have their samples used in the future will be destroyed after all the tests for the current study are completed.

Other than obtaining samples by phlebotomy and questionnaire completion, no additional samples or time will be needed from volunteers. Future testing of archived samples may or may not require WRAIR IRB approval (depending on if WRAIR investigators are involved in the study), however, it will require local Ministry of Defense (MOD) Military Hospital IRB approval. Approval may also be needed by other IRBs depending on the nature and collaborators involved in the future study.

We do not anticipate that volunteers will develop any significant decline in blood volume through participation in this study since only 10 mL of blood will be drawn.

3.4 Clinical Assessment

Each participant will complete an interview in which a trained study team member administers a questionnaire documenting prior clinical history and risk of exposures to the infections studied in this protocol. In particular, the questionnaire will be completed by the physicians at the military hospital who work at the out-patient department and who will be investigators in this study. This interview will occur after the informed consent process has been completed.

3.5 Status of Results

The results of the blood testing will not be provided to the study participants. Laboratory results from this study will not go into the recruits’ permanent medical or military record or to their military command. These laboratory results will also not be used to determine eligibility for military service. The results of this study will be reported in aggregate form to the investigators at the military hospital. In the event that reporting participant resuit is relevant to the investigators, only the identification number (VIN) will be used.

Epidemiologic data, relevant to Tularemia and results of F. tularensis ELISA of the first 500 volunteers will be used as a control group data for a separate clinical protocol (DTRA project GG19 – A seroprevalence study of tularemia among healthy individuals in Georgia). The data shared for this purpose will be deidentified.

4.0 CLINICAL/MEDICAL MONITORING

The following groups in the United States may review the study records of all volunteers who participate in this protocol and annotate any instance of failure to comply with the requirements of this protocol: the Walter Reed Army Institute of Research (WRAIR) Institutional Review Board (IRB), the Military Hospital Institutional Review Board (IRB) in Georgia may also review records to ensure compliance with Georgian regulations. Additionally, any data generated by this study must be available for inspection on request by the Military Hospital IRB, public health authorities of Georgia and representatives of the U.S. Department of Defense (DoD). A member of the study team will monitor the study for quality control and quality assurance.

5.0       PROTOCOL REVISIONS

With the exception of emergency situations, no changes or deviations in the conduct of this protocol are permitted without the prior documented approval of the Military Hospital IRB and the WRAIR IRB.

In the event of an emergency, the investigator will institute any medical procedures deemed appropriate. However, all such procedures must be promptly reported to the Military Hospital IRB and the WRAIR IRB. Any change or amendment to the protocol affecting study volunteers, study objectives, study design, study procedures, or significant administrative aspects will require a formal amendment to the protocol. Such amendment will be submitted to the WRAIR IRB and the Military Hospital of the Ministry of Defense of Georgia IRB (and possibly the NCDC) for review and approval prior to implementation. Administrative changes to the protocol are corrections and/or clarifications that have no effect on the way the study is to be conducted. Such administrative changes will be submitted to the WRAIR IRB and the Military Hospital of the Ministry of Defense of Georgia IRB f(and possibly other the NCDC) or review and approval prior to implementation.

6.0       ETHICAL CONSIDERATIONS

6.1        Institutional Review Board or Independent Ethics Committee

Prior to the initiation of the study, the investigator will submit the study protocol, informed consent document,

CRFs, and any other documents that may be requested for review and approval by the Military Hospital IRB and the WRAIR IRB. The investigator will request the written approval of the study and will keep on file records of approval and all documents pertaining to this study. The Military Hospital IRB and WRAIR IRB will review the approval of the study at regular intervals but not less than once annually.

Continuing review reports will be submitted at intervals designated by the WRAIR IRB (or IRB of record) and a final report in accordance with 32 CFR 219 and Army regulations. The continuing review report should be submitted to the USrmy.detrick.medcom-wrair.mbx.hspb to the WRAIR IRB, thru the WRAIR HSPB.

