THE WAR AGAINST COVID-19

The U.S. military’s ongoing fight against the novel coronavirus

It was more than a year ago when the first cases of COVID-19 were reported in the United States. From the start of the pandemic, the Department of Defense (DOD) took on multiple roles in the battle against SARS-CoV-2, the coronavirus that causes the disease: protecting its own people, maintaining military readiness, supporting the national interagency (and sometimes international) response, and contributing valuable research and technology to the effort to learn about and fight COVID-19.

To help handle patients in multiple states and territories, the U.S. Army Corps of Engineers, with support from the Naval Facilities Engineering System Command (NAVFAC), designed and built 38 alternate care facilities. Deployable augmentation teams from the Army, Navy, and Air Force assisted medical providers across the country. At the height of the pandemic, more than 47,000 National Guard members deployed in support of emergency medical care and public health efforts in different states and territories, communications, transport, and logistics.

The nationwide effort that began as Operation Warp Speed (OWS), a public-private partnership among DOD, the U.S. Department of Health and Human Services (HHS), and vaccine manufacturers, has been a historic success, so far leading to the Food and Drug Administration’s (FDA) emergency use authorization for two of the six OWS vaccine candidates. Five DOD medical treatment facilities have participated in Phase 3 vaccine trials. As the partnership evolved into a nationwide vaccination effort led by the Federal Emergency Management Administration (FEMA), it has led to the distribution of more than 180 million vaccine doses – and administration of more than 140 million doses – by the end of March 2021. OWS was folded into broader efforts of the White House COVID-19 Response Team at the end of February 2021.

Blue Angels receive the COVID-19 vaccine aboard Marine Corps Air Station Miramar on Jan. 29, 2021. Vaccines were being administered in a phased approach prioritizing health care workers and first responders as well as mission-critical and deploying personnel.

DOD has also helped more than 143 countries with testing, diagnostics, and medical supplies and equipment since the beginning of the pandemic, through the work of its combatant commands, humanitarian assistance programs, or the Cooperative Threat Reduction Program.

All of these successes have been achieved without sacrificing the readiness and effectiveness of the military’s 2.2 million uniformed service members, or of the 700,000 civilians in the contract workforce.

FORCE PROTECTION AND MISSION READINESS

In the beginning weeks of the pandemic, the Pentagon acted quickly to protect service members at home and abroad, issuing a series of travel restrictions, stay-at-home orders, and quarantines for service members returning from some overseas locations. These social distancing requirements compelled the department to adapt in several ways. In March 2020, the Pentagon began to implement and expand a “commercial virtual remote” (CVR) environment, based on Microsoft Teams, that enabled DOD employees to work remotely; by the fall, more than a million users were able to perform telework and attend virtual conferences, meetings, and teamwork sessions. The success of CVR has led the Pentagon to extend its use through June 2021, and to examine what functionalities and features, including network architecture and security, will be necessary as it continues to adapt this commercial network to the military’s needs.

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Likewise, the Military Health System began to maximize the scope and reach of its telehealth capabilities to maintain the quality of basic clinical and pharmacy services throughout the department while keeping patients safe. The department is looking to expand these capabilities to reach from deployments abroad to fixed facilities, community clinics, and partners such as the Department of Veteran Affairs.

Operation Warp Speed Chief Operating Officer Army Gen. Gus Perna, right, led a table top exercise on Nov. 6, 2020, to explore COVID-19 vaccine distribution scenarios and contingency plans as pharmaceutical companies came closer to an approved vaccine.

From the start, DOD has done a good job of protecting service members and their families from the worst effects of COVID-19; its hospitalization rates and case fatality rates remain far lower than the overall U.S. population’s. As of April 1, 2021, more than 265,825 of the department’s uniformed service members, their dependents, and civilian and contract employees had been infected with the virus. Among them, 325 had died: a case fatality rate of 0.001, or a tenth of 1 percent. This may in part be explained by demographics – service members are generally younger and fitter than most Americans – but even within these age groups, DOD employees and their dependents have fared relatively well.