Continuing review reports and the final report also will be submitted to the Military Hospital IRB. The continuing review report will be submitted at least once a year. The military hospital IRB may request a continuing review report more frequently. The reports will be sent to the following address: hpaqorimh@qmail.com.

It is the responsibility of the Principal Investigator to promptly report changes or unanticipated problems in research activity to the Military Hospital IRB and the WRAiR IRB. Changes in protocol procedures or personnel may not be initiated without the approval of the Military Hospital IRB and WRAIR IRB except when necessary to eliminate apparent hazard to the volunteer.

6.2         Ethical Conduct of the Study

This study will be conducted in compliance with the protocol and the applicable regulatory requirements for Georgia. The study will be compliant with U.S. Army Regulation AR 70-25. Besides, the study will be compliant with 45 CFR 46, the Federal regulation for the protection of human subjects.

Notice of compliance inspections will be immediately reported to the WRAIR Human Subjects Protection Branch by telephone (301-319-9940), fax (301-319-9961 ) or email USrmy.detrick.medcom-wrair.mbx. hspb) (or local IRB Office) and the USMRMC Office of Research Protections upon knowledge of a pending compliance inspection by the any governmental agency concerning clinical investigation or research.

6.3        Volunteer Information and Consent

6.3.1 Routine informed consent procedures

Prior to enrollment in the study, each volunteer will be informed in detail about the protocol purpose and procedures and the risks and discomforts and benefits to be expected. The key elements of informed consent as specified by U.S. DOD regulations and regulations in Georgia will be followed. Written consent will be obtained from each volunteer using the iR3-approved Informed Consent Document. If the volunteer is unable to read the Informed Consent Document, it will be read aloud to them by a study team member, the volunteer will place his mark or fingerprint on the signature line, and a non-study team member witness will observe the process and provide their signature and date on the ICD. Volunteers will have ample time to ask questions and will be asked questions to ensure they understand the ICD. This document will be written in the Georgian language. The person explaining the consent and verifying the volunteer’s signature will sign and date the same ICD. Each volunteer will be given a signed copy of the completed ICD Volunteers will be told that they are free to withdraw their consent and discontinue participation at any time without prejudice or loss of benefits to which the volunteer is otherwise entitled.

6.3.2 Informed consent translation

All translations will be performed by a trained translator. The translator will translate the English version into the Georgian language. For the ICD, a second translator will review the Georgian translation of the ICD and discuss any differences in the translation with the primary translator. If a disagreement occurs, the differences will be resolved in a discussion with the Principal Investigator (PI). Once consensus on the accurate translation of the ICD is reached, a Translation Verification Form will be completed by the reviewing translator. The final country language version of the ICD and the Translation Verification Form will be submitted to the WRAIR and the military hospital IRB.

6.4 Benefit to Host Country

• This project will enhance epidemiological and laboratory capabilities of the Military Hospital.
• This project will enhance laboratory and epidemiological analytical capabilities in the Georgian military medical system.
• This project will establish research collaboration between the Military Hospital, NCDC, USMRU-G and U.S. military medical institutions. It will be a possibility to exchange experience between military and civilian health care professionals and will provide a foundation for further joint work.

Volunteers will not draw direct benefit from this minimal-risk phlebotomy study. The study may elucidate some of the infectious diseases issues in Georgia, ultimately leading to preventive and therapeutic strategies to minimize the health care burden in both civilian and military populations.