After the FDA authorized the emergency use of monoclonal antibodies for the treatment of COVID-19 – an intravenous “cocktail” developed through Operation Warp Speed – Brooke Army Medical Center opened an infusion clinic to help high-risk COVID-19 patients with mild to moderate symptoms. The goal of the treatment is to hinder the disease’s progression and avoid inpatient admissions, and so far patients appear to be responding well. As of mid-March 2020, the clinic had treated 59 patients; among them, only five required hospital admission.

Crystal Tyler, pharmacy technician, prepares an injection for an Operation Warp Speed patient volunteer at Brooke Army Medical Center (BAMC), Fort Sam Houston, Texas, Nov. 16, 2020. BAMC and Wilford Hall Ambulatory Surgical Center were participating in the Phase III trial to evaluate the vaccine under development by AstraZeneca as part of a national initiative to accelerate the development, production, and distribution of COVID-19 vaccines, therapeutics, and diagnostics.

The first COVID-19 vaccines were authorized for emergency use by the FDA in mid-December 2020, and DOD promptly launched its aggressive immunization program, administering COVID-19 vaccines at 343 sites around the world. Its vaccine distribution plan had three phases: first, health care and support personnel, emergency services and public safety workers, deploying personnel, and other essential workers; second, high-risk beneficiaries; and the third and final phase moving on to the healthy DOD population.

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By March of 2021, more than half of U.S. military installations had lifted travel restrictions, some of which had been imposed more than a year earlier.

In a March 26, 2021 press briefing, the Pentagon announced that about a third of active-duty, Reserve, and National Guard service members had received at least one injection, and the department expected to open up vaccination to all eligible DOD beneficiaries by May 1. Army Lt. Gen. Ronald J. Place, director of the Defense Health Agency, said it was possible that every person within DOD could be vaccinated by mid-July.

RESEARCH AND TECHNOLOGY

Military research played a crucial role in protecting health care workers as the COVID-19 infections surged in the spring of 2020. In May, the FDA authorized the emergency use of a device developed by the U.S. Army Medical Research and Development Command: the COVID-19 Airway Management Isolation Chamber (CAMIC), which has been used to prevent aerosolization of the virus during the treatment and intubation of patients.

Military medical facilities and personnel continue to play a critical role in the clinical trials of Operation Warp Speed’s vaccine candidates.

The Defense Health Program is funding DNA vaccine dose manufacturing for COVID-19 prevention and monoclonal antibody manufacturing for COVID-19 prevention and treatment.

In early April 2021, the Army announced that it would begin testing a next-generation protein-based vaccine, developed by investigators at the Walter Reed Army Institute of Research (WRAIR) to be effective against newer, more transmissible variants of the SARS-CoV-2 virus. Initial results of the study, which will involve adult volunteers aged 18 to 55, were expected to be available by midsummer – and if those results are promising, Army researchers will likely try to partner with a pharmaceutical company to further test and develop the vaccine.

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In addition to vaccine work, investigators are researching the potential protective effect of monoclonal antibodies: human-made proteins that may assist the body’s natural immune response in fighting off a SARS-CoV-2 infection. STORM CHASER, a study led in the Military Health System by the Infectious Disease Clinical Research Program at the Uniformed Services University of the Health Sciences (USUHS), is currently seeking to discover whether a monoclonal antibody might prevent infection in those recently exposed to the virus. At multiple sites, including five DOD facilities, investigators are administering the antibody therapy, via intramuscular injection to asymptomatic study participants within eight days of a known SARS-CoV-2 exposure. If the antibody proves successful in preventing infection during the virus’s incubation period, it could be a benefit to those in high-risk circumstances: health care workers, for example, or people with COVID-19-positive household members.

In a separate study, USUHS researchers have discovered tiny antibodies, or “nanobodies,” produced by a llama, that may be useful in blocking infection altogether by grabbing hold of the SARS-CoV-2 virus’s spike protein.

Navy Lt. Caroline Mosher, a nurse anesthesia student at USUHS Graduate School of Nursing, conducts “proof-of-concept” testing using the COVID-19 Airway Management Isolation Chamber, or CAMIC.

Monoclonal antibodies and convalescent plasma – blood plasma rich in COVID-19 antibodies, donated by those who have recovered from the disease – have shown promise as therapeutics that can reduce the length and severity of the disease. In January 2021, DOD and HHS purchased more than a million treatment courses of a monoclonal antibody, REGN-COV2, that was developed by Regeneron Pharmaceuticals with Operation Warp Speed funding.

Aviation Boatswain’s Mate (Equipment) 2nd Class Bryan Bennett, a sailor assigned to the aircraft carrier USS Theodore Roosevelt (CVN 71), donates COVID-19 convalescent plasma (CCP) at the hospital’s Armed Services Blood Program Blood Donation Center. Those who have tested positive for COVID-19 and since recovered are encouraged to donate CCP as part of a Department of Defense-wide effort to alleviate the symptoms of those currently suffering during the pandemic.

Investigators at several military research facilities – including WRAIR, the Air Force Research Laboratory (AFRL), and the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) – are investigating COVID-19 diagnostics: devices that can rapidly detect the SARS-CoV-2 virus during the early days of infection, as well as immunoassays that can detect COVID-19 antibodies in people without a confirmed history of exposure to or illness from the disease. A team at the Army’s Edgewood Chemical Biological Center is developing a rapid genetic sequencing tool capable of detecting the virus not only in clinical samples, but also in environmental samples – in air, water, or soil. The U.S. Army Research Institute of Environmental Medicine (USARIEM) is evaluating the potential for using wearable monitors to detect the onset of COVID-19 illness: Using machine learning algorithms, the monitors can analyze changes in heart rate to estimate core body temperature and detect early symptoms.

Lt. Cmdr. Raben Talvo, Naval Medical Center San Diego’s (NMCSD) Office of Clinical Quality department head, administers the hospital’s first monoclonal antibody (mAb) treatment to a COVID- 19-positive patient Jan. 26. Bamlanivimab, the mAb treatment, was administered under emergency use authorization (EUA) guidance from the U.S. Food and Drug Administration (FDA) to treat mild to moderate COVID-19 symptoms in some adult and pediatric patients who are at high risk for progressing to severe COVID-19 symptoms.

Meanwhile, DOD researchers continue to publish significant findings about the etiology, epidemiology, and pathology of the disease: Navy investigators, for example, in their study of the spring 2020 outbreak aboard the aircraft carrier USS Theodore Roosevelt, showed that young, healthy, working-age adults can play a role in the spread of SARS-CoV-2. The study was reported in the New England Journal of Medicine in November 2020. In the same issue, a team of researchers from the Naval Medical Research Center and the Icahn School of Medicine at Mount Sinai in New York City reported on their study of nearly 2,000 Marine recruits, which yielded several surprising results: Few of the infected recruits displayed symptoms before their COVID-19 diagnosis; transmission of the virus occurred despite many of the best-practice public health measures; and diagnoses were made only by scheduled tests, rather than by tests performed in response to symptoms. These insights have had implications for the development of safe approaches for settings where young adults are concentrated, such as schools, camps, and sports teams.

SUPPORTING THE INTERAGENCY RESPONSE

DOD’s participation in the whole-of-government response to the COVID-19 pandemic has included a leadership role in Operation Warp Speed, which contributed to the development of effective COVID-19 vaccines in record time – about nine months, from the beginning of development efforts to the FDA’s emergency use authorization of the first vaccines in mid-December 2020. Previously, the mumps vaccine was the quickest to have been developed, over a period of about four years.

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DOD experts also played a crucial role in the early stages of vaccine manufacturing: OWS leaders deployed 16 DOD personnel to two manufacturing sites to assist with quality control until the organization could hire required personnel.