• STUDY ADMINISTRATION
• Study Initiation

Prior to the start of this study, the investigators and the study site must meet all pre-investigational requirements. These include having on file copies of current curricula vitae of the PI and all co-investigators, the Informed Consent Document, and written documentation of approval of the protocol (identified by protocol number and title) by the Military Hospital IRB and the WRAIR IRB

7.2       Case Report Forms

The Epiinfo ^TM data entry form will serve as an electronic CRF. An original of the volunteer consent to participate and source documents that include the paper questionnaire and volunteer enrollment log will be kept at a secure location at the study site once completed. The investigator will be responsible for the complete, accurate, and timely recording of the information on the CRF. Ultimately, the participant folders, containing the signed intormed consent document, the questionnaire and lab result forms will be transferred to the USMRU-G by USMRIID/WRAIR CRU members. Per Department of Defense Instruction (DODI) 3216.02, Section 15, the study records will be kept at the USMRU-G for at least 3 years after the completion of the research. Study investigators will have access to the records. Representatives of the Military Hospital IRB and the WRAIR IRB are eligible to photocopy and review medical and research records related to this study as a part of their responsibility to protect human subjects in clinical research.

7.3           Specimen Collection

Trained phlebotomists will draw approximately 10 mL of blood.

7.4          Study Completion

This study will be completed when a maximum of 1000 volunteers have been enrolled and when the collected clinical specimens have been tested in the laboratory. The duration of the study will be approximately 5 years. The retention period for coded electronic data and samples will be indefinite, and this retention is indicated in the ICD.

   7.5          Final Report/Data Analysis

The investigator is required to submit a summary report to the Ministry of Defense of Georgia, the Military Hospital iRB, the WRAIR iRB, and the Defense Threat Reduction Agency after completion or termination of the study. This summary will be completely de-identified in order to protect the confidentiality of the participants.

All WRAIR intramural protocols, to include exempt, minimal risk, and greater than minimal risk studies, will be closed five years from the date of final approval (by the WRAIR IRB) unless otherwise requested and approved during the initial protocol review or unless the PI is granted an extension.

If data analysis for an ongoing human subjects research study has not been completed by the predetermined closeout date established during the initial protocol review, investigators may request a onetime extension by submitting an extension request stating the length of time needed (from 6 months to 3 years), a strong justification for the extension, and a summary of the work remaining. A second extension of these human subjects research studies may be considered under extenuating circumstances, however, strong justification must be provided. Exceptions to this extension policy are protocols such as repository, cohort development, epidemiology, or those, which by their very nature may require extensions up to 5 years each. At the discretion of the WRAIR IRB Chair or WRAIR IRB, as appropriate, up to two extensions with a strong justification will be considered.

All protocol extensions may require both a scientific review and a human subject’s review, as additional protocol modifications may be required to update regulatory reporting requirements. Investigators should plan to submit extenson requests at least 30 days prior to the pre-determined protocol closure date to allow time for review and approval, and to avoid interruptions in work. If a closeout report or extension request has not been submitted by the pre-determined protocol closure date, then the protocol will be involuntarily closed by the WRAIR Institutional Official within 30 days following the protocol expiration.

7.6       Confidentiality/Security

Participants will be identified on CRFs by VIN. Ail samples will be labeled with a VIN and date of collection and will not contain personal identifiers. Representatives of the Military Hospital IRB and the WRAIR IRB are eligible to photocopy and review medical and research records related to this study as a part of their responsibility to protect human subjects in clinical research.

Records and all regulatory documents associated with the study will be stored in a secure location at the

USMRU-G

No personal identifier will be used in any publication or communication to support this research study.

7.7         Publication of Study Results

All information collected during this study may oe published in the medical or military literature with the identity of the volunteers protected. Any data to be published will be reviewed and approved by a U.S. sponsoring institution (DTRA, USMRIID/WRAIR), NCDC and by the Georgian MOD. The publication procedures required by the WRAIR and other collaborating institutes will be followed.

7.8        Funding for the Research Project

Epidemiologic assessments to establish baseline levels of disease and clinical diagnostic assay assessments are programmatic requirements for implementation of the Biological Threat Reduction Program (BTRP) for the Defense Threat Reduction Agency. This study is a shared effort between the Ministry of Defense of Georgia, NCDC, USMRU-G, WRAIR, and USMRIID.