During the pandemic’s most intense surges, DOD health care providers, including Reserve health care professionals, have been deployed to either embed with civilian facilities or to establish supplemental or alternate care facilities.

After the FDA’s authorization of the first COVID-19 vaccines, the DOD began to focus on supporting the federal vaccination program led by FEMA. In early February 2021, Secretary of Defense Lloyd Austin announced that active-duty service members, both medical and support personnel, would be deployed in support of five FEMA vaccination centers. Each team, which would be composed of either 222 people (capable of administering 6,000 vaccinations a day) or 139 (about 3,000 vaccinations daily), would include service members from all four of the service branches.

The first 222-person team arrived in California to support a mass vaccination site in Los Angeles beginning on Feb. 15. By mid-March, about 6,235 activeduty service members had been mobilized to support COVID-19 vaccination centers – in addition to the more than 26,000 National Guard members and 3,000 active-duty personnel who have supported COVID-19 efforts over the last year. By March 11, 2021, DOD vaccination teams had administered 500,000 injections, and had achieved a daily rate of 50,000 vaccinations given.

Key to the success of DOD in these vaccination rollouts, both throughout DOD and in support of the domestic effort, has been the scope and sweep of military logistics. Before the FDA had authorized the first COVID-19 vaccine for emergency use in the United States, medical logistics experts at the U.S. Army Medical Materiel Agency (USAMMA) began receiving vaccine orders from all four service branches. USAMMA tracked shipments from the vendor to each military site where the vaccine was used to immunize service members and military beneficiaries. Using a new software platform, Tiberius, developed specifically for the OWS partnership, logisticians were able to incorporate information from several sources – including the U.S. Census, Vaccine Tracking System, and commercial logistics organizations – and to provide visibility for every component of the partnership, from the manufacturing of the vaccine to its allocation, down to the planning of administration sites down to the provider level.

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As the first vaccinations were being administered to health care workers, the Defense Logistics Agency (DLA) prepared to ship doses for DOD employees outside the continental United States and aboard the deployed U.S. Navy Fleet – using the well-developed cold-chain management practices it’s been using to ship flu vaccines for two decades.

As the federal vaccination campaign has ramped up, DOD assisted HHS by transporting needles and syringes to support the delivery of vaccines.

DOD personnel, along with New Jersey state troopers, support FEMA in providing COVID-19 vaccinations to members of the local community in Somerset, New Jersey. FEMA is working with state, local, tribal, and territorial governments on the critical need to open vaccination centers in underserved communities.

As it has from the beginning of the pandemic, the military has stepped up to fill gaps in the nation’s supply chain when necessary. DLA helped to procure a massive stockpile of material for the nation’s COVID-19 fight by mid-summer 2020, including millions of non-medical and surgical masks, N95 respirators, gloves, gowns, ventilators, and test components. The Army, Navy, and Marine Corps partnered to produce 3 D-printed face shields and test swabs to assist in the response. The surge in demand for N95 respirators led to the creation of an N95 working group within the U.S. Army Medical Materiel Development Activity (USAMMDA), to help the DOD work with commercial partners to produce respirators that comply with military needs.

When President Joe Biden took office in January 2021, he named the fight against COVID-19 as “Job 1” for the entire federal government. DOD has done its part. It has, arguably, played a larger role in the response to the national COVID-19 emergency than in any other homeland event in American history – often with personnel or assets who have been deployed for the first time. While assuring the readiness of the nation’s military troops, the Military Health System has exchanged knowledge and best practices with its civilian counterparts.

In March 2021, looking back on the year-long pandemic response effort, Deputy Defense Secretary Kathleen H. Hicks praised the military’s work in support of HHS, FEMA, and other federal partners – and assured Americans that the Pentagon was ready to continue in a supporting role: “It is such a tremendous, phenomenal effort,” she said. “Now it’s about making sure that we help stand up civilian capacity that can endure over the long term.”