   8.0      RISK/BENEFIT ASSESSMENT

The risks of this study are primarily associated with the risks of phlebotomy and breach of confidentiality. The risks of ph\ebotomy are the following: pain during the procedure, ecchymosis (bruising), cellulitis (localized skin infection), thrombophlebitis (blood clot at the phlebotomy site), and dizziness or syncope (fainting) during or after the procedure. None of these side effects are considered severe. These risks can be minimized with appropriate training and supervision of phlebotomy staff. Strict adherence to sterile technique can minimize the risk of infection. Appropriate technique can minimize the need for multiple blood draw attempts and reduce the occurrence of ecchymosis after phlebotomy. The phlebotomist and those scientists performing the assays will follow universal precaution procedures when handling volunteer specimens Medical personnel will be thoroughly trained prior to study initiation. It is very unlikely that the amount of blood drawn from each volunteer during this study would lead to any signs/symptoms of anemia.

Confidentiality will be protected by limiting access to personally identifying information to study team members and data management personnel. Paper questionnaires, consent forms, and enrollment logs will be stored in a locked cabinet at the Military Hospital and later at the USMRU-G. Volunteers will be identified on the electronic CRFs by volunteer identification number (VIN). Clinical samples will be labeled only with the VIN, study number, and date of collection. No personal identifier will be used in any publication or communication to support this study.

All exclusion criteria will be self-reported; no verification of age will be performed. As previously stated, there is no direct benefit to individual volunteers for participation in this research study.

    9.0   REPORTING OF UNANTICIPATED PROBLEMS AND DEATHS

An unanticipated problem is defined as any incident, experience, or outcome that meets all of the followinq criteria

1. Unexpected (In terms or nature, severity, or frequency) given the approved research procedures and the subject population studied;
2. Related or possibly related to a subject’s participation in research; and
3. Suggests that the research places subjects or others at greater risk of harm (physical, psychological, economic, or social harm) than was previously known or recognized.

Examples of unanticipated problems Include (but are not exclusive to) exposure to HIV or other infectious disease due to an unintentional needle stick, disclosure of protected health information, occurrences of breaches of confidentiality, destruction of study records, unaccounted for study drug, etc.

Unanticipated problems involving risks to subjects or others should be promptly report (within 48 hours of the PI becoming aware of the problem ) by telephone (301-319-9940), fax (301-319-9961) or email (USrmy.detrick.medcom-wrair.mbx.hspb) to the ‘vVRAiR FRB, thru the WRAIR HSPB, and then must be followed-up in writing within 10 working days from awareness of the problem.

Unanticipated problems involving risk to volunteers or others and all volunteer deaths will be promptly (usually within 48 hours of the PI being notified) reported to the Military Hospital IRB (Military Hospital of the Ministry of Defense of Georgia 56 Chavchavadze St., Gori, Georgia) by phone ((995) 370270314) or by E-mail (n_chaduneli@yahoo.com) and to the WRAIR IRB by phone (001 301 319 9940), by E-mail (WRAIRDHSP@amedd.army.mil) or by facsimile (001 301 319 9961

10.0 REFERENCES

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4. Ergonul O. Crimean-Congo haemorrhagic fever. Lancet Infect Dis. 2006:6(4):203-14.
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6. Kaiser R. The clinical and epidemiological profile of tick-borne encephalitis in southern Germany 1994-98. A prospective study of 656 patients. Brain. 1999. 122:2067-2078.
7. Hoizmann H. Diagnosis of tick-borne encephalitis. Vaccine. 2003. Sl/36-S1/40.
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17. Kuchuloria T, Clark DV, Hepburn MJ, Tsertsvadze T, Pimentel G, Imnadze P. Hantavirus infection in the Republic of Georgia. Emerg Infect Dis [serial on the Internet]. 2009 Sep [date cited]. Available from http://wwwnc.cdc.qov/eid/article/15/9/09-0617. htm
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11.0 SIGNATURE OF INVESTIGATOR

“l have read the foregoing protocol and agree to conduct the study as outlined herein in accordance with Georgian regulations, and U.S. DOD, and U S. Army Regulations.

Principal Investigator                                                            Date (dd/mon/yy